Carpal tunnel syndrome (CTS) is the most common compressive neuropathy of the upper extremity. It involves the median nerve at the wrist. The results of CTS are activity limitation, work disability, and considerable discomfort. 1,2 The current conservative treatment for CTS consists of wrist splinting, activity modification, nonsteroidal antiinflammatory drugs, and in some cases, local corticosteroid injections into the carpal tunnel. 3–8
The finding that flexion and extension of the wrist increases carpal tunnel pressure and the implication of increased carpal tunnel pressure in the pathophysiology of CTS suggest that immobilization in a splint benefits the patients by preventing the elevation of carpal tunnel pressure. 9,10 Many authors have suggested that placing the wrist in a neutral position may provide the optimal reduction in pressure and therefore provide a greater potential to obtain relief from symptoms. 3,4,9–11
Until recently, hand exercise programs have not been used in the conservative treatment of CTS. Szabo et al. 12 showed that the relationship between median nerve and flexor tendon excursion was consistently linear. They suggested that active finger motion would provide sufficient motion of the median nerve and flexor tendons in the vicinity of the wrist to prevent adhesion formation even if the wrist is immobilized. A study by Seradge et al. 13 demonstrated that intermittent active wrist and finger flexion-extension exercises reduce the pressure in the carpal tunnel. Sunderland and Biadley 14 reported that a nerve may stretch 7–20% of its resting length without damage. Totten and Hunter 15 proposed a series of exercises enhancing the gliding of the median nerve at the carpal tunnel for the management of postoperative CTS. They suggested tendon gliding exercises for nonoperative treatment of CTS. In a more recent study, Rozmaryn et al. 16 reported their experience of these exercises in the conservative treatment of CTS. By employing these nerve and tendon gliding exercises, symptom resolution could be obtained by stretching the adhesions in the carpal canal, broadening the longitudinal area of contact between the median nerve and transverse carpal ligament, reducing tenosynovial edema by a milking action, improving venous return from the nerve bundles, and reducing pressure inside the carpal tunnel. The aim of this study was to investigate the overall therapeutic effect of nerve and tendon gliding exercises in combination with splinting compared with splinting alone on a common entrapment neuropathy CTS.
MATERIAL AND METHODS
A total of 28 patients (26 women and two men) with clinical and electrophysiologic evidence of CTS were studied. Their mean age ± standard deviation was 51.93 ± 5.1 yr, with a range of 38–64 yr. CTS was bilateral in eight patients. Exclusion criteria were underlying metabolic disorders (such as diabetes mellitus or thyroid disease), rheumatoid arthritis, pregnancy, history of steroid injection to a carpal tunnel, severe thenar atrophy, and a history of splint use.
Patients were included according to subjective symptoms, physical examination, and electrophysiologic findings. Subjective symptoms were history of paresthesia or pain in the median nerve distribution, nocturnal pain, and dysesthesia. Physical examination included Phalen’s sign, Tinel’s sign, two-point discrimination, and grip and pinch strength measurement. All patients required subjective symptoms and either a positive Phalen’s sign or a positive Tinel’s sign for inclusion in the study. Phalen’s sign was performed by full flexion of the patients’ wrists for 60 sec. The test was recorded positive if the patient experienced paresthesia in at least one of three radial digits. Tinel’s sign was performed by percussing the median nerve at the wrist. The test was recorded positive if the patient experienced paresthesia in at least one of three radial digits. 17 Grip and pinch strength were measured with a Martin vigorimeter (Tutlingen,Germany). 18 The mean score of three trials was recorded. Measurement of static two-point discrimination was performed on the pulp of the three radial digits, and the mean was recorded. 17 Electrophysiologic investigation confirmed the diagnosis of CTS. All patients had sensory and motor nerve conduction studies of median and ulnar nerves according to standard techniques as described in our previous study. 19 Latency, conduction velocity, or amplitude of the responses were considered abnormal when it was 2.5 standard deviations above or below the normal values of our laboratory. The main electrophysiologic criteria for diagnosis of CTS were the slowing of sensory nerve conduction velocity of the median nerve in the palm-wrist segment or absence of sensory nerve action potential of the median nerve along with prolonged terminal motor latency. 20
Symptoms and functional status were evaluated by the Symptom Severity Scale and the Functional Status Scale, respectively. 1 The Symptom Severity Scale has 11 items concerning pain, nocturnal symptoms, numbness, tingling, and weakness. The Functional Status Scale has eight items (difficulty in writing, buttoning clothes, opening jars, holding a book, gripping of a telephone handle, household chores, carrying of grocery bags, bathing, and dressing). Each item of these scales has five ordinal response categories ranging from 1 (no symptoms or no difficulty) to 5 (very severe symptoms completely preventing the activity).
The patients were randomly divided into two groups. When the patients satisfied inclusion criteria, numbers were given to them. Group 1 consisted of the patients with odd numbers, and group 2 consisted of the patients with even numbers. If the patient had bilateral involvement, they were separately randomized by the same method. There were 14 patients in each group. A custom made neutral volar wrist splint was given to patients in both groups. The patients were instructed to wear the splints all night and during the day as much as possible for 4 wk. The patients in group 2 were also instructed to perform nerve and tendon gliding exercises developed by Totten and Hunter. 15 An exercise program was given by the same physiatrist, and a brochure describing exercises was also given to all patients in group 2. During tendon gliding exercises, the fingers were placed in five discrete positions. Those were straight, hook, fist, table top, and straight fist (Fig. 1). During the median nerve gliding exercise, the median nerve was mobilized by putting the hand and wrist in six different positions (Fig. 2). In position 3, the greatest excursion was achieved as the wrist extended. 21 During these exercises, the neck and the shoulder were in a neutral position, and the elbow was in supination and 90 degrees of flexion. Each position was maintained for 5 sec. The exercises were applied as five sessions daily. Each exercise was repeated 10 times at each session. Exercise treatment was continued for 4 wk. Physical examination and functional status evaluations were performed before treatment began and 8 wk after the end of the treatment. At the final follow-up, the patients were called by telephone, and their satisfaction was evaluated. Results were considered excellent if a patient was completely asymptomatic, good if a patient had occasional symptoms, fair if a patient had frequent symptoms but still obtained some improvement, and poor if a patient had continuous symptoms that did not respond to the treatment program. Patient satisfaction investigation was performed at an average of 8.3 ± 2.5 mo, ranging from 5 to 11 mo. The mean and standard deviation of each parameter for all patients were obtained. Group 1 and 2 data were compared by using a Mann-Whitney U test. Dichotomous variables (Phalen’s and Tinel’s signs) were tested with Fisher’s exact test. Wilcoxon and McNemar tests were used to compare the parameters of the two groups before and after treatment, and P < 0.05 was considered statistically significant. The level of patient satisfaction after treatment was categorized into two groups (excellent/good and fair/poor) and was evaluated with Fisher’s exact test.
Demographic characteristics and clinical features of both groups before the treatment are shown in Table 1. There was no significant difference between the groups in all of the parameters. Eight of 28 patients had bilateral symptoms, four in group 1 and four in group 2.
At the examination performed after 8 wk of the treatment, there was statistically significant improvement in all parameters in both groups, except for the two-point discrimination in group 1 (Table 2). The improvement in group 2 was slightly greater than group 1, but this difference was not statistically significant, except for pinch strength value. Pinch strength evaluation was significantly better in group 2 (P = 0.026).
The patient satisfaction questionnaire results are shown in Table 3. The results of group 2 were better than those of group 1, but the difference was not significant (P = 0.088).
Patient work status is shown in Table 1. A total of 14 patients (77%) in group 1 and 15 patients (83%) in group 2 were retired or homemakers. After the treatment, all the patients returned to their previous work activities.
Several studies have been published concerning the conservative treatment of CTS. Some authors suggested that patients with CTS could be successfully treated without surgery. 3,6,16 However, there are some studies reporting the conservative treatment of CTS as ineffective. 2,5,22–24 A population-based study of CTS showed that approximately 40% of conservatively treated patients with CTS continued to experience symptoms after 30 mo. 23 In another study, 66% of conservatively treated patients remained symptomatic for 2 yr. 24 Katz et al. 2 reported that approximately 60–70% of conservatively managed patients remained symptomatic after 18 mo. However, these studies did not have a standardized, consistent, conservative treatment program. Additionally, none of them has investigated the effects of exercise treatment. Kaplan et al. 22 identified five factors in predicting the outcome of medical management of CTS. These factors are an age over 50 yr, duration of symptoms over 10 mo, constant paraesthesia, stenosing flexor tenosynovitis, and a positive Phalen’s test in less than 30 sec. Although our patients’ mean age was over 50 yr and the duration of symptoms was over 10 mo, none of them had flexor tenosynovitis or a positive Phalen’s test in less than 30 sec. The other possible reason for the successful results obtained in our study could be the absence of thenar atrophy in the patients.
Among the conservative treatments of CTS, splinting is the most popular method. 2–6,22,23 The rationale for this comes from the finding that elevated pressure in carpal tunnel is an important factor in the pathophysiology of CTS. 25 Immobilizing the wrist in a neutral position maximizes the available carpal tunnel space and minimizes compression. 3 There are many studies stressing the effectiveness of neutral-angle wrist splinting in CTS. 3,22,26 In this study, symptoms of the patients treated with splinting were relieved significantly after treatment. A total of 72.2% of the patients reported good or excellent results at the follow-up investigation, and only 27.8% of the patients remained symptomatic.
Of the many studies of conservative treatment of CTS, only one has used exercise treatment. 16 Similar to our study, they gave their patients nerve and tendon gliding exercises. They reported 70.2% good or excellent results in the patients performing the exercises, and only 3% of patients underwent surgery. Although they had a large number of patients and a long follow-up period, their control group’s treatment was not standardized.
Tendon and nerve gliding exercises may maximize the relative excursion of the median nerve in the carpal tunnel and the excursion of flexor tendons relative to one another. The pathophysiology of CTS is related to the duration and the magnitude of the increased pressure within the carpal tunnel. 27 During the activity, carpal tunnel pressure fluctuates. The median nerve is exposed to a higher pressure on average, but there are intervals during which the pressure is below average. 27 During the exercise, there may be redistribution of the point of maximal compression on the median nerve. This milking effect would promote venous return from the median nerve, thus decreasing the pressure inside the perinerium. 16 In our study, nerve and tendon gliding exercises together with splint treatment were given to patients.
In previous studies determining the effectiveness of conservative treatment of CTS, patient satisfaction and symptomatic relief achieved by treatment were considered as important outcome parameters. Functional assessment should also have been considered. The previous studies have failed to demonstrate the success of conservative treatment by functional assessment. In the present study, all of these outcome parameters were used.
The major limitation of our study is the design, having a rather a small number of patients. We also could not evaluate the electrophysiologic efficacy of our treatment methods. However, there are methodologic strengths of our study. These include the prospective, randomized design, the use of valid, standard measures, and the evaluation of the functional status of patients. The data of this study emphasize the efficacy of conservative treatment in CTS. Statistically significant improvement was obtained in the symptoms, signs, and functional status of the patients in both treatment groups. The improvement evaluated by the patient satisfaction questionnaire was continued at the follow-up, especially in the exercise treatment group. These findings suggest that a combination of splinting and exercise treatment is effective in CTS patients, without significant thenar atrophy. Although clinical and electrophysiologic efficacy of tendon and nerve gliding exercises in CTS need further investigation, they should be tried before a surgical procedure is performed.
We thank Prof. Oğuz Dicle for drawings.
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