Journal of Back and Musculoskeletal Rehabilitation 28 (2015) 221–228 221

DOI 10.3233/BMR-140507
IOS Press

Short-term effectiveness of short-wave

diathermy treatment on pain, clinical
symptoms, and hand function in patients with
mild or moderate idiopathic carpal tunnel
syndrome
Serap Incebiyika,b , Ahmet Boyacia,∗ and Ahmet Tutoglua
a
Department of Physical Medicine and Rehabilitation, Harran University Medical School, Sanliurfa, Turkey
b
Department of Physical Medicine and Rehabilitation, Sanliurfa State Hospital, Sanliurfa, Turkey

Abstract.
OBJECTIVE: We determined the effects of short-wave diathermy (SWD) treatment on mild and moderate idiopathic carpal
tunnel syndrome (CTS).
METHODS: This was a prospective, randomized, controlled, double-blind clinical trial. The study involved 58 wrists in 31
patients diagnosed clinically and electrophysiologically with mild and moderate CTS. They were assigned randomly to one of
two groups. Group 1 received a hot pack, SWD, and nerve and tendon gliding exercises and Group 2 received a hot pack, placebo
SWD, and nerve and tendon gliding exercises. The treatment was applied five times weekly for a total of 15 sessions. Patients
were evaluated using the Tinel test, Phalen test, carpal compression test, reverse Phalen test, carpal tunnel compression test,
Boston Carpal Tunnel Questionnaire (BCTQ) Symptom Severity Scale (SSS), Functional Status Scale (FSS), and a visual analog
scale (VAS). Clinical tests and scales were evaluated at the beginning and end of therapy.
RESULTS: In the SWD group, in the Tinel test, Phalen test, reverse Phalen test, carpal compression test, VAS, BCTQ-FSS, and
BCTQ-SSS, statistically significant improvements were detected (p < 0.001). In the placebo group, although improvements were
seen in all parameters, the results were not statistically significantly different (p > 0.05) from baseline. All parameters improved
significantly in the SWD group versus the controls (p < 0.05).
CONCLUSION: SWD provided short-term improvements in pain, clinical symptoms, and hand function in patients with mild
and moderate CTS.

Keywords: Carpal tunnel syndrome, short wave diathermy, tendon and nerve gliding exercise, hand function

1. Introduction are idiopathic but various etiologies of CTS, such as di-

Carpal tunnel syndrome (CTS) is the most fre-
quently seen entrapment neuropathy, with a prevalence
of 3.4% in females and 0.6% in males [1]. Most cases
∗ Corresponding author: Assistant Prof Ahmet Boyaci, Harran
University Medical School, Department of Physical Medicine and
Rehabilitation, Yenisehir Kampusu, 63100, Sanliurfa, Turkey. Tel.:
+90 414 3182348; Fax: +90 4143181185; E-mail: drboyaci@
hotmail.com.
abetes mellitus, rheumatoid arthritis, acromegaly, hy-
pothyroidism, pregnancy, and tenosynovitis, have been
reported [2]. The pathophysiology is characterized by
increased interstitial pressure in the carpal tunnel. Par-
ticularly at the level of the carpal ligament, compres-
sion of the median nerve results in reduced epineural
blood flow and development of median nerve damage,
associated with local ischemia [3].
Clinical symptoms of pain in the hand, forearm, el-
bow, and sometimes the shoulder, paresthesia or hy-

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222 S. Incebiyik et al. / Short-term effectiveness of SWD treatment in patients with mild or moderate idiopathic CTS
poesthesia in the area of median nerve innervation
of the hand, and weakness or atrophy in the abduc-
tor pollicis brevis (APB) and opponens pollicis (OP)
have been reported in CTS. The incapacity associated
with these symptoms results in reduced hand skills
and thus may lead to disability in daily activities [4].
A CTS diagnosis is made using anamnesis and clini-
cal symptoms together with the Tinel, Phalen, and re-
verse Phalen tests, and an abnormal nerve conduction
study [5].
The first stage of treatment for patients with mild-
to-moderate CTS includes standard conservative ther-
apies such as a resting wrist splint, local steroid injec-
tions, NSAID medications, physical therapy, diuretics,
vitamin B6, and activity modifications. However, the
effectiveness of these treatments is limited [6].
Recent studies have shown the efficacy of SWD in
the treatment of musculoskeletal system diseases [7–
9]. SWD is effective in reducing clinical symptoms
and enhancing function by producing heat in the deep
tissue by means of high-frequency waves, of 10–
100 MHz. The 27.12-MHz frequency is used most
commonly. There is a physiological response at a lo-
cal temperature of 40–45◦C. This treatment modality
provides pain relief by increasing endorphins or rais-
ing the pain threshold. Reduced muscle spindle and
gamma fiber activity leads to reduced muscle spasms,
and removing the adrenergic vasoconstrictor effect in-
creases blood flow, either passively or directly by caus-
ing vasodilatation [10]. Thus, the recovery or renewal
of damaged tissue is facilitated, and metabolic waste
is cleared from the tissue with increased oxygena-
tion [11]. By increasing the rate of metabolism, phago-
cytosis also increases, the renewal of damaged tissue is
accelerated, and the elasticity of connective tissues is
enhanced [11]. This study was based on the hypothesis
that SWD may be effective in the treatment of local is-
chemia, which is considered to be a significant mecha-
nism in the pathogenesis of CTS.
To our knowledge, this is the first reported study to
investigate the effects of SWD on mild and moderate
idiopathic CTS. The study was intended to assess the
short-term effectiveness of SWD in terms of pain, clin-
ical symptoms, and hand function in patients with mild
and moderate idiopathic CTS.
2. Methods
This was a prospective, randomized, placebo-contro-
lled, double-blind, clinical study. It involved patients
who presented at Harran University Medical Faculty
Research and Practice Hospital, Physical Medicine and
Rehabilitation Clinic, with complaints of numbness,
tingling, pain, and/or weakness in the hands and were
diagnosed with mild or moderate idiopathic CTS by
clinical and electrophysiological tests (median motor
distal latency greater than 4 ms or reduced sensory
nerve conduction velocity in the palm-wrist segment
less than 40 m/s) [12]. Patients were excluded if they
had neurological, rheumatological, endocrinological or
renal disease, CTS surgery, a history of forearm frac-
ture, steroid injection to the carpal tunnel within the
last 3 months, splint usage, a history of malignancy,
or findings of severe CTS in the electrophysiological
examination.
Approval for the study was granted by the Insti-
tutional Ethics Committee. Written informed consent
was obtained from all patients.
Patients were allocated randomly to two groups us-
ing the closed envelope method. Patients with bilateral
CTS were considered to be in the same group for both
hands, but each hand was evaluated separately. Treat-
ment was applied by the same therapist over 3 weeks,
5 days per week, for a total of 15 sessions. The SWD
device used in the treatment was the Curapulse 970
(Enraf-Nonius, Rotterdam, Netherland).
2.1. Evaluation
A visual analog scale (VAS) was used to evaluate
pain severity. Hand and finger pain of patients were
graded on a scale of 0–10, where 0 = no pain and 10 =
unbearable pain. To evaluate the severity of symptoms
and functional status, the Boston Carpal Tunnel Syn-
drome Questionnaire (BCTSQ), developed by Levine
et al. [13], was used. This questionnaire consists of
two sections: the symptom severity scale (SSS) with
11 questions and the functional status scale (FSS) with
eight questions. The study by Sezgin et al. [14] con-
firmed the validity and reliability of the BCTSQ in a
Turkish population. The clinical evaluation included
the Tinel test, Phalen test, reverse Phalen test, and
carpal compression test, and a manual evaluation of
APB muscle strength and a two-point discrimination
test. Static two-point discrimination of the index fin-
ger was tested by palpation and less than 6 mm was
deemed normal [15]. Two evaluations were performed,
prior to treatment and immediately following the end
of the 3-week treatment, by the same physician who
was blinded to the type of treatment.
 S. Incebiyik et al. / Short-term effectiveness of SWD treatment in patients with mild or moderate idiopathic CTS 223

Table 1
Baseline characteristics of the study population according to treatment allocation
Grp I Grp II p
(n = 15, 28 wrist) (n = 13, 24 wrist)
Age (years) 51 ± 10.07 44.92 ± 10.84 0.137
Mean symptoms duration (month) 10.03 ± 4.46 9.45 ± 4.05 0.630
Measured wrist circumference (cm) 17.17 ± 0.77 17.20 ± 0.72 0.887
BMI (kg/m2 ) 30.19 ± 4.89 30.17 ± 5.51 0.992
Gender (F/M) 15/0 13/0 1.000
Affected wrist 0.506
Right 1 2
Left 1 0
Both 13 11
Abductor 1st finger strength impairment 0 0 1.000
Impaired static two-point discrimination 0 0 1.000
Neurophysiological class 0.299
Mild 10 12
Moderate 18 12
Grp: Group, BMI: body mass index, F: female, M: male, n: count.

(a)

(b)

Fig. 1. (a). The five discrete positions in which fingers are placed in tendon gliding exercises: 1, straight; 2, hook; 3, fist; 4, tabletop; 5, straight fist.
(b). The median nerve gliding program: 1, wrist in neutral position, fingers and thumb in flexion; 2, wrist in neutral position, fingers and thumb
extended; 3, wrist and fingers extended, thumb in neutral position; 4, wrist, fingers, and thumb extended; 5, forearm in supination; 6, the opposite
hand applies a gentle stretch to the thumb. (Colours are visible in the online version of the article; http://dx.doi.org/10.3233/BMR-140507)

2.2. Intervention
For treatment, the hot pack was applied for 15 min
on the transverse carpal ligament in the patients in both
groups. Then, for patients in the SWD group, the 15-
min SWD treatment (f = 27.12 MHz) was applied
in continuous mode with 10-cm-diameter electrodes
placed parallel, 2.5–5 cm from the wrist, with the pa-
tient seated on a wooden chair with the elbow at 90◦
flexion and the wrist in a neutral position. The dosage
was adjusted to the level at which the patient felt a
comfortable heat. With the device switched off, 15-min
placebo SWD treatment was applied to the placebo
group patients in the same position. At the end of the
session, both groups were given three sets of 10 repe-
titions of nerve and tendon gliding exercises [16]. The
tendon gliding exercises were completed in five posi-
tions: straight finger, hook, fist, table form, and straight
224 S. Incebiyik et al. / Short-term effectiveness of SWD treatment in patients with mild or moderate idiopathic CTS

Table 2
Comparison of the pre-treatment and the post-treatment clinical characteristics of the groups and inter-group treatment efficacy
Variables Grp I Grp II P
(n = 15, 28 wrist) (n = 13, 24 wrist)
Tinel test Pre-treat 22/6 21/3 0.480
(positive/negative) Post-treat 7/21 19/5 < 0.001
P < 0.001 0.500
Phalen test Pre-treat 25/3 21/3 1.000
(positive/negative) Post-treat 5/23 20/4 < 0.001
P < 0.001 1.000
Reverse phalen test Pre-treat 25/3 21/3 1.000
(positive/negative) Post-treat 3/25 20/4 < 0.001
P < 0.001 1.000
Carpal compression test Pre-treat 25/3 22/2 1.000
(positive/negative) Post-treat 10/18 21/3 < 0.001
P <0.001 1.000
VAS Pre-treat 5.50 ± 2.53 4.83 ± 2.76 0.368
Post-treat 2.32 ± 1.80 4.20 ± 2.53 0.003
P < 0.001 1.105
Levine–Boston SSS Pre-treat 30.78 ± 7.92 29.25 ± 11.41 0.571
Post-treat 18.53 ± 9.09 27.62 ± 10.63 0.002
P < 0.001 0.234
Levine–Boston FSS Pre-treat 22.42 ± 7.77 23.00 ± 7.11 0.785
Post-treat 13.25 ± 5.36 21.62 ± 6.76 < 0.001
P < 0.001 0.204
FSS: Functional Status Scale, Grp: Group, n: count, Pre-treat: Pre-treatment, Post-treat: Post-treatment, SSS: Symptom Severity Scale, VAS:
visual analog scale.

Fig. 2. Flow diagram of the study.

 S. Incebiyik et al. / Short-term effectiveness of SWD treatment in patients with mild or moderate idiopathic CTS 225

fist (Fig. 1A). Nerve gliding exercises provided median

nerve mobilization through six different positions of
the hand and wrist (Fig. 1B).

2.3. Statistical analyses

The SPSS software was used for statistical analy-

ses (ver. 18.0 for Windows; SPSS Inc. Chicago, IL,
USA). Pre- and post-treatment data for both groups
were compared between and within groups. The in-
dependent t-test was used to compare data between
groups; the paired-sample test was used within groups.
The χ2 test was used in comparing categorical data
between groups, while the McNemar test was used to
compare related categorical data within groups. In all
statistical analyses, a value of p < 0.05 was considered
to indicate statistical significance. All data are given as
means ± standard deviations or percentages.

3. Results
In this study, we evaluated the effectiveness of SWD
in 58 wrists of 31 patients (all females). The SWD
group consisted of 15 patients (28 wrists, 13 bilateral)
while the control group consisted of 16 patients (30
wrists, 14 bilateral). Three patients (6 wrists) withdrew
from the study in the control group, thus leaving a total
of 52 wrists (24 bilateral) of 28 patients for evaluation
(Fig. 2).
Baseline values for the study group are shown in Ta-
ble 1. No difference was observed between the groups
with respect to age, mean duration of symptoms, wrist
circumference measurements, body mass index, gen-
der, affected wrist, or neurophysiological classifica-
tion. In the clinical evaluation, there was no sensory
and motor impairment in any patient.
Prior to treatment, there was no difference between
the groups in Tinel positivity, Phalen positivity, reverse
Phalen positivity, carpal compression positivity, VAS,
BCTSQ-SSS, or BCTSQFSS (p > 0.05; Table 2). At
the end of treatment, in the SWD group, a signifi-
cant difference was observed in Tinel positivity, Phalen
positivity, reverse Phalen positivity, carpal compres-
sion positivity, VAS, BCTSQ-SSS, and BCTSQ-FSS
(p < 0.001; Table 2). At the end of the treatment, in
the placebo group, no significant difference was ob-
served in Tinel positivity, Phalen positivity, reverse
Phalen positivity, carpal compression positivity, VAS,
BCTSQ-SSS, or BCTSQ-FSS (p > 0.05; Table 2).
Fig. 3. VAS before treatment (T 0) and after treatment (T 1). *VAS
visual analog scale. (Colours are visible in the online version of the
article; http://dx.doi.org/10.3233/BMR-140507)
In the post-treatment comparison of groups, statis-
tically significant differences were identified in Tinel
positivity, Phalen positivity, reverse Phalen positivity,
carpal compression positivity, VAS, BCTSQ-SSS, and
BCTSQ-FSS parameters in the SWD group versus the
placebo group (p < 0.05; Table 2).
4. Discussion
In this study, we examined the short-term effects of
SWD treatment for 3 weeks on pain, clinical symp-
toms, and hand function in patients with mild and
moderate CTS. While significant improvements were
identified in pain, clinical symptoms and hand func-
tions of the SWD group following treatment, no sig-
nificant improvement was seen in the placebo group.
Compared with the placebo group, statistically signif-
icant improvements were found in the SWD group in
all parameters. These results showed the efficacy of
SWD treatment in terms of pain, clinical symptoms,
and hand function in the SWD study group.
In this study, hot pack treatment and tendon and
nerve gliding exercises were applied to both groups.
Tendon and nerve gliding exercises are often applied
together with conservative treatments [17] to reduce
226 S. Incebiyik et al. / Short-term effectiveness of SWD treatment in patients with mild or moderate idiopathic CTS

(a) (b)

Fig. 4. BCTSQ-SSS before treatment (T0) and after treatment (T1). b. BCTSQ-FSS before treatment (T 0) and after treatment (T 1). *BCT-
SQ-SSS Boston Carpal Tunnel Syndrome Questionnaire – Symptom Severity Scale; BCTSQ-FSS Boston Carpal Tunnel Syndrome Question-
naire – Functional Status Scale. (Colours are visible in the online version of the article; http://dx.doi.org/10.3233/BMR-140507)

pressure on adhesions and tendons. Due to the increase
in intraneural blood flow, inflammatory products are
discarded and positive therapeutic effects are seen in
edema control [18]. The efficacy of tendon and nerve
gliding exercises in CTS treatment has been shown in
several clinical studies [17,19,20], although other stud-
ies have reported no evidence of the efficacy of such
exercises [21,22]. In the current study, although there
was an improvement in all parameters in the placebo
group, in which the hot pack and exercises were used,
no statistically significant difference versus baseline
was found.
Although several conservative treatment modalities
are routinely used in the treatment of CTS, no con-
sensus on a treatment protocol has yet been reached.
In a recent review of CTS treatment, it was reported
that there was moderate evidence for the effectiveness
of splint usage and limited or conflicting evidence of
the effectiveness of yoga, lasers, and therapeutic ultra-
sound [6]. Several studies have reported the efficacy of
therapeutic ultrasound and/or low-level laser therapy
(LLLT) treatments in CTS [23–28].
The efficacy of SWD is associated with the physio-
logical effects created in the deep tissue by electromag-
netic waves at 27.12 MHz. It may be applied in contin-
uous or intermittent mode. In continuous SWD treat-
ment, it is accepted that the major physiological effect
is related to the increase in heat in the tissue. This ef-
fect increases vasodilatation, raises the pain threshold,
reduces muscle spasms, and increases local blood flow,
cellular activity, and soft tissue elasticity [10]. Statisti-
cally significant improvements in the Tinel, Phalen, re-
verse Phalen, carpal compression tests, VAS, BCTSQ-
SSS, and BCTSQ-FSS scores were identified in the
SWD group in the present study. This might have been
due to the positive effect of SWD treatment on local
ischemia, which plays an important role in the patho-
genesis of CTS.
SWD has been suggested to be useful in various
musculoskeletal disorders, although there are conflict-
ing findings regarding its efficacy [7–9,29–31]. SWD
was reported to be effective for the treatment of pa-
tients with chronic low back pain [8]. In knee os-
teoarthritis, pain reduction and improvement in func-
tion with SWD [9] and enhanced isokinetic exercise
performance, reduced pain, and improved function
with pre-exercise physical agent use including SWD
in females [7] were reported, in contrast to Akyol et
al. [29], who reported no significant difference be-
tween the treatment group (SWD + exercise) and the
control group (exercise alone) with respect to treatment
efficacy. Rattanachaiyanont et al. [30] also reported no
significant difference in function or pain levels with
SWD.
This study had several limitations, including the
short duration and limited sample size. However, its
 S. Incebiyik et al. / Short-term effectiveness of SWD treatment in patients with mild or moderate idiopathic CTS
strengths lie in the use of standard measurement tech-
niques, which were applied prospectively, the double-
blind nature of the assessment with placebo-controlled
randomization, and meticulous patient selection based
on well-defined diagnostic and exclusion criteria.
In conclusion, this study showed the efficacy of
SWD in the treatment of mild and moderate CTS. It is
recommended that further studies on a larger scale be
conducted to assess the role of conservative treatment,
single or combined treatment modalities, and possi-
bly early surgical decompression in CTS, especially in
cases associated with neurological deficits.
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