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[ research report ]

CÉSAR FERNÁNDEZ-DE-LAS-PEÑAS, PT, PhD, DMSc1 • JOSHUA CLELAND, PT, PhD, OCS, FAAOMPT2-4 • MARÍA PALACIOS-CEÑA, PT1
STELLA FUENSALIDA-NOVO, PT1 • JUAN A. PAREJA, MD, PhD5 • CRISTINA ALONSO-BLANCO, PT, PhD1

The Effectiveness of Manual Therapy


Versus Surgery on Self-reported Function,
Cervical Range of Motion, and Pinch Grip
Force in Carpal Tunnel Syndrome:
A Randomized Clinical Trial

TTSTUDY DESIGN: Randomized parallel-group


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1 month for self-reported function (mean change,


trial. –0.8; 95% confidence interval [CI]: –1.1, –0.5)
TTBACKGROUND: Carpal tunnel syndrome (CTS) and pinch-tip grip force on the symptomatic side
is a common pain condition that can be managed (thumb-index finger: mean change, 2.0; 95% CI:
surgically or conservatively. 1.1, 2.9 and thumb-little finger: mean change, 1.0;

C
95% CI: 0.5, 1.5). Improvements in self-reported
TTOBJECTIVE: To compare the effectiveness of function and pinch grip force were similar between arpal tunnel syndrome
manual therapy versus surgery for improving self-
reported function, cervical range of motion, and
the groups at 3, 6, and 12 months. Both groups (CTS), a pain condition
reported improvements in symptom severity that
pinch-tip grip force in women with CTS. were not significantly different at all follow-up associated with repetitive
TTMETHODS: In this randomized clinical trial, 100 periods. No significant changes were observed in movements, accounts for
women with CTS were randomly allocated to either pinch-tip grip force on the less symptomatic side nearly 50% of all work-related
J Orthop Sports Phys Ther 2017.47:151-161.

a manual therapy (n = 50) or a surgery (n = 50) and in cervical range of motion in either group.
injuries.31 The prevalence of CTS
group. The primary outcome was self-rated hand
TTCONCLUSION: Manual therapy and surgery had
function, assessed with the Boston Carpal Tunnel in the general population has been re-
similar effectiveness for improving self-reported
Questionnaire. Secondary outcomes included
function, symptom severity, and pinch-tip grip ported to range between 6% and 12%.32
active cervical range of motion, pinch-tip grip
force on the symptomatic hand in women with Individuals diagnosed with CTS have
force, and the symptom severity subscale of the
CTS. Neither manual therapy nor surgery resulted been identified as significantly more
Boston Carpal Tunnel Questionnaire. Patients were
in changes in cervical range of motion.
assessed at baseline and 1, 3, 6, and 12 months likely to miss more work days than
after the last treatment by an assessor unaware TTLEVEL OF EVIDENCE: Therapy, level 1b. Pro- a­symptomatic individuals, which results
of group assignment. Analysis was by intention to spectively registered September 3, 2014 at www.
in a massive economic burden to the in-
treat, with mixed analyses of covariance adjusted clinicaltrials.gov (NCT02233660). J Orthop Sports
Phys Ther 2017;47(3):151-161. Epub 3 Feb 2017.
dividual and society.2
for baseline scores.
The management of CTS can be either
TTRESULTS: At 12 months, 94 women completed
doi:10.2519/jospt.2017.7090
TTKEY WORDS: carpal tunnel syndrome, cervical
conservative or surgical. Conservative
the follow-up. Analyses showed statistically sig-
nificant differences in favor of manual therapy at spine, force, manual therapy, neck, surgery management is often chosen as the first
approach when symptoms are mild or

1
Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Spain. 2Department of Physical Therapy,
Franklin Pierce University, Manchester, NH. 3Rehabilitation Services, Concord Hospital, Concord, NH. 4Manual Therapy Fellowship Program, Regis University, Denver, CO.
5
Department of Neurology and Neurophysiology, Hospital Universitario Fundación Alcorcón, Madrid, Spain. The local human research committee (HUFA PI-12/0023) approved
the study project. The study was funded by a research project grant (FIS PI14/ 00364) from the Health Institute Carlos III (PN I+D+I 2014-2017; Spanish Government). The study
was prospectively registered September 3, 2014 at www.clinicaltrials.gov (NCT02233660). The authors certify that they have no affiliations with or financial involvement in any
organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Dr César Fernández de las Peñas,
Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Avenida de Atenas s/n, 28922 Alcorcón, Madrid, Spain. E-mail: cesar.fernandez@urjc.es t Copyright ©2017
Journal of Orthopaedic & Sports Physical Therapy®

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[ research report ]
for CTS, with surgical treatment appear-
Baseline Characteristics ing to be only slightly superior for im-
TABLE 1
of Participants by Group* proving pain and self-reported function
compared to conservative treatment at 6
Manual Therapy (n = 50) Surgery (n = 50) and 12 months.30 Nevertheless, the vast
Age, y 46 ± 9 47 ± 8 majority of patients with CTS attempt to
Years with pain 2.8 ± 1.6 3.1 ± 1.8 avoid surgery.18
Occupation, n (%) Previous studies comparing the use of
Work at home 20 (40) 22 (44) physical therapy and surgical interven-
Secretary/office 30 (60) 28 (56) tions for the management of CTS have
Unilateral/bilateral arm distribution, n (%) applied localized treatments (ultrasound,
Unilateral symptoms: right side 8 (16) 9 (18) splinting, laser, or exercises) mainly fo-
Unilateral symptoms: left side 3 (6) 3 (6) cused on the hand. Although CTS is
Bilateral symptoms 39 (78) 38 (76) primarily considered a local peripheral
Severity, n (%) neuropathy, recent evidence suggests that
Minimal CTS 12 (24) 10 (20) CTS represents a complex pain syndrome
Moderate CTS 19 (38) 23 (46) that includes sensitization of the central
Severe CTS 19 (38) 16 (32) nervous system, and that physical therapy
Boston Carpal Tunnel Questionnaire should consider a comprehensive nocicep-
Functional status subscale (1-5) 2.1 ± 0.5 2.2 ± 0.5 tive pain rationale for the management of
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Symptom severity subscale (1-5) 2.5 ± 0.7 2.6 ± 0.6 this condition.9 A recent randomized clin-
Cervical range of motion, deg ical trial compared the effects of physical
Flexion 49 ± 8 48 ± 7 therapy, consisting of manual therapies
Extension 57 ± 10 57 ± 8 that included desensitization maneuvers
Lateral flexion toward the side of CTS 39 ± 6 40 ± 7 of the central nervous system, with those
Lateral flexion away from the side of CTS 40 ± 6 40 ± 7 of surgery on pain and self-reported func-
Rotation toward the side of CTS 71 ± 10 70 ± 9 tion in CTS.12 The results were significant-
Rotation away from the side of CTS 69 ± 11 71 ± 7 ly in favor of the manual therapy group
Pinch-tip grip force, lb for pain and function at 1 and 3 months;
Thumb-index finger: (more) symptomatic side 4.3 ± 2.2 4.1 ± 2.3 however, no between-group differences
J Orthop Sports Phys Ther 2017.47:151-161.

Thumb-little finger: (more) symptomatic side 1.2 ± 0.7 1.1 ± 0.6 for pain and self-reported function at 6
Thumb-index finger: less (non)symptomatic side 4.4 ± 1.7 4.2 ± 1.6 and 12 months were observed.
Thumb-little finger: less (non)symptomatic side 1.1 ± 0.7 1.1 ± 0.6 The aforementioned trial did not
Abbreviation: CTS, carpal tunnel syndrome. report on measures of physical impair-
*Values are mean ± SD unless otherwise indicated.
ments, despite the fact that it has been
shown that individuals with CTS exhibit
surgery is contraindicated. When symp- this disorder.25 This may be the reason reduced cervical range of motion6,7 and
toms are severe, surgery is often chosen why a recent Delphi study, including decreased pinch grip strength.8,13 In fact,
as the first line of defense.4 Conservative experts, developed a multidisciplinary it has been demonstrated that disability
interventions can include splinting, cor- guideline for the management of CTS and self-reported function are associated
ticosteroid injections, and physical ther- that did not include physical therapy in- with pain, reduced pinch-tip grip force
apy. Though recent Cochrane Reviews tervention, with the exception of exercise between the thumb and little finger, and
have found that splinting and injections postsurgery.16 cervical lateral flexion away from the
may be beneficial in the short term, this While surgery continues to be a com- symptomatic side.11 However, it is not
effect has not been found at long-term monly used intervention, there is much known whether patients with CTS who
follow-ups.23,24 Physical therapy is a com- debate surrounding its efficacy, as more receive either manual therapy or surgery
monly utilized management strategy for than one third of individuals do not re- will exhibit superior outcomes in terms of
people with CTS; however, the most cur- turn to work within 8 weeks after surgi- cervical range of motion and grip strength
rent Cochrane systematic review found cal intervention.26 The most up-to-date associated with changes in self-reported
that there was limited and very low–qual- review analyzing conservative versus function. Therefore, the purpose of our
ity evidence of benefit to support exercise surgical management in CTS showed that randomized clinical trial was to compare
and mobilization for the management of both interventions may achieve benefits the effectiveness of manual therapy ver-

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sus surgery for improving cervical range ulnar or radial nerve; (2) age greater than Treatment Allocation
of motion, pinch grip strength, symptom 65 years; (3) previous surgery or steroid Patients were randomly assigned to re-
severity, and self-reported function in injections; (4) multiple diagnoses on the ceive manual therapy or surgery. Con-
women with CTS. A secondary objec- upper extremity (eg, coexisting cervical cealed allocation was conducted using a
tive was to determine whether changes radiculopathy); (5) cervical, shoulder, or computer-generated randomized table
in cervical range of motion or pinch grip hand trauma; (6) systemic disease caus- of numbers created prior to the start of
strength were associated with changes in ing CTS (eg, diabetes mellitus, thyroid the data collection by a researcher not
self-reported function. We hypothesized disease); (7) comorbid musculoskeletal involved in subject recruitment. Indi-
that women receiving manual therapy medical conditions (eg, rheumatoid ar- vidual and sequentially numbered index
would exhibit better outcomes in cervical thritis or fibromyalgia); (8) pregnancy; cards with the random assignment were
range of motion, pinch grip strength, and or (9) male sex. All subjects signed an prepared, folded, and placed in sealed
symptom severity, but similar outcomes informed-consent form prior to inclu- opaque envelopes. Another researcher
in self-reported function, than those re- sion in the study. The local human re- opened the envelope and hence proceed-
ceiving surgery. search committee (HUFA PI-12/0023) ed with treatment according to group
approved the study project. assignment. We blinded clinicians who
METHODS
Participants Patients with carpal tunnel

T
syndrome screened for Excluded, n = 40
his study was a single-blind, eligibility criteria, n = 140 • Previous surgery, n = 20
randomized clinical trial (regis- • Pregnancy, n = 8
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tered at www.clinicaltrials.gov on • Previous steroid


September 3, 2014: NCT02233660). injections, n = 6
Baseline measurements,
• Previous whiplash, n = 6
Consecutive women with clinical and n = 100
electrophysiological findings of CTS were • BCTQ, cervical range of
motion, pinch-tip grip
screened from a local regional hospital
force
(Madrid, Spain) for eligibility. To be eli-
gible, individuals had to meet the follow-
ing criteria: pain and paresthesia in the Randomized, n = 100
median nerve distribution, positive Tinel
sign, and positive Phalen sign. Symp-
J Orthop Sports Phys Ther 2017.47:151-161.

toms had to have persisted for at least 12


months. Further, the electrodiagnostic Allocated to manual therapy, Allocated to surgery, n = 50
examination had to reveal deficits of sen- n = 50
sory and motor median nerve conduction
(ie, median nerve sensory conduction ve-
locity less than 40 m/s and median nerve 1-mo follow-up, n = 50 1-mo follow-up, n = 50
distal motor latency greater than 4.20
milliseconds), according to guidelines of
the American Association of Electrodi- 3-mo follow-up, n = 50 3-mo follow-up, n = 50
agnostic Medicine, American Academy
of Neurology, and American Academy of
6-mo follow-up, n = 49 6-mo follow-up, n = 50
Physical Medicine and Rehabilitation.17
• 1 lost to follow-up: surgery
Severity of CTS was classified as follows: in the study hand
minimal (abnormal segmental-compara-
tive tests only), moderate (abnormal me-
dian nerve sensory velocity conduction 12-mo follow-up, n = 47 12-mo follow-up, n = 47
and distal motor latency), or severe (ab- • 2 lost to follow-up: surgery • 3 lost to follow-up:
sence of median nerve sensory response in the hand corticoid injection
in the hand
and abnormal distal motor latency).17
Participants were excluded if they ex-
hibited any of the following: (1) any sen- FIGURE 1. Flow diagram of patients throughout the course of the study. Abbreviation: BCTQ, Boston Carpal Tunnel
Questionnaire.
sory and/or motor deficit in either the

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[ research report ]
obtained follow-up information to group received the educational session for per- severity subscale have been reported.19
allocation. forming the same cervical spine exercise In the current trial, the BCTQ functional
program as the physical therapy group. status subscale was the main outcome, on
Interventions which a reduction of 0.7 or more points
All treatments were applied by physical Outcomes or a 30% improvement from baseline was
manual therapists with more than 10 Clinical records of all participants in- considered to be a successful outcome in
years of experience in manual therapy ap- cluded questions regarding the location self-reported function.
proaches. Patients allocated to the man- of the symptoms, aggravating and reliev- Secondary outcomes of the current
ual therapy group received 3 treatment ing factors, intensity, duration, and previ- study included the BCTQ symptom se-
sessions of manual therapies, including ous treatments. verity subscale, cervical range of motion,
maneuvers targeted to the cervical spine Outcomes were assessed at baseline and pinch-tip grip force. Cervical range
and to those areas anatomically related to and 1, 3, 6, and 12 months after the end of motion was measured with the CROM
potential entrapment of the median nerve of therapy. Our primary outcome con- device (Performance Attainment Associ-
(ie, shoulder, elbow, forearm, wrist, and sisted of changes at the 12-month fol- ates, Lindstrom, MN), following previous
fingers), of 30 minutes’ duration, once low-up in self-reported function, which guidelines.6,7 Cervical range of motion was
per week. The interventions applied to was measured with the functional status recorded in flexion, extension, lateral flex-
the neck consisted of lateral glides applied subscale of the Boston Carpal Tunnel ion toward or away from the symptomatic
to the cervical spine and posteroante- Questionnaire (BCTQ).22,27 This ques- side, and rotation toward or away from
rior pressure directed to the mid cervical tionnaire evaluates 2 domains: (1) func- the symptomatic side. For women with
spine. In addition, soft tissue interven- tional status on a subscale that assesses unilateral symptoms, sides were classified
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tions targeting the scalene muscles, cos- performance of 8 common hand-related as affected/unaffected, whereas in those
toclavicle space, pectoralis minor, biceps tasks and (2) symptom severity on a sub- with bilateral symptoms, the most pain-
brachii muscle, bicipital aponeurosis, pro- scale9 that assesses pain severity, numb- ful side was considered as the affected
nator teres, transverse carpal ligament, ness, and weakness at night and during side and the less painful side as the unaf-
palmar aponeurosis, and lumbrical mus- the day. Items of the BCTQ are answered fected side. The mean of 2 measurements
cles were also applied. These techniques on a 5-point scale, ranging from 1 (no for each motion was used in the analysis.
are described in detail in APPENDIX A (avail- complaint) to 5 (severe complaint), with For CROM measurements, previous stud-
able at www.jospt.org). Finally, patients a total score on each subscale ranging ies have reported an intratester reliability
performed a cervical spine exercise pro- from 1 to 5, where higher scores indicate of 0.87 to 0.96, a standard error of mea-
gram for stretching neck muscles. Specific worse self-reported function and greater surement of 2.3° to 4.1°, and a minimal
J Orthop Sports Phys Ther 2017.47:151-161.

details regarding cervical spine stretching symptom severity. The BCTQ has been detectable change (MDC) across the 6
exercises are provided in APPENDIX B (avail- shown to be valid, reliable, and respon- movements ranging from 3.6° to 6.5°.3,14
able at www.jospt.org). The third and last sive in individuals with CTS.21 Minimal Pinch-tip grip force between the
treatment appointment included an edu- clinically important differences (MCIDs) thumb and index finger or the thumb and
cational session on how to perform the of 0.74 points in the functional status little finger was measured (in pounds)
cervical exercises as homework during subscale and 1.14 points in the symptom with a pinch-grip dynamometer (Psympt-
the follow-up period, as needed. Patients
were encouraged to not modify any work 5 5
BCTQ Symptom Severity Score
BCTQ Functional Status Score

or activity levels and only perform the cer- 3 3


vical spine exercises if they experienced
increases in their symptoms during the
follow-up period. 2 2
*
Patients randomly allocated to the
surgery group received endoscopic de-
compression and release of the carpal 1 1
tunnel. For pragmatic reasons and be- Preinter- 1 mo 3 mo 6 mo 1y Preinter- 1 mo 3 mo 6 mo 1y
vention vention
cause no evidence supports any surgical
procedure, surgery was based on each Manual therapy Surgery
surgeon’s and patient’s preference.28 All
surgeons were experienced, with at least FIGURE 2. Evolution of the primary outcome throughout the course of the study, stratified by randomized
15 years of practice focusing on hand sur- treatment assignment. Values are mean and 95% confidence interval. *Statistically significant difference between
gery. Patients allocated to this group also manual therapy and surgery (P<.001). Abbreviation: BCTQ, Boston Carpal Tunnel Questionnaire.

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ec; Spain), with its digital display visible were based on pilot data to detect treat- dence intervals (CIs) were calculated for
to participants to provide feedback. The ment differences of 0.8 units on the main each variable. The Kolmogorov-Smirnov
pinch tip was performed with the thumb outcome,19 assuming a standard deviation test revealed a normal distribution of all
below and either the index or little finger of 1.0, a 2-tailed test, an alpha level of .05, the quantitative data (P>.05). A 5-by-2
on top, following previous guidelines.8,13 and a desired power (beta) of 90%. The repeated-measures analysis of covari-
The mean of 3 trials with each finger estimated desired sample size was calcu- ance, with time (baseline and 1, 3, 6, and
was calculated and used for the analysis, lated to be at least 39 subjects per group. 12 months) as the within-subjects factor
with a 10-second rest between each trial. A dropout rate of 15% was expected, so and group (manual therapy and surgery)
Schreuders et al29 reported an excellent 50 patients were included in each group. as the between-subjects factor and ad-
interexaminer reliability for pinch-tip justed for baseline outcomes, was used to
grip assessment, with intraclass corre- Statistical Analysis determine the effects of the intervention
lation coefficients ranging from 0.82 to Statistical analysis was performed using in all outcomes. The main hypothesis of
0.93. The standard error for pinch-tip SPSS Version 20.0 (IBM Corporation, interest was the group-by-time interac-
grip measurement has been reported to Armonk, NY) and conducted according tion. Chi-square tests were used to com-
be 0.36 kg, and the MDC has been re- to intention-to-treat analysis for patients pare success rates at 6 and 12 months in
ported to be 1.01 kg.29 in the group to which they were allocated. both groups. To allow for comparison
When any data were missing, the multi- of significant effect sizes, standardized
Sample-Size Determination ple-imputation method was used. Means, mean differences (SMDs) were calculat-
Calculations to determine sample size standard deviations, and/or 95% confi- ed by dividing the mean score differences
between groups by the pooled standard
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A B deviation of the change scores. Finally, a


linear regression analysis was conducted
Pinch-Tip Grip Force: Thumb-Index Finger, lb

Pinch-Tip Grip Force: Thumb-Little Finger, lb

6 6 to determine the association between the


5 5 changes in the outcomes during the trial.
*
4 4 RESULTS
3 3

B
etween September 2014 and Feb-
2 2
ruary 2015, 140 consecutive patients
1 1 * with CTS were screened for eligibil-
J Orthop Sports Phys Ther 2017.47:151-161.

ity to participate. One hundred (71%)


0 0
satisfied all the eligibility criteria, agreed
Preinter- 1 mo 3 mo 6 mo 1y Preinter- 1 mo 3 mo 6 mo 1y to participate, and were randomly allo-
vention vention
C D cated into the manual therapy (n = 50)
or the surgical (n = 50) group. Random-
Pinch-Tip Grip Force: Thumb-Index Finger, lb

Pinch-Tip Grip Force: Thumb-Little Finger, lb

6 6 ization resulted in similar baseline char-


5 5 acteristics for all variables (TABLE 1). In
the group that received manual therapy,
4 4 1 patient at 6 months and 2 patients at
3 3 12 months were lost to follow-up because
they received surgery. Similarly, 3 pa-
2 2
tients allocated to the surgical group were
1 1 lost at the 1-year follow-up because they
received corticosteroid injection in the
0 0
hand. None of the participants in either
Preinter- 1 mo 3 mo 6 mo 1y Preinter- 1 mo 3 mo 6 mo 1y group reported having received other
vention vention
interventions during the study, exclud-
Manual therapy Surgery ing the occasional use of nonsteroidal
anti-inflammatory drugs. No clinically
FIGURE 3. Evolution of pinch-tip grip force (symptomatic side, A and B; less symptomatic side, C and D) important adverse events and no surgi-
throughout the course of the study, stratified by randomized treatment assignment. Values are mean and 95% cal complications were reported during
confidence interval. *Statistically significant difference between manual therapy and surgery (P<.01). the trial. The reasons for ineligibility can

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[ research report ]

Function and Pinch-Tip Grip Force Outcomes by Group
TABLE 2
and Within-Group and Between-Group Change Scores*

Outcome/Time Manual Therapy Surgery Between-Group Change Score


BCTQ functional status subscale (1-5)
Baseline 2.1 ± 0.5 (2.0, 2.3) 2.2 ± 0.5 (2.1, 2.3)
1 mo 1.6 ± 0.6 (1.4, 1.8) 2.3 ± 0.7 (2.2, 2.5)
Within-group change: baseline to 1 mo –0.5 (–0.6, –0.4) 0.1 (–0.1, 0.3) 0.6 (0.45, 0.75)†
3 mo 1.6 ± 0.7 (1.4, 1.9) 1.7 ± 0.7 (1.5, 1.9)
Within-group change: baseline to 3 mo –0.5 (–0.7, –0.3) –0.5 (–0.7, –0.3) 0.0 (–0.5, 0.5)
6 mo 1.6 ± 0.5 (1.4, 1.8) 1.6 ± 0.6 (1.4, 1.8)
Within-group change: baseline to 6 mo –0.5 (–0.65, –0.35) –0.6 (–0.8, –0.4) –0.1 (–0.2, 0.0)
12 mo 1.6 ± 0.6 (1.4, 1.7) 1.5 ± 0.6 (1.3, 1.8)
Within-group change: baseline to 12 mo –0.5 (–0.6, –0.4) –0.7 (–0.9, –0.5) –0.2 (–0.3, –0.1)
BCTQ symptom severity subscale (1-5)
Baseline 2.5 ± 0.7 (2.3, 2.7) 2.6 ± 0.6 (2.4, 2.8)
1 mo 1.7 ± 0.6 (1.5, 1.9) 1.7 ± 0.5 (1.6, 1.9)
Within-group change: baseline to 1 mo –0.8 (–1.0, –0.6) –0.9 (–1.2, –0.6) –0.1 (–0.2, 0.0)
3 mo 1.7 ± 0.7 (1.6, 1.9) 1.5 ± 0.5 (1.3, 1.7)
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Within-group change: baseline to 3 mo –0.8 (–1.05, –0.55) –1.1 (–1.3, –0.9) –0.3 (–0.4, –0.2)
6 mo 1.6 ± 0.6 (1.5, 1.7) 1.4 ± 0.5 (1.2, 1.6)
Within-group change: baseline to 6 mo –0.9 (–1.1, –0.7) –1.2 (–1.5, –0.9) –0.3 (–0.5, –0.1)
12 mo 1.6 ± 0.6 (1.5, 1.7) 1.4 ± 0.5 (1.25, 1.55)
Within-group change: baseline to 12 mo –0.9 (–1.2, –0.6) –1.2 (–1.4, –1.0) –0.3 (–0.6, –0.0)
Pinch-tip grip force: thumb-index finger on (more) symptomatic side
Baseline 4.3 ± 2.2 (3.7, 5.0) 4.1 ± 2.3 (3.5, 4.8)
1 mo 5.3 ± 2.2 (4.7, 5.9) 3.3 ± 2.1 (2.7, 3.9)
Within-group change: baseline to 1 mo 1.0 (0.5, 1.5) –1.2 (–1.6, –0.8) 2.2 (1.8, 2.6)†
3 mo 5.4 ± 2.6 (4.6, 6.1) 4.8 ± 2.7 (4.1, 5.5)
J Orthop Sports Phys Ther 2017.47:151-161.

Within-group change: baseline to 3 mo 1.1 (0.5, 1.7) 0.7 (0.2, 1.1) 0.4 (0.2, 0.6)
6 mo 5.3 ± 2.5 (4.7, 5.9) 4.6 ± 2.2 (4.0, 5.3)
Within-group change: baseline to 6 mo 1.0 (0.4, 1.6) 0.5 (0.2, 0.8) 0.5 (0.2, 0.8)
12 mo 5.3 ± 2.9 (4.6, 5.9) 4.9 ± 2.4 (4.2, 5.7)
Within-group change: baseline to 12 mo 1.0 (0.5, 1.5) 0.8 (0.2, 1.4) 0.2 (0.0, 0.4)
Table continues on page 157.

be found in FIGURE 1, which provides a effect size was large (SMD, 1.6). Chang- teractions for pinch-tip grip force on the
flow diagram of patient recruitment and es in self-reported function were similar symptomatic side (thumb-index finger: F
retention. in both groups at 3-, 6-, and 12-month = 6.550, P = .01 and thumb-little finger: F
Adjusting for baseline outcomes, follow-ups (P>.4). Additionally, both = 4.625, P = .036). Patients who received
the mixed-model analysis of covariance groups exhibited similar improvements manual therapy exhibited higher increas-
found a significant group-by-time inter- in severity of symptoms at all follow-up es in pinch-tip grip force on the symp-
action for the functional status subscale periods (TABLE 2). The manual therapy tomatic hand at 1 month (thumb-index
(F = 13.512, P<.001), but not for the group and the surgical group did not finger: mean change, 2.0; 95% CI: 1.1, 2.9
symptom severity subscale (F = 0.678, P significantly differ in success criteria in and thumb-little finger: mean change,
= .382), of the BCTQ, in that patients re- the intention-to-treat analyses at 6 (48% 1.0; 95% CI: 0.5, 1.5) than patients who
ceiving manual therapy exhibited a sta- versus 52%; χ2 = 0.093, P = .459) and 12 received surgery (FIGURE 3). The between-
tistically greater increase in self-reported (57% versus 64%; χ2 = 1.314, P = .273) group effect size was large (SMD, 1.1).
function at 1 month (mean change, –0.8; months. Changes in pinch-tip grip force on the
95% CI: –1.1, –0.5) than those receiving The intention-to-treat analysis also symptomatic hand were similar in both
surgery (FIGURE 2). The between-group revealed significant group-by-time in- groups at 3, 6, and 12 months (P>.2). No

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Function and Pinch-Tip Grip Force Outcomes by Group
TABLE 2
and Within-Group and Between-Group Change Scores* (continued)

Outcome/Time Manual Therapy Surgery Between-Group Change Score


Pinch-tip grip force: thumb-little finger on (more) symptomatic side
Baseline 1.2 ± 0.7 (1.0, 1.4) 1.1 ± 0.6 (0.8, 1.4)
1 mo 1.5 ± 1.1 (1.2, 1.8) 0.5 ± 0.7 (0.3, 0.7)
Within-group change: baseline to 1 mo 0.3 (0.0, 0.6) –0.5 (–0.7, –0.3) 0.8 (0.5, 1.1)†
3 mo 1.5 ± 0.9 (1.2, 1.7) 1.0 ± 0.8 (0.7, 1.3)
Within-group change: baseline to 3 mo 0.3 (0.1, 0.5) –0.1 (–0.3, 0.1) 0.4 (0.2, 0.6)
6 mo 1.7 ± 1.0 (1.3, 2.1) 1.2 ± 0.7 (0.7, 1.7)
Within-group change: baseline to 6 mo 0.5 (0.1, 0.9) 0.1 (–0.1, 0.3) 0.4 (0.1, 0.7)
12 mo 1.7 ± 0.9 (1.2, 2.2) 1.2 ± 0.7 (1.0, 1.4)
Within-group change: baseline to 12 mo 0.5 (0.2, 0.8) 0.1 (0.0, 0.3) 0.4 (0.2, 0.6)
Pinch-tip grip force: thumb-index finger on less (non)symptomatic side
Baseline 4.4 ± 1.7 (4.0, 4.8) 4.2 ± 1.6 (3.7, 4.7)
1 mo 4.5 ± 2.1 (4.0, 5.0) 4.2 ± 1.8 (3.6, 4.8)
Within-group change: baseline to 1 mo 0.1 (–0.3, 0.5) 0.0 (–0.3, 0.3) 0.1 (0.0, 0.3)
3 mo 4.4 ± 2.2 (3.8, 5.0) 4.3 ± 1.7 (3.7, 4.9)
Downloaded from www.jospt.org by Univ Canberra on 12/29/17. For personal use only.

Within-group change: baseline to 3 mo 0.0 (–0.4, 0.4) 0.1 (–0.3, 0.5) 0.1 (–0.1, 0.3)
6 mo 4.5 ± 2.0 (4.0, 5.0) 4.3 ± 1.4 (3.8, 4.8)
Within-group change: baseline to 6 mo 0.1 (–0.4, 0.6) 0.1 (–0.1, 0.3) 0.0 (–0.3, 0.3)
12 mo 4.6 ± 2.1 (4.1, 5.1) 4.2 ± 1.7 (3.5, 4.9)
Within-group change: baseline to 12 mo 0.2 (0.0, 0.4) 0.0 (–0.4, 0.4) 0.2 (0.0, 0.4)
Pinch-tip grip force: thumb-little finger on less (non)symptomatic side
Baseline 1.1 ± 0.7 (0.9, 1.3) 1.1 ± 0.6 (0.9, 1.3)
1 mo 1.3 ± 0.9 (1.1, 1.5) 1.1 ± 0.7 (0.9, 1.3)
Within-group change: baseline to 1 mo 0.2 (0.0, 0.4) 0.0 (–0.2, 0.2) 0.2 (0.0, 0.4)
3 mo 1.3 ± 0.9 (1.0, 1.6) 1.3 ± 0.8 (1.1, 1.5)
J Orthop Sports Phys Ther 2017.47:151-161.

Within-group change: baseline to 3 mo 0.2 (–0.1, 0.5) 0.2 (–0.1, 0.5) 0.0 (–0.3, 0.3)
6 mo 1.5 ± 1.0 (1.3, 1.7) 1.3 ± 0.7 (1.1, 1.5)
Within-group change: baseline to 6 mo 0.4 (0.1, 0.7) 0.1 (0.0, 0.2) 0.3 (0.1, 0.5)
12 mo 1.5 ± 0.9 (1.1, 1.9) 1.3 ± 0.7 (1.0, 1.6)
Within-group change: baseline to 12 mo 0.4 (0.2, 0.6) 0.1 (–0.1, 0.3) 0.3 (0.0, 0.6)
Abbreviation: BCTQ, Boston Carpal Tunnel Questionnaire.
*Outcome values at each time point are mean ± SD (95% confidence interval) and values for change scores are mean (95% confidence interval).

Statistically significant between-group difference (analysis of variance) (P<.05).

changes were observed in pinch-tip grip the symptomatic side (F = 0.115, P = .805) self-reported function, symptom sever-
force on the less-affected side at any fol- (TABLE 3). ity, and pinch grip strength than surgery,
low-up period (P>.12) (TABLE 2). No association was observed between but yielded similar outcomes at 6 months
Finally, no significant changes were changes in self-reported function, cervi- and 1 year. While the 1-month between-
observed in cervical range of motion in cal range of motion, and pinch-tip grip group differences were statistically sig-
both groups for any motion: flexion (F = force in either group (all, P>.5). nificant, they did not surpass the MCID
0.117, P = .740), extension (F = 0.550, P for self-reported function19 or the MDC
= .655), lateral flexion toward the most DISCUSSION for pinch-tip grip strength,29 calling into
symptomatic side (F = 0.220, P = .965), question the clinical relevance. Similarly,

T
lateral flexion away from the most symp- he current randomized clinical changes observed in both groups at all
tomatic side (F = 0.185, P = .670), rota- trial found that multimodal manual follow-ups were also modest and did not
tion toward the symptomatic side (F = therapy resulted in significantly surpass the MCID for the functional sta-
0.415, P = .495), and rotation away from greater improvements at 1 month in tus subscale of the BCTQ19 or the MDC

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[ research report ]
for pinch-tip grip force.29 Further, at 1 the short term than surgery for improv- tion maneuvers of the central nervous
year, the upper bounds of the 95% CIs ing pinch-tip grip, the results do not sup- system, was equally effective at 6 and 12
for the between-group differences in port our initial hypothesis that changes months as surgery in improving pain and
self-reported function, symptom sever- in pinch-tip grip and cervical range of self-reported function in women with
ity, pinch-tip grip strength, and cervical motion would be greater with manual CTS.12 This could be expected, as the re-
range of motion all excluded the MCID therapy than with surgery. covery time postsurgery would typically
or MDC. While additional research with In our study, the manual therapy exceed a 1-month time frame.
other large samples is needed, this find- group experienced significantly greater Although it has previously been iden-
ing would strengthen the potential for outcomes in terms of self-reported func- tified that cervical range of motion is
equivalent effectiveness between multi- tion and pinch grip force at the 1-month restricted in women with CTS and that
modal manual therapy and surgery at 1 follow-up, similar to a previous study that lateral flexion away from the symptom-
year. Therefore, though manual therapy found that physical therapy consisting of atic side is related to self-reported func-
seemed to be slightly more effective in manual therapies, including desensitiza- tion,11 it is interesting to note that in the


Cervical Range-of-Motion Outcomes by Group and
TABLE 3
Within-Group and Between-Group Change Scores*
Downloaded from www.jospt.org by Univ Canberra on 12/29/17. For personal use only.

Outcome/Time Manual Therapy Surgery Between-Group Change Score


Cervical flexion, deg
Baseline 49 ± 8 (47, 51) 48 ± 7 (46, 50)
1 mo 49 ± 8 (47, 51) 48 ± 8 (45, 51)
Within-group change: baseline to 1 mo 0.0 (–2.3, 2.3) 0.0 (–2.5, 2.5) 0.0 (–1.3, 1.3)
3 mo 50 ± 8 (47, 53) 49 ± 10 (47, 51)
Within-group change: baseline to 3 mo 1.0 (–1.5, 3.5) 1.0 (–1.9, 3.9) 0.0 (–2.0, 2.0)
6 mo 51 ± 9 (48, 54) 49 ± 9 (47, 51)
Within-group change: baseline to 6 mo 2.0 (–1.3, 5.3) 1.0 (–1.8, 3.8) 1.0 (–1.0, 3.0)
12 mo 51 ± 8 (48, 54) 49 ± 8 (46, 52)
J Orthop Sports Phys Ther 2017.47:151-161.

Within-group change: baseline to 12 mo 2.0 (–1.5, 5.5) 1.0 (–2.3, 4.3) 1.0 (0.0, 2.0)
Cervical extension, deg
Baseline 57 ± 10 (55, 59) 57 ± 8 (54, 60)
1 mo 59 ± 9 (56, 62) 57 ± 9 (54, 60)
Within-group change: baseline to 1 mo 2.0 (–1.5, 5.5) 0.0 (–1.7, 1.7) 2.0 (–0.8, 4.8)
3 mo 60 ± 10 (58, 62) 59 ± 8 (56, 62)
Within-group change: baseline to 3 mo 3.0 (–0.5, 6.5) 2.0 (–0.5, 4.5) 1.0 (–1.5, 3.5)
6 mo 59 ± 8 (57, 61) 58 ± 8 (56, 60)
Within-group change: baseline to 6 mo 2.0 (–1.5, 5.5) 1.0 (–1.4, 3.4) 1.0 (–1.3, 3.3)
12 mo 59 ± 8 (57, 61) 58 ± 7 (56, 60)
Within-group change: baseline to 12 mo 2.0 (–0.7, 4.7) 1.0 (–1.3, 3.3) 1.0 (0.0, 3.0)
Cervical lateral flexion toward the side of CTS, deg
Baseline 39 ± 6 (37, 41) 40 ± 7 (38, 42)
1 mo 39 ± 7 (37, 41) 40 ± 7 (37, 43)
Within-group change: baseline to 1 mo 0.0 (–2.0, 2.0) 0.0 (–2.2, 2.2) 0.0 (–1.5, 1.5)
3 mo 40 ± 9 (38, 42) 40 ± 6 (37, 43)
Within-group change: baseline to 3 mo 1.0 (–1.5, 3.5) 0.0 (–1.8, 1.8) 1.0 (–1.2, 3.2)
6 mo 41 ± 8 (38, 44) 41 ± 6 (39, 43)
Within-group change: baseline to 6 mo 2.0 (–0.5, 4.5) 1.0 (–1.2, 3.2) 1.0 (–2.0, 4.0)
12 mo 40 ± 6 (38, 42) 40 ± 6 (38, 42)
Within-group change: baseline to 12 mo 1.0 (–1.4, 3.4) 0.0 (–1.9, 1.9) 1.0 (0.0, 2.0)
Table continues on page 159.

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present trial no real changes in cervical of the median nerve.5 Because we did not short-term outcomes were found with
range of motion were observed after ei- perform neurodynamic interventions, as manual therapy, patients may be able
ther treatment, despite targeting mus- previously applied in this patient popula- to return earlier to their activities of
culoskeletal restrictions in the cervical tion,12 changes in cervical range of motion daily living and work when they receive
spine in people randomized to the man- might not have occurred. It is possible manual therapy, compared to those who
ual therapy group. A possible explanation that the inclusion of neurodynamic inter- undergo surgery. In fact, the use of con-
of this finding could be that the interven- ventions in the manual therapy approach servative versus surgical procedures in
tions applied to the cervical spine did not used in the current study would have had the management of individuals with CTS
provide sufficient management of the an additive effect. is sometimes controversial. The Ameri-
neck impairments. It is also possible that The findings of the current study have can Academy of Orthopaedic Surgeons
restricted cervical range of motion ob- potential clinical implications and open guidelines for the management of CTS re-
served in CTS is related to neural tension new lines of research. Because better cently concluded that there is strong evi-


Cervical Range-of-Motion Outcomes by Group and
TABLE 3
Within-Group and Between-Group Change Scores* (continued)

Outcome/Time Manual Therapy Surgery Between-Group Change Score


Downloaded from www.jospt.org by Univ Canberra on 12/29/17. For personal use only.

Cervical lateral flexion away from the side of CTS, deg


Baseline 40 ± 6 (38, 42) 40 ± 7 (38, 42)
1 mo 42 ± 5 (40, 44) 40 ± 6 (38, 42)
Within-group change: baseline to 1 mo 2.0 (–0.7, 4.7) 0.0 (–1.4, 1.4) 2.0 (0.5, 3.5)
3 mo 41 ± 11 (38, 44) 41 ± 8 (38, 44)
Within-group change: baseline to 3 mo 1.0 (–1.4, 3.4) 1.0 (–0.8, 2.8) 0.0 (–1.0, 1.0)
6 mo 42 ± 9 (39, 45) 40 ± 9 (38, 42)
Within-group change: baseline to 6 mo 2.0 (–1.5, 5.5) 0.0 (–2.1, 2.1) 2.0 (–0.5, 4.5)
12 mo 40 ± 7 (37, 43) 41 ± 5 (39, 43)
Within-group change: baseline to 12 mo 0.0 (–2.0, 2.0) 1.0 (–1.8, 3.8) –1.0 (–3.0, 1.0)
J Orthop Sports Phys Ther 2017.47:151-161.

Cervical rotation toward the side of CTS, deg


Baseline 71 ± 10 (68, 74) 70 ± 9 (67, 73)
1 mo 71 ± 11 (67, 75) 72 ± 11 (68, 76)
Within-group change: baseline to 1 mo 0.0 (–2.0, 2.0) 2.0 (–1.0, 5.0) –2.0 (–4.3, 0.3)
3 mo 72 ± 12 (68, 72) 74 ± 10 (71, 77)
Within-group change: baseline to 3 mo 1.0 (–2.5, 4.5) 4.0 (1.0, 7.0) –3.0 (–6.0, 0.0)
6 mo 71 ± 12 (67, 75) 73 ± 11 (70, 76)
Within-group change: baseline to 6 mo 0.0 (–1.8, 1.8) 3.0 (0.5, 5.5) –3.0 (–6.5, 0.5)
12 mo 74 ± 12 (70, 78) 74 ± 13 (71, 77)
Within-group change: baseline to 12 mo 3.0 (0.8, 5.2) 4.0 (0.5, 7.5) –1.0 (–2.0, 0.0)
Cervical rotation away from the side of CTS, deg
Baseline 69 ± 11 (67, 71) 71 ± 7 (69, 73)
1 mo 71 ± 12 (68, 74) 73 ± 11 (69, 77)
Within-group change: baseline to 1 mo 2.0 (–1.9, 5.9) 2.0 (–0.5, 4.5) 0.0 (–1.4, 1.4)
3 mo 72 ± 13 (68, 76) 74 ± 11 (71, 77)
Within-group change: baseline to 3 mo 3.0 (–0.5, 6.5) 3.0 (–1.0, 7.0) 0.0 (–2.0, 2.0)
6 mo 71 ± 13 (67, 75) 75 ± 12 (71, 79)
Within-group change: baseline to 6 mo 2.0 (–1.1, 5.1) 4.0 (0.0, 8.0) –2.0 (–3.5, –0.5)
12 mo 74 ± 10 (71, 77) 74 ± 12 (71, 77)
Within-group change: baseline to 12 mo 5.0 (1.2, 8.8) 3.0 (–0.5, 6.5) 2.0 (–0.8, 4.8)
Abbreviation: CTS, carpal tunnel syndrome.
*Outcome values at each time point are mean ± SD (95% confidence interval) and values for change scores are mean (95% confidence interval).

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[ research report ]
dence that surgical treatment has greater therapy; therefore, it is possible that, with Additionally, there are no available data
benefit at 6 and 12 months than splinting, more treatment sessions, patients may on the proper dosage for the manual
nonsteroidal anti-inflammatory drugs/ experience greater improvement.10 Fu- therapy protocol applied.
therapy, and a single steroid injection.1 ture research should attempt to replicate
However, there is increasing evidence the current findings in a different sample
showing that multimodal manual ther- of individuals with CTS. A key element REFERENCES
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therapists, and physical medicine and rehabili- https://doi.org/10.1002/14651858.CD001554. 32. Thiese MS, Gerr F, Hegmann KT, et al. Effects
tation physicians agree on a multidisciplinary pub2 of varying case definition on carpal tunnel syn-
treatment guideline—results from the European 24. Page MJ, Massy-Westropp N, O’Connor D, Pitt V. drome prevalence estimates in a pooled cohort.
HANDGUIDE Study. Arch Phys Med Rehabil. Splinting for carpal tunnel syndrome. Cochrane Arch Phys Med Rehabil. 2014;95:2320-2326.
J Orthop Sports Phys Ther 2017.47:151-161.

2014;95:2253-2263. https://doi.org/10.1016/j. Database Syst Rev. 2012:CD010003. https://doi. https://doi.org/10.1016/j.apmr.2014.08.004


apmr.2014.06.022 org/10.1002/14651858.CD010003
17. J ablecki CK, Andary MT, Floeter MK, et al. 25. Page MJ, O’Connor D, Pitt V, Massy-Westropp

@ MORE INFORMATION
Practice parameter: electrodiagnostic studies in N. Exercise and mobilisation interventions
carpal tunnel syndrome. Report of the American for carpal tunnel syndrome. Cochrane Data-
Association of Electrodiagnostic Medicine, Amer- base Syst Rev. 2012:CD009899. https://doi. WWW.JOSPT.ORG

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APPENDIX A

DESCRIPTION OF MANUAL THERAPY INTERVENTIONS

Technique: lateral glides applied to the cervical spine Technique: longitudinal stroke over the scalene muscles
Description of technique: the patient lies supine with the head in a neutral Description of technique: the patient lies supine with the neck in a neu-
position. The therapist supports the patient’s head with the mobilization tral position. Longitudinal strokes over the anterior and middle scalene
hand at the C5-C6 level. The other hand is placed on the contralateral muscles were performed from a cranial to caudal direction. A total of 5
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side of the patient’s neck. The lateral glide of the cervical spine was ap- strokes on each muscle were applied. The degree of pressure was based
plied as a translational movement of the neck away from the symptomatic on the tension perceived by the clinician from the patient’s tissue, which
side. This transverse movement was performed until the therapist felt tis- was usually pain free
sue resistance (Maitland grade III). The intervention was completed over
5 minutes in 2 sets of 2 minutes each, with 1 minute of rest between sets
J Orthop Sports Phys Ther 2017.47:151-161.

Technique: transversal stretching of the costoclavicle space


Description of technique: with the patient in sidelying, the thumb of the
caudal hand of the therapist is placed on the anterior part of the axilla,
Technique: posteroanterior nonthrust mobilization of the mid cervical behind the pectoralis minor tendon. The second and third fingers of the
spine other hand are placed over the superior part of the clavicle bone. From
Description of technique: the patient is prone with the neck in a neutral that position, the therapist maintains a pain-free compression for 3
position. The pads of the therapist’s thumbs contact the skin over the minutes
articular process of the targeted level, directed slightly medially (30°).
Patients received 30-second bouts of grade III or IV, central posteroante-
rior nonthrust mobilization from the C4 to C6 articular processes, for an
overall time of approximately 3 minutes

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[ research report ]
APPENDIX A

Technique: soft tissue compression over the pectoralis minor muscle


Description of technique: with the patient in sidelying, one hand is placed
over the ribs behind the pectoralis minor muscle. The other hand grasps
the elbow of the patient. The therapist maintains a pain-free compression
for 3 minutes over the pectoralis minor muscle and, at the same time,
increases the abduction of the patient’s shoulder
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Technique: transversal stroke of the bicipital aponeurosis


Description of technique: the patient lies supine with the elbow flexed.
The therapist grasps the bicipital aponeurosis (lacertus fibrosus) of the
biceps brachii muscle with one hand and with the other hand grasps the
wrist of the patient. From that position, the therapist rhythmically extends
the elbow of the patient 10 times
J Orthop Sports Phys Ther 2017.47:151-161.

Technique: longitudinal stroke over the biceps muscle


Description of technique: the patient lies supine with the elbow extended
and the forearm supinated. The therapist applies 5 longitudinal strokes
over the biceps brachii muscle from a cranial to caudal direction

Technique: dynamic stroke of the pronator teres muscle


Description of technique: the patient lies supine with the elbow flexed.
The therapist induces static compression on the pronator teres muscle
with one hand and grasps the wrist of the patient with the other hand.
From that position, the therapist rhythmically pronates the forearm of the
patient 10 times

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APPENDIX A

Technique: stretching of the transverse carpal ligament Technique: manual compression of the lumbrical muscles
Description of technique: the clinician places the thumbs on the region of Description of technique: the clinician places the thumbs over the palmar
the carpal tunnel and the flexed index fingers, over the back of the wrist, face of the metacarpophalanx articulations, so that they may separate
forming a clamp. From that position, the clinician rhythmically induces an the proximal phalanxes of the patient’s fingers. The other fingers stabilize
extension movement of the wrist 10 times the patient’s hand. The clinician induces an opening motion of the meta-
carpophalanx articulations for 2 minutes
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J Orthop Sports Phys Ther 2017.47:151-161.

Technique: stretching of the palmar aponeurosis


Description of technique: the clinician opens the hand of the patient by
grasping all the fingers. The clinician induces an opening motion of the
fingers for 2 minutes

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[ research report ]
APPENDIX B

GUIDELINE FOR CERVICAL SPINE EXERCISES

Technique: self-stretching of the upper fibers of the trapezius muscle Technique: self-stretching of the upper fibers of the scalene muscles
Description of technique: the patient is sitting in a relaxed position. With Description of technique: the position is the same as for the other stretch-
the contralateral hand, the patient grasps her head, whereas the homolat- ing exercises. The scalene muscles are stretched with slight cervical
eral hand grasps the chair to avoid shoulder elevation. The upper fibers of extension, contralateral lateral flexion, and contralateral rotation. The
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the trapezius muscle are stretched by including cervical flexion, contralat- stretching position was maintained for 45 seconds 2 times. Opinions dif-
eral lateral flexion, and homolateral rotation. This stretching position was fer on the degree and direction of rotation required for the stretch of the
maintained for 45 seconds 2 times scalene muscles
J Orthop Sports Phys Ther 2017.47:151-161.

Technique: self-stretching of the levator scapulae muscle


Description of technique: the position is the same as for upper trapezius
muscle stretching. The levator scapulae muscle is stretched with cervi-
cal flexion, contralateral lateral flexion, and contralateral rotation. This
stretching position was maintained for 45 seconds 2 times

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jospt perspectives for patients

Carpal Tunnel Syndrome


Physical Therapy or Surgery?
J Orthop Sports Phys Ther 2017;47(3):162. doi:10.2519/jospt.2017.0503

C
arpal tunnel syndrome causes pain, numbness, and Although surgery may be considered when the symptoms are se-
weakness in the wrist and hand. Nearly 50% of all vere, more than a third of patients do not return to work within 8
work-related injuries are linked to carpal tunnel syn- weeks after an operation. Based on the potential side effects and
drome, and people with this injury are more likely risks of surgery, patients often ask if they might try physical therapy
to miss work because of it. Patients with carpal tun- first. An article in the March 2017 issue of JOSPT assesses the ef-
nel syndrome can be treated with physical therapy or surgery. fectiveness of therapy and surgery to treat carpal tunnel syndrome.

NEW INSIGHTS
The researchers studied the cases of 100 women
with carpal tunnel syndrome and compared 50
patients who were treated with physical therapy
and 50 patients who were treated with surgery. The
patients who did not receive surgery were treated
with manual therapy techniques that focused on
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the neck and median nerve for 30 minutes, once


a week, with stretching exercises at home. After 1
month, the patients in the physical therapy group
had better hand function during daily activities and
better grip strength (also known as pinch strength
between the thumb and index finger) than the
patients who had surgery. At 3, 6, and 12 months
after treatment, patients in both the physical therapy
and surgery groups showed similar improvements in
function and grip strength. Pain also decreased for
patients in both groups. The researchers concluded
that physical therapy and surgery for carpal tunnel
INTERVENTIONS AND EXERCISES. Your physical therapist will provide a combination of manual therapy (A) and syndrome yield similar benefits.
J Orthop Sports Phys Ther 2017.47:151-161.

stretching exercises (B) to improve your recovery from carpal tunnel syndrome. These illustrations show a few of the
manual therapy and exercise treatment options your therapist may recommend and use.
PRACTICAL ADVICE
This JOSPT Perspectives for Patients is based on an article by Fernández-de-las-Peñas et al, titled “The Effectiveness The researchers found that after 1 year, patients
of Manual Therapy Versus Surgery on Self-reported Function, Cervical Range of Motion, and Pinch Grip Force in who had physical therapy that focused on manual
Carpal Tunnel Syndrome: A Randomized Clinical Trial” (J Orthop Sports Phys Ther 2017;47(3):151-161. doi:10.2519/ therapy of the neck and median nerve, combined with
jospt.2017.7090). stretching exercises, had outcomes similar to those
of patients who had surgery. In addition, the physical
This Perspectives article was written by a team of JOSPT’s editorial board and staff. Deydre S. Teyhen, PT, PhD, Editor,
therapy patients experienced faster improvements at
and Jeanne Robertson, Illustrator.
the 1-month mark than did patients whose condition
was treated surgically. This research supports the
decision of patients who want to try physical therapy
first before considering surgery. If you have been
diagnosed with carpal tunnel syndrome, physical
therapy offers strong evidence-based treatment
options to help you recover. Evidence indicates that
physical therapy is as effective as surgery to treat this
condition.
For this and more topics, visit JOSPT Perspectives for
Patients online at www.jospt.org.

JOSPT PERSPECTIVES FOR PATIENTS is a public service of the Journal of Orthopaedic & Sports Physical Therapy®. The information and recommendations
contained here are a summary of the referenced research article and are not a substitute for seeking proper health care to diagnose and treat this condition. For
more information on the management of this condition, contact your physical therapist or other health care provider specializing in musculoskeletal disorders.
JOSPT Perspectives for Patients may be photocopied noncommercially by physical therapists and other health care providers to share with patients. The
official journal of the Orthopaedic Section and the Sports Physical Therapy Section of the American Physical Therapy Association (APTA) and a recognized
journal of more than 35 international partners, JOSPT strives to offer high-quality research, immediately applicable clinical material, and useful supplemental
information on musculoskeletal and sports-related health, injury, and rehabilitation. Copyright ©2017 Journal of Orthopaedic & Sports Physical Therapy ®

162 | march 2017 | volume 47 | number 3 | journal of orthopaedic & sports physical therapy

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