Author Names
Sheereen, F. J., Sarkar, B., Sahay, P., Shaphe, M. A., Alghadir, A. H., Iqbal, A., Ali, T., & Ahmad, F
Reviewer Name
Emma Kosbab, LAT, ATC, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Background. Carpal tunnel syndrome (CTS) is the symptomatic compression neuropathy of the median nerve at the wrist level that may become a reason for upper limb disability, in the women and men population. Objective. This study aimed to compare the efficacy of the neurodynamic technique (NT) and carpal bone mobilization technique (CBMT) incorporated with tendon gliding exercises (TGE) as an effect-enhancing adjunct while managing the participants with chronic CTS. Methods. The study followed a two-arm parallel-group randomized comparative design. Thirty participants (aged 30–59 years) with chronic CTS were recruited randomly to both the NT and CBMT groups. In addition to the TGE (a common adjunct), NT and CBMT were performed in the NT and CBMT groups, respectively, for three weeks. The primary outcome measures including pain intensity, functional status, grip strength, and motor nerve conduction study were assessed using a visual analogue scale (VAS), Boston Carpal Tunnel Questionnaire (BCTQ), hand-held dynamometer, and electromyograph, respectively, at baseline, 3 weeks postintervention, and follow-up at one week post end of the intervention. Paired and unpaired t-test were used to calculate the differences in intervention effects within and between the groups with keeping the level of significance α at 0.05. Results. The data analysis revealed a significant (95% CI, p < 0.05) difference for all outcomes within each group compared across different time intervals. Similarly, a significant difference was found for all outcomes except pain and grip strength compared between groups at 3 weeks postintervention and follow-up at one week post end of the intervention. Conclusions. The NT revealed more effectiveness than the CBMT when incorporated with TGE to improve nerve conduction velocity and functional status of the hand. However, both NT and CBMT were equally effective in improving pain and grip strength while managing the participants with chronic CTS. In addition, the TGE contributed as a beneficial, effect-enhancing adjunct to the NT and CBMT differently. Significance. The study will guide the physiotherapist in applying either of the combination techniques suitable for achieving treatment objectives while managing the participants with chronic CTS.
NIH Risk of Bias Tool
Quality Assessment Tool for Before-After (Pre-Post) Studies With No Control Group
- Was the study question or objective clearly stated?
- Yes
- Were eligibility/selection criteria for the study population prespecified and clearly described?
- Yes
- Were the participants in the study representative of those who would be eligible for the test/service/intervention in the general or clinical population of interest?
- Yes
- Were all eligible participants that met the prespecified entry criteria enrolled?
- Yes
- Was the sample size sufficiently large to provide confidence in the findings?
- Yes
- Was the test/service/intervention clearly described and delivered consistently across the study population?
- Yes
- Were the outcome measures prespecified, clearly defined, valid, reliable, and assessed consistently across all study participants?
- Yes
- Were the people assessing the outcomes blinded to the participants’ exposures/interventions?
- Yes
- Was the loss to follow-up after baseline 20% or less? Were those lost to follow-up accounted for in the analysis?
- Yes
- Did the statistical methods examine changes in outcome measures from before to after the intervention? Were statistical tests done that provided p values for the pre-to-post changes?
- Yes
- Were outcome measures of interest taken multiple times before the intervention and multiple times after the intervention (i.e., did they use an interrupted time-series design)?
- Yes
- If the intervention was conducted at a group level (e.g., a whole hospital, a community, etc.) did the statistical analysis take into account the use of individual-level data to determine effects at the group level?
- Cannot Determine, Not Reported, Not Applicable
Key Finding #1
Following three weeks of intervention, NT produced a statistically significant improvement in functional status and nerve conduction speed as noted by the Boston Carpal Tunnel Questionaire (BCTQ), Nerve conduction study for median nerve (NCSa and NCSb).
Key Finding #2
Both NT and CBMT interventions (in conjunction with tendon gliding exercises) showed similar improvement in pain (visual analog scale) and grip strength (hand-held dynamometry).
Key Finding #3
Both treatment groups provided improved subjective and objective symptoms over the three week period without surgical intervention.
Please provide your summary of the paper
This study compared two intervention strategies for treatment of carpal tunnel syndrome. One group used neurodynamic technique and tendon gliding exercises (NT group) and the other used carpal bone mobilization technique in addition to the tendon gliding exercises (CBMT group) all applied for three weeks. The NT group interventions specifically included passive median nerve mobilization in the supine position performed by the physical therapist moving to ranges that did not produce pain for 2 sets of 5 minutes with 1 minute rest between sets 3 times per week for the 3 week period. The CBMT group received AP and Pa mobilizations joints of the carpal bones, radius, ulna, and adjunct metacarpals for 3 sets of 30 repetitions 3 times per week for the 3 week period. The interventions did present statistically significant findings in both interventions for the majority of outcomes (related to pain and function). The analysis included 30 participants, but may have been more conclusive with a control group that did not receive any interventions to justify their efficacy more completely.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
Based on the outcomes that showed improvement, it could be assumed that the neurodynamic technique in conjunction with tendon gliding exercises is most useful if the patient’s goals to improve functional status and for general improvement in the physiology of the nerve conduction. Both approaches demonstrated improvements in pain and grip strength which may be helpful in achieving patient goals. Understanding the value of each variable to achieve patient goals is critical, but the common tendon gliding may be most useful of the three interventions as it is the intervention that provides the patient with autonomy in their rehabilitation. Clinically, it is important to know the nerve conduction and integrity along with general function is improved more by NT, but CBMT was equally as beneficial at NT for the pain and strength outcomes. Overall patient goals, clinical experience, and ensuring there are options for home application are important considerations for application.
