Author Names
Talebi, G., Saadat, P. Javadian, Y. and Taghipour, M.
Reviewer Name
Haley Mills, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Background: Manual therapy techniques are part of physiotherapy treatment of carpal tunnel syndrome (CTS) which are classified into two groups including nerve mobilization and mechanical interface mobilization. The aim of the study was to find which manual therapy method-technique directed to mechanical interface and nerve mobilization–has superior beneficial effects on clinical and electrophysiological findings in conservative management of patients with CTS. Methods: Thirty patients with CTS participated into two groups namely: mechanical interface and nerve mobilization in this randomized clinical trial. The intervention was performed three times weekly for 4 weeks. Mechanical interface mobilization was directed to structures around the median nerve at the forearm and wrist. Techniques of median nerve gliding and tension were used in the nerve mobilization group. The outcome measures included visual analogue scale (VAS), symptom severity scale (SSS), hand functional status scale (FSS) and motor and sensory distal latencies of median nerve. Paired t-test and ANCOVA were used for statistical analysis. Results: At the end of the 4th week of the treatment, the mean of VAS, SSS and FSS significantly improved in both groups (p<0.05), but the difference was not significant between the two groups (P>0.05). Although the mean of motor and sensory distal latencies of median nerve at the end of the treatment period only improved in the nerve mobilization group (p<0.05), the difference was not significant between the two groups (P>0.05). Conclusion: Mechanical interface mobilization and nerve mobilization techniques are not superior to each other in reducing pain and improving hand symptoms and functional status.
NIH Risk of Bias Tool
Quality Assessment of Controlled Intervention Studies
- Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT?
- Yes
- Was the method of randomization adequate (i.e., use of randomly generated assignment)?
- Yes
- Was the treatment allocation concealed (so that assignments could not be predicted)?
- Yes
- Were study participants and providers blinded to treatment group assignment?
- Yes
- Were the people assessing the outcomes blinded to the participants’ group assignments?
- Cannot Determine, Not Reported, or Not Applicable
- Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
- No
- Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
- No
- Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
- Cannot Determine, Not Reported, or Not Applicable
- Was there high adherence to the intervention protocols for each treatment group?
- Yes
- Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
- Yes
- Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
- Yes
- Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
- No
- Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
- Yes
- Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
- Cannot Determine, Not Reported, or Not Applicable
Key Finding #1
Manual therapy methods, including mobilization of the mechanical interface and specific neurodynamic techniques, have significant therapeutic benefits for the conservative treatment of mild to moderate forms of carpal tunnel syndrome.
Key Finding #2
The benefits of manual therapy for mild to moderate carpal tunnel syndrome include but are not limited to improvements in hand symptoms and functional status and reduction of pain.
Key Finding #3
These manual techniques, mechanical interface, and nerve mobilization, are not superior to each other in reducing pain and improving hand symptoms and functional status.
Key Finding #4
Research should be done comparing sliding and tensioning neurodynamic techniques to get more information on separate treatment potentials.
Please provide your summary of the paper
In this randomized control trial, researchers aimed to determine which manual therapy techniques were superior for the conservative management of carpal tunnel syndrome. The two manual therapy methods they were comparing were mechanical interface (wrist distraction, transverse carpal ligament stretch, palmar fascia release, finger flexor glides, and upper forearm fascia and muscle release) and nerve mobilization (median nerve glide and tension maneuvers). They initially had 57 participants enter the study, 18 did not meet the inclusion criteria and 9 did not complete all pre-intervention outcome measures ending in removal from the study, leaving researchers with 30 participants to split randomly into the two treatment groups. Interventions were performed 3 times per week for 4 weeks. Both groups received 15 minutes of intervention per session. The outcome measure used to assess pre vs post-intervention outcomes was the Boston Questionnaire, which includes questions regarding symptom severity and functional status. After 4 weeks the results were collected and evaluated. The researchers concluded that both techniques successfully improved hand symptoms and functional status and reduced pain, noting that one method was not superior to the other. They recommend that some combination of both methods be used for best results. They recognize some limitations of their study as being too short, the use of ultrasound and TENS in conjunction with manual therapies, and the small sample size. That being said, they recommend longer studies be done to further investigate these effects.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This study can be extremely valuable in helping physical therapists as they prepare a plan of care for patients with carpal tunnel syndrome. Since the researchers found that neither method of manual therapy was superior, therapists could feel comfortable using either method or a combination of the two. The fact that the researchers included specifics regarding dosage makes this information easy to replicate for future research and in the clinic when treating a patient with carpal tunnel syndrome. It is worth mentioning however that the use of US and TENS for each patient in the study in conjunction with the manual therapies could be a huge confounding variable to the research and a potential barrier if attempting to apply these findings in practice if a therapist does not have access to these modalities. Another limitation of the study, the small sample size, is worth noting but in my interpretation does not eliminate the value of the findings. However, the researchers disclosed these limitations, making them easy to filter through, allowing for ease of understanding and application for future research and clinical practice.
