Diagnostic criteria for CTS:
In each case CTS was diagnosed by a physician. Clinical diagnoses were primarily based on the data obtained in interviews and the presence of two or more positive symptoms:
Numbness and tingling in the area of the median nerve
Paraesthesia at night
Positive Phalen’s symptom
Positive Tinel’s symptom
Pain in the wrist area radiating to the shoulder [15
The exclusion criteria: earlier surgical treatment, steroid and non-steroid treatment, cervical radiculopathy, tendon sheath inflammation, rheumatoid diseases, diabetes, pregnancy, past traumas to the wrist, muscular atrophy of the thenar eminence.
The diagnostic criterion of inclusion in the experiment did not include electrophysiological test because as it is stated by Nora [16
] most authors believe that the clinical symptoms are more useful to accurately diagnose a patient even if disorders in the nerve conduction are not found [17
All patients were informed about the objective and, risks and benefits of the experiment. They could resign from taking part in the experiment at any stage without giving the reasons. Patients diagnosed with mild to moderate CTS who met the diagnostic criteria were included in the study (For mild and moderate forms of CTS those patients were enrolled who received results from 1 to 3 on a Hi-Ob Scale) [19
]. Each consecutive person who met the inclusion criteria and was not excluded was randomly assigned to either a manual therapy including neurodynamic techniques (MT) group or electrophysical modalities (EM) group. Patients were randomised by drawing lots with the group number. Individuals who drew the number “1” were assigned to the MT group and those that drew number “2” were assigned to the EM group.
Blinding of the study:
Next, the patient was directed to a physical therapist who performed a physical examination where they completed the relevant questionnaires and documentation. The examination of nervous conduction was performed by an independent EMG laboratory at an off-site centre by a specialist. The physical therapy procedures were performed by other physical therapists. were not members of the study team. The specialists who performed the conduction examinations were not aware of the therapy administered to the participants. After a cycle of treatment, study participants were examined by the same physical therapist. The second examination of nerve conduction was performed at the same site as the first one by the same specialists. The same procedures and study records were also used in both examinations before and after the therapeutic cycle.
In assessing the ROM and KDM two analyzes were performed. The first evaluated the effect of therapy in symptomatic limbs. In this case 140 patients were analyzed (180 hands). The second analysis was a comparison of the ROM and KDM in the symptomatic limb in relation to the asymptomatic limb which is why individuals with bilateral CTS were excluded. In this case 100 patients were analyzed (100 hands).
In the analyses concerning the comparison of the ROM and KDM in the symptomatic limb in relation to the asymptomatic limb relative values were used. They were obtained by dividing the values of symptomatic side compared to the asymptomatic side. They pointed out the differences in the considered variables between the analyzed limbs.
The range of motion of bending and straightening in the radiocarpal joint was analyzed [6
]. For this purpose the Saunders digital inclinometer was used. The measurements were carried out in accordance with the guidelines set by the manufacturer on the basis of the American Medical Association guidelines [21
]. The test was performed in the sitting position, the patient's upper limb was straightened in the shoulder joint, bent to an angle of 90 ° at the elbow with the forearm in pronation, resting on the therapeutic table, and the radiocarpal joint set in an intermediate position. Palmar side of the hand facing towards the substrate was outside the therapeutic table so as to be able to freely obtain the full range of flexion and extension. Fingers were bent to loosen the flexors of the fingers, which could limit the movement of the extension in the radiocarpal joint. An inclinometer was applied on the dorsal side of the hand parallel to the third metacarpal bone and middle finger. In this setting, the display of inclinometer presented a value of 0°, then the subject actively fully straightened the radiocarpal joint. After reading the result the 0° position was restored and the measurement of the active bending in the radiocarpal joint was performed. Measurement of the active range of motion was performed three times, and a mean value was used for further analysis. In the case of a unilateral carpal tunnel syndrome a healthy limb was analyzed first, while the affected limb second. Evaluation was performed before and after the completion of the rehabilitation therapy cycle.
During examining the range of motion in the radiocarpal joint, the assessment of the ability to kinesthetically differentiate the sensation of motion was also performed. Measurement methodology was the same as in the measurement of the range of motion with the difference being that after performing the full range active motion, the subject's task was the performance of the active motion to 50% of the maximum range of motion. In this analysis, measurement was performed three times, and a mean value was used for further analysis. In case of a unilateral carpal tunnel syndrome a healthy limb was analyzed first, and the affected one secondly. The evaluations were performed before and after the completion of the rehabilitation therapy cycle.
Examination of the ROM and ability to KDM allowed for the calculation of the error committed by each subject. For this purpose the following formula was used:
(50%ZR – RPZR) / 50%ZR × 100 = %
50%ZR – 50% of the range of motion
RPZR– real measurement value in the measurement of the mid-range of motion.
The obtained percentages allow for an estimation of the severity of error. Lower percentages indicate a less severity of error committed by the subject.
Techniques used for therapy:
During a 10-week observation period, patients in each group underwent physical therapy. No other form of treatment was used during the entire therapeutic cycle.
In the MT group, physical therapy was based on manual therapy including neurodynamic techniques for the median nerve. Functional massage of the descending part of the trapezius (duration 3 min.), as well as wrist mobilization techniques described by Shacklock [22
] were used. In both techniques, three series with 10 repetitions were used. The duration of one mobilisation was 15 s with a rest period of 10 s. Gliding and tension mobilisations of the median nerve were performed in the median neurodynamic test position (median neurodynamic test 1 – NM 1) with support. One-direction proximal and distal slider mobilisations and one-direction proximal and distal tension mobilisations were performed [22
]. The standard approach was to perform three series of 60 repetitions of glide and tension mobilisations. The duration of the inter-series intervals was 15s. The entire course of therapy included all the therapeutic techniques above and 20 therapeutic sessions were performed twice a week.
In the EM group, physical therapy was based on electrophysical modalities therapy. Laser therapy was performed using a contact method at three points on the palmar surface of the wrist in the transverse ligament area [23
]. Each procedure started with a red laser (using a R650/50 probe) emitting 658 nm light at 50 mW; the duration of biostimulation was 1 min 40s. The dose was 5J. Next, an infrared laser (with a IR810/400 probe) emitting 808 nm light at 400 mW was used; the duration of the biostimulation was 1 min. The dose was 24J. Thus, each point was stimulated for two minutes 40 s. The entire procedure was eight minutes long. Ultrasound therapy was used to treat the palmar surface of the hand in the transverse ligament area. The following parameters were used: frequency 1 MHz, intensity 1.0 W/ cm and impulse mode with a pulse width factor of 75%. Each procedure was 15 minutes long [24
]. Each therapeutic cycle included 20 therapeutic sessions performed twice a week.
To evaluate the uniformity of the groups, Student’s t-test was used for quantitative variables and a Chi2 test for qualitative variables. An ANOVA model for analysis of variables with repeated measures in which the repeated measures factor was 2 (measurements 1,2) and the independent factor was -2 (MT and EM groups) was used. Analysis of variancewas supplemented by the post hoc Bonferroni’s test. The critical p level was set at 0.05.