A study by Wainner et. al took a sample of individuals to develop a clinical prediction rule for practitioners to rule in patients with CTS.1 Of almost equal curiosity to me, was the duration of symptoms in patients with unilateral CTS vs. bilateral CTS was nearly double – 184 days, vs. 262 days respectfully.1 Understandable that duration would be of added time due to the nature of protection being eliminated as both upper extremities are involved. Although doubled duration seems higher than expected for me. It has been noted that heightened pain sensitivity is correlated with this condition.2 Again, we find another diagnosis with altered pain processing in CNS. Even if a patient demonstrates unilateral CTS, bilateral heightened pain sensitivity is observed.3 Therefore, is the duration for bilateral CTS captured by Wainner et al. elevated due to pain cycles, or adaptive behaviors? Unsure.
This idea left me with the assumption that manual therapy is of added benefit. This theory has been hypothesized, but not demonstrated in literature to the degree I would have assumed.
Fortunately, Wainner et al study developed clinical prediction rules to assist therapists and physicians in capturing these patients appropriately.2 Ruling in this diagnosis has been of challenge, especially when comparing against other areas of peripheral nerve entrapments (i.e. TOS).11 Clinical criteria to assess are stated in this paper as: shaking hands decrease symptoms, wrist-ratio index >.67, SSS score >1.9, diminished sensory field at digit 1, and age >45 years old.1 Of note, 4/5 positive there is a post test probability of 70%, and 5/5 positive there is a post test probability of 90%.1 Seemingly ruling in or out CTS provides information for diagnostic purposes which should drive us to proper treatment. So what treatment options are out there?
From a surgical and injection standpoint, evidence supports that these areas achieve good outcomes.6 Injection has few studies that show good clinical outcomes in the short term, but still, within 1 year of steroid injection half patients with CTS require surgical intervention.6 As stated by a recent cochrane review for surgical management of CTS the following conclusion was stated: ” Surgical treatment of carpal tunnel syndrome relieves symptoms significantly better than splinting. Further research is needed to discover whether this conclusion applies to people with mild symptoms and whether surgical treatment is better than steroid injection.”12
Where is a physical therapists place in treatment of CTS? Although I rarely see this diagnosis in clinic – treatments I utilize include: tendon glides, instrument assisted soft tissue mobilization (IASTM), mobilization of carpal bones, nerve flossing , a regional interdependence approach at assessing postural impairments and spinal mobility if needed. Where is the literature though?
A study by Akalin et al, showed that patients with splint and tendon glide programs had 93% reported good or excellent results.4 The only statistical significant improvement was for the lateral pinch strength value.4Unfortunately, wait and see method or control group of any kind was not involved in this RCT – leaving us with lack of assessing passage of time outcomes. Personally, I care more about patient perceived outcomes than pinch strength, but it is important to track impairments as well. It is of excellent point by Dr. Wainner editorial in 2007 that if physical therapists want to prove their place in treatment of conditions then they need to prove that they are more effective than natural history or passage of time.8Otherwise, wait and see method should be instructed for all conditions that are not to be shown to be improved with PT. This is something of reflection that I have learned since graduating. Although I hope to never lose the drive and fight to possibly naively think that I help more than I do, it is a healthy check point to assess treatments against science and assess the probability of positive outcomes under PT care vs. surgeons. Therefore, I do like RCT’s that utilize a control group for reference standard.
Fortunately for us, the Tal Akabi study demonstrates positive outcomes with mobilization of carpals and nerve flossing compared to a control.5Interesting point made by this study was that although a low n, 43% of patients with intervention opted out of surgery, while only 14% of patients without treatment opted out of surgery.5 Thus indicating patient perceived successful treatment.
Instrumented assisted manual therapy has been discussed a lot these past few years, and frequently utilized in clinic. A 2007 study examined soft tissue modalities using instruments vs. manual (IASTM vs STM). The findings were reported as follows: “after both manual therapy interventions, there were improvements to nerve conduction latencies, wrist strength, and wrist motion.”9 No difference was noted between the two methods. Although I may just be unaware, I do not see any RCT supporting instrument administered soft tissue vs. manual. I have heard therapists say that think IASTM causes damage to tissues drawing blood flow and healing, again I can’t find evidence of this. Not pigeon holing this treatment method to being ineffective just because we don’t understand pathophysiology, as I still administer IASTM. Regardless of evidence, I do understand that patients with CTS have tissue limitations distally, or even proximally and whether a therapist addresses this with their hands, or instrument, it does seem effective, within literature and clinically.
Lastly, regional interdependence treatment of CTS is to be considered. As previously discussed with other pathology associated with increased thermal hypersensitivity manual techniques have been shown to modulate afferent input, right? Proper posturing to obtain neutral hand placement may be focused distally but proximal as well. Thus, inferring that thoracic spine attention may be warranted. Sparks et. al has a very interesting study from this year that performed a noxious stimulus pre-and post TSM. They found a “significant reduction in subjects’ perception of pain (P<.01), as well as a reduction in cerebral blood flow as measured by the blood oxygenation level.”10 Thus leading us back to the patient with altered pain behaviors may need manual treatments, but to be weary to tracking outcomes as we this is making a general assumption not proven cause and effect within this diagnosis.
Overall, I think that physical therapy is still defining our place within treatment of CTS. Although I do have to say that we have groundwork in place as moderate amount of evidence to show that you should mobilize soft tissue and carpals, along with assessment of joints above as well. Personally, I treat very few patients with CTS, possibly due to lack of access to PT, possibly due to lack of strong evidence in our favor. Regardless, if a patient does present in clinic, best approach is addressing a patient locally and globally as we do within other areas. Hopefully the future will drive more research with therapy and CTS outcomes.
Original post: September 30, 2013
1) Wainner, R. S., Fritz, J. M., Irrgang, J. J., Delitto, A., Allison, S., & Boninger, M. L. (2005). Development of a clinical prediction rule for the diagnosis of carpal tunnel syndrome. Archives of physical medicine and rehabilitation, 86(4), 609–18. doi:10.1016/j.apmr.2004.11.008
2) Bialosky JE, Bishop MD, George SZ. Heightened Pain Sensitivity in Individuals with Signs and Symptoms of Carpal Tunnel Syndrome and the Relationship to Clinical Outcomes Following a Manual Therapy Intervention. Manual Therapy. 2011; 16: 602-608.
3) Llave De la, Fernandez-de-las-Penas C, Gernandez-Carnero J, Padua L, Arendt-Nielsen L, Pareja JA. Bilateral Hand/Wrist Heat and Cold Hyperagesia, but no Hypoesthesia in Unilateral Carpal Tunnel Syndrome. Exp Brain Res. 2009; 198: 455-63.
4) Akalin E, El, Peker O, Senocak , Tamci S, Gulbahar S, Cakmur R, Oncel S.: Treatment of Carpal Tunnel Syndrome With Nerve and Tendon Gliding Exercises. Am J Phys Med Rehabil. 2002;81:108–113.
5) Tal-Akabi, a, & Rushton, a. (2000). An investigation to compare the effectiveness of carpal bone mobilisation and neurodynamic mobilisation as methods of treatment for carpal tunnel syndrome. Manual therapy, 5(4), 214–22. doi:10.1054/math.2000.0355
6) Huisstede, B. M., Hoogvliet, P., Randsdorp, M. S., Glerum, S., van Middelkoop, M., & Koes, B. W. (2010). Carpal tunnel syndrome. Part I: effectiveness of nonsurgical treatments–a systematic review. Archives of physical medicine and rehabilitation, 91(7), 981–1004. doi:10.1016/j.apmr.2010.03.022
7) Goodyear-smith, F. (2004). Patients With Carpal Tunnel Syndrome Other Than Surgery ? A Systematic Review of Nonsurgical Management ABSTRACT, 267–273. doi:10.1370/afm.21.’
8) Wainner, R. S., Whitman, J. M., Cleland, J. a, & Flynn, T. W. (2007). Regional interdependence: a musculoskeletal examination model whose time has come. The Journal of orthopaedic and sports physical therapy,37(11), 658–60. doi:10.2519/jospt.2007.0110
9) Burke JM, Buchberger DJ, Carey-Loghmani CT, Doughterty PE, Greco DS, Dishman JD. A Pilot Study Comparing Two Manual Therapy Interventions for Carpal Tunnel Syndrome. Journal of Manipulative and Physiological Therapeutics. 2007; 30: 50-61.
10) Sparks, C., Cleland, J. a, Elliott, J. M., Zagardo, M., & Liu, W.-C. (2013). Using Functional Magnetic Resonance Imaging to Determine if Cerebral Hemodynamic Responses to Pain Change Following Thoracic Spine Thrust Manipulation in Healthy Individuals. The Journal of orthopaedic and sports physical therapy, 43(5), 340–8. doi:10.2519/jospt.2013.463
11) Nord KM, Kapoor P, Fisher J, Thomas G, Sundaram A, Scott K, Kothari MJ; False positive rate of thoracic outlet syndrome diagnostic maneuvers. Department of Neurology, Penn State Collage of Medicine, Hershey, PA 17033, USA. Electromyogr Clin Neurophysiol. 2008 Mar;48(2):67-74.
12) Verdugo RJ, Salinas RA, Castillo JL, Cea JG. Surgical versus non-surgical treatment for carpal tunnel syndrome. Cohrane Library. 2008.