Degrees Of Carpal Tunnel Syndrome Health And Social Care Essay
Carpal tunnel syndrome is a most common compression neuropathy of the upper extremity. It is caused by compression of median nerve in the carpal tunnel.
Women are more commonly affected than men. It is commonly seen in age group between 30 and 60 years. Carpal tunnel syndrome usually occurs due to excessive use of the hands and occupational exposure to repeated trauma.
Average cross sectional area of the carpal tunnel is 1.7 cm2 with the wrist in neutral position. Passive flexion and extension of the wrist has been increased the carpal tunnel pressure. Wrist extension increases carpal tunnel pressure more than the wrist flexion. Any space occupying mass or swelling of the structures in the tunnel also causes pressure on the median nerve.
Mostly, the cause of carpal tunnel syndrome is unknown. Any condition which causes pressure on median nerve at the wrist will result in carpal tunnel syndrome. Obesity, pregnancy, hypothyroidism, arthritis, diabetes and trauma are the common conditions that lead to carpal tunnel syndrome. Repetitive work such as uninterrupted typing which result in tendon inflammation can also cause carpal tunnel symptoms. Carpal tunnel syndrome due to repetitive activities has referred to one of the repetitive stress injuries. In some rare diseases such as amyloidosis, leukemia, multiple myeloma, and sarcoidosis, deposition of abnormal substances in and around the carpal tunnel leads to nerve irritation.
Prolonged flexion or extension of the wrists under the patients head or pillow during sleep is believed to contribute to the prevalence of nocturnal symptoms. Usually patient complaints pain, numbness and tingling sensation in the hand and fingers. Symptoms worsening at night typically awakening the patient or occurring on bunching up the hand for tasks such as writing.
Carpal tunnel syndrome is the most common cause of acroparaesthesiae often pain and paraesthesiae may be the only symptoms for many months or years. The syndrome is essentially a sensory one; the loss or impairment of superficial sensation affects the thumb, index and middle fingers and may be or may not split the ring finger. There may be wasting and weakness of the thenar muscles. Weakness and atrophy of the abductor pollicis brevis and other muscles supplied by median nerve occur in only the most advanced cases of compression.
Degrees of carpal tunnel syndrome are classified as dynamic, mild, moderate and severe. The pathophysiology of carpal tunnel syndrome is typically demyelination. Secondary axon loss may present in more severe cases. With 20 to 30 mm hg compression, the initial insult is a reduction in epineural blood flow. With wrist extension, intracarpal pressures routinely measure atleast 33 mm hg and often upto 110 mm hg in patients with carpal tunnel syndrome. Edema in the epineurium and endoneurium is caused by continued or increased pressure.
Carpal tunnel syndrome diagnosed by detailed history collection, phalen maneuver, percussion test, two point discrimination test, vibrometry, monofilament test, distal sensory latency and conduction velocity, distal motor latency conduction, upper limb tension tests. X-ray is taken to check for arthritis and fracture. If there is a suspected medical condition that is associated with carpal tunnel syndrome, laboratory tests may be done.
This condition could be mistaken for a brachial neuritis due to cervical intervertebral disc prolapse at C5 – C7 level. Nerve conduction tests on the median nerve help to localize the lesion in the tunnel.
Both conservative and surgical management options are available in order to reduce pressure over median nerve. The current conservative treatments include non steroidal anti inflammatory drugs, sometimes rest, local injection of corticosteroids, activity modification, ultrasound therapy, carpal bone mobilization, magnetic therapy, night and/or daytime wrist splint positioned at 0 to 15 degrees of extension, nerve and tendon gliding exercises. Anyone of the measures alone or in combination can be effective in treating early carpal tunnel syndrome.
Tendon gliding exercises are performed to lubricate and increase gliding of the flexor pollicis longus, flexor digitorum superficialis and flexor digitorum profundus tendons. They are best performed with the hand elevated to concurrently control local edema. Median nerve gliding exercises and the upper limb tension test with median nerve bias can be used as treatment techniques.
Modality treatment can also control symptoms and enhance the therapeutic exercise program.
Exercise intervention for carpal tunnel syndrome focuses on mobility and strengthening without producing an exacerbation. Stretches for the extrinsic and intrinsic muscles are prescribed for several times each day. If working, a patient should perform them before work. They should be performed slowly and gently; the patient feel only a gentle stretching sensation. In workplace, modification of the job site or complete ergonomic redesign is typically the most helpful approach. In addition yoga, chiropractics, laser treatment have been advocated.
Surgery is indicated in advanced cases with objective sensory loss and /or weakness or atrophy of the abductor pollicis brevis. In severe cases surgical division of the transverse carpal ligament relieves the condition. Surgical management includes open carpal tunnel release and endoscopic release. It aims to decompress nerve, to improve excursion and to prevent flexor damage.
Splinting is the most popular method of conservative management of carpal tunnel syndrome. Splints are recommended by the American Academy of Neurology for the Carpal tunnel syndrome with light and moderate pathology.
Immobilization of the wrist joint in a neutral position with splint will increase the carpal tunnel volume and minimize the median nerve pressure. Wrist Splinting in a neutral position will help reduce and may even completely relieve Carpal tunnel syndrome (Slater RR et al 1999).
Ultrasound therapy is more useful in the management of Carpal tunnel syndrome. It has the potential to accelerate normal resolution of inflammation. Ultrasound therapy elicit anti inflammatory and tissue stimulating effects. Ultrasound therapy accelerates the healing process in damaged tissues.
Pulsed Ultrasound therapy with the intensity of 1.0 w/cm2, 1:4 for fifteen minutes per session has significantly improved subjective symptoms in patients with carpal tunnel syndrome (Ebenbichler GR et al).
Nerve and tendon gliding exercises are used in conservative treatment of carpal tunnel syndrome to decrease adhesions and to regulate venous return in nerve bundles (Rozmaryn et al).
Nerve and tendon gliding exercises may maximize the relative movement of the median nerve within the Carpal tunnel and the excursion of flexor tendon relative to one another (Rempel D, Manojlovic R et al).
Wrist splint along with nerve and tendon gliding exercises showed significant improvement in reducing symptoms in Carpal tunnel syndrome. (Akalin et al)
NEED FOR THE STUDY:
Ultra sound therapy, splints, nerve and tendon gliding exercises are significantly effective in reducing symptoms in the treatment of Carpal tunnel syndrome. Combination of various treatments is also useful in reducing symptoms in Carpal tunnel syndrome. Ultrasound therapy helps to increase healing process in damaged tissue.
This study aimed to find out the effect of Ultrasound therapy in reducing pain in patients with Carpal tunnel syndrome.
STATEMENT OF THE PROBLEM
Effect of Ultrasound Therapy in reducing pain in patients with Carpal tunnel syndrome.
KEY WORDS:
Carpal tunnel syndrome
Ultrasound therapy
Splint
Exercises
Pain
Visual analogue scale (VAS)
AIM:
To find out the Effect of Ultrasound Therapy in reducing pain in patients with Carpal Tunnel Syndrome.
OBJECTIVE:
To study the Effect of Ultrasound Therapy in reducing pain in patients with Carpal Tunnel Syndrome.
HYPOTHESIS:
1.6.1. NULL HYPOTHESIS
There is no significant effect of Ultrasound Therapy, Splint and Exercises in reducing pain in patients with Carpal Tunnel Syndrome.
There is no significant effect of Splint and Exercises in reducing pain in patients with Carpal Tunnel Syndrome.
There is no significant difference between the effect of Ultrasound Therapy, Splint and Exercises and Splint and Exercises in reducing pain in patients with Carpal Tunnel Syndrome.
1.6.2. ALTERNATE HYPOTHESIS
There is significant effect of Ultrasound Therapy, Splint and Exercises in reducing pain in patients with Carpal Tunnel Syndrome.
There is significant effect of Splint and Exercises in reducing pain in patients with Carpal Tunnel Syndrome.
There is significant difference between the effect of Ultrasound Therapy, Splint and Exercises and Splint and Exercises in reducing pain in patients with Carpal Tunnel Syndrome.
II.REVIEW OF LITERATURE
CARPAL TUNNEL SYNDROME
DAVID A FULLER, MD, et al (2010)
Stated that carpal tunnel syndrome is the most common entrapment neuropathy. The syndrome is characterised by pain, paraesthesia, and weakness in the median nerve distribution of the hand. The etiology of carpal tunnel syndrome is multifactorial which is contributed by various degrees of local and systemic factors. Symptoms of carpal tunnel syndrome are due to ischemia and impaired axonal transport of the median nerve which results from median nerve compression at the wrist. (Lunborg G, Dahlin LB 1992). Elevated pressure inside the carpal tunnel leads to compression.
HARVEY SIMON, MD et al, (2009)
Stated that carpal tunnel syndrome is considered as an inflammatory disorder caused by medical conditions, physical injury or repetitive stress.
JEFFREY G NORVELL, MD et al (2009)
Stated that carpal tunnel syndrome (CTS) is caused predominantly by median nerve compression at the wrist because of hypertrophy or oedema of the flexor synovium. Pain is thought to be secondary to nerve ischemia rather than direct physical damage of the nerve.
S.BRENT BROTZMAN, MD (2003)
Explained that degree of the carpal tunnel syndrome as dynamic, mild moderate and severe. In mild cases, patients has intermittent symptoms, decreased light touch, positive digital compression test and positive tinel sign or phalen test may or may not be present. In moderate cases, patients have frequent symptoms, decreased vibratory sense, muscle weakness, positive tinel sign, phalen test and digital compression test.
GERRITSEN AA, DE KROM MC, STRUIJS MA, ET AL (2002)
Stated that carpal tunnel syndrome (CTS) is caused by median nerve compression at the wrist and is considered to be the more common entrapment neuropathy. Symptoms of carpal tunnel syndrome include pain, numbness or tingling sensation, paraesthesia, involving the fingers innervated by the median nerve. (Bakhtiary AH, Rashidy Pour AR et al 2004)
GELBERMAN RH, HERGENROEDER PT, HARGENS AR, RYDEVIK B, LUNDBORG G, BAGGE U (1981)
Fracture callus, osteophytes, anomalous muscle bodies, tumours, hypertrophic synovium, and infection as well as gout and other inflammatory conditions can produce increased pressure within the carpal tunnel. Extremes of wrist flexion and extension also elevate pressure within the carpal tunnel. Intraneural blood flow is affected by compression on nerve. Venular blood flow in a nerve is reduced by pressure as low as twenty to thirty mm Hg. At level of thirty mm Hg, axonal transport is impaired. At forty mm Hg, neurophysiologic changes manifested as sensory and motor dysfunctions are present. Any further increase in pressure will produce sensory and motor block. At level of sixty to eighty mm Hg, complete cessation of intraneural blood flow is seen. In one study, the carpal tunnel pressure in patients with carpal tunnel syndrome averaged thirty two mm Hg, compared with only about two mm Hg in control subjects.
RH GELBERMAN, AR HARGENS, GN LUNDBORG, PT HERGENROEDER et al, (1981)
Measured intra carpal canal pressures with the wick catheter in 15 patients with carpal tunnel syndrome and in 12 control subjects. The average pressure in the carpal tunnel was raised significantly in the patients with carpal tunnel syndrome. When the wrist was in neutral position, the mean pressure was 32 millimeters of mercury. With ninety degrees of wrist flexion the pressure raised to 94 millimeters of mercury. While with ninety degrees of wrist extension the average pressure was 110 millimeters of mercury. The pressure of carpal canal in the control subjects with the neutral position of wrist was 2.5 millimeters of mercury; with wrist flexion the carpal canal pressure rise to 31 millimeters of mercury, and with wrist extension it increased to 30 millimeters of mercury.
GEORGE S. PHALEN M.D, et al (1966)
Stated that diagnosed Carpal tunnel syndrome has been made in 654 hands of 439 patients during the last seventeen years. The typical patient with this syndrome is a middle-aged housewife with numbness and tingling in the thumb and index, long, and ring fingers, which is worse at night and worse after excessive activity of the hands. The sensory disturbances both objective and subjective must be directly related to the sensory distribution of the median nerve distal to the wrist but pain may be referred proximal to the wrist as high as the shoulder. There is usually a positive tinel sign over the median nerve at the wrist, and the wrist flexion test is also usually positive. About half of the patients also have some degree of thenar atrophy.
In clinical practice, Carpal tunnel syndrome is the most commonly seen entrapment mononeuropathy which is caused by median nerve compression at the wrist (PHALEN 1966, GELBERMAN et al 1998). Usually patients show one or more symptoms of hand weakness, pain, numbness or tingling in the hand, especially in the thumb, index and middle fingers (SIMOVIC and WEINBERG 2000). Symptoms are worst during night time and often wakeup the patient.
WILLIAM C. SHIEL JR., MD.FACP, FACR, et al
Stated that the cause of the carpal tunnel syndrome is unknown. Any condition which causes pressure on the median nerve at the wrist will result in carpal tunnel syndrome. Common conditions such as obesity, pregnancy, hypothyroidism, arthritis, diabetes, and trauma can lead to carpal tunnel syndrome. Repetitive work such as uninterrupted typing result in tendon inflammation can also cause Carpal tunnel symptoms. In some rare diseases such as amyloidosis, leukemia, multiple myeloma, and sarcoidosis, deposition of abnormal substances in and around the carpal tunnel leads to nerve irritation.
MEDIAN NERVE
LUNDBORG G, DAHLIN LB, et al (1996)
Stated that throughout the extremity movement, mobility of the peripheral nerve changes and longitudinal movement of the median nerve mostly occur in the carpal tunnel. In Carpal tunnel syndrome, this physiologic mobility of the median nerve disappears.
REMPEL D, MANOJLOVIC R, LEVINSOHN DG, et al (1994)
Stated that during the exercise there may be redistribution of the point of maximal compression on the median nerve. This milking effect would promote venous return from the median nerve, thus decreasing the pressure inside the perineurium.
NAKAMICHI AND S. TACHIBANA et al
Conducted a study the motion of median nerve in patients with carpal tunnel syndrome and normal subjects. Median nerve motion was assessed by axial ultrasonographic imaging the mid carpal tunnel. They concluded that wrist of patients with Carpal tunnel syndrome showed less sliding which indicates that physiological motion of the nerve is restricted. This decrease in nerve mobility may be of significance in the pathophysiology of carpal tunnel syndrome.
ULTRASOUND THERAPY
BAKHTIARY AH, RASHIDY-POUR A et al (2004)
Conducted a study to compare the effect of Ultrasound and laser therapy in patients with mild to moderate idiopathic carpal tunnel syndrome. By electromyography findings, 90 hands in 50 consecutive patients with carpal tunnel syndrome were confirmed and allocated randomly in two groups. One group received low level laser therapy and the other group received ultrasound therapy. Ultrasound treatment (pulsed 1:4, 1.0 W/cm2, 1 MHz, 15 min/session) and low level laser therapy (infrared laser, 830nm, 9 Joules, at five points) were given to the carpal tunnel for fifteen daily treatment sessions. Ultrasound group showed more significant improvement than low level laser therapy group in motor latency, motor action potential amplitude, finger pinch strength, and pain reduction. Effects were also sustained in the follow-up period. They concluded that ultrasound therapy was more effective than laser therapy in the management of carpal tunnel syndrome.
EBENBICHLER GR, RESCH KL et al (1998)
Studied the efficacy of Ultrasound therapy in patients with mild to moderate idiopathic Carpal tunnel syndrome. Ultrasound with parameters 1MHZ, 1.0 W/cm2 pulsed mode 1:4, 15 minutes per session was applied over the carpal tunnel and compared with Sham Ultrasound. Actively treated ultrasound group showed significant improvement than sham treated wrists in both subjective symptoms and electroneurographic variables. To confirm the usefulness of ultrasound therapy for Carpal tunnel syndrome, more studies are needed. Additional randomized trials comparing conservative therapies for Carpal tunnel syndrome would be useful in selecting appropriate treatments for individual patients.
EL HAG M, COGHLAN K, CHRISMAS P et al (1985)
Stated that Ultrasound could elicit anti-inflammatory and tissue-stimulating effects as already shown in clinical trials and experimentally (Byl et al 1992, Young and Dyson 1990). In this way, Ultrasound has the potential to accelerate normal resolution of inflammation (Dyson 1989).
The results of these studies confirm that Ultrasound may accelerate the healing process in damaged tissues. In mild to moderate carpal tunnel syndrome patients, these mechanisms may explain their findings including pain relief, increased grip and pinch strength, and changed electrophysiological parameters toward normal values better than Laser therapy.
WRIST SPLINT
Wrist splints help to keep the wrist straight and reduce pressure on the compressed nerve. Doctor may recommend the patients to wear wrist splints either at night, or both day and night, although patient may find that they get in the way when they are doing their daily activities. Some research indicates that ultrasound treatment may help to reduce the symptoms of carpal tunnel syndrome. (BUPA’S health information team 2010)
BRININGER TL, ROGERS JC et al (2007)
Fabricated customized neutral splint and nerve and tendon gliding exercises is more effective than wrist cock up splint and nerve and tendon gliding exercises in reducing symptoms and improving functional status in the treatment of Carpal tunnel syndrome.
GERRITSEN AA, DE KROM MC, STRUIJS MA, et al (2002)
Immobilization of the wrist joint in a neutral position with a splint will maximizes carpal tunnel volume and minimize the pressure acting on median nerve.
AKALIN E, EL O, SENOCAK O, et al (2002)
Compared the effect of wrist splint alone to wrist splint with nerve and tendon gliding exercises in the treatment of carpal tunnel syndrome. In their study, both groups showed significant improvement in clinical parameters, functional status scale and symptom severity scale. They also reported significant improvement only in pinch strength in the group with wrist splint in combination with exercises compared with the wrist splint group.
MANENTE G, TORRIERI F, et al (2001)
Stated that wearing a specially designed wrist splint at night time for four weeks was more effective than no treatment in reducing the symptoms of Carpal tunnel syndrome.
SLATER RR, et al (1999)
Stated that splinting the wrist in a neutral position will help to reduce and may even completely relieve carpal tunnel syndrome symptoms.
SAILER SM, et al (1996)
Stated that the optimal splinting regimen depends on the patient’s symptoms and preferences. To prevent prolonged wrist flexion or extension, night splint use is recommended.
BURKE DT, STEWRT GW, CAMBER A, et Al (1994)
Stated that carpal tunnel syndrome is the commonest compression neuropathy in the upper limb. Several studies have demonstrated the effect of wrist splint in reducing the symptoms of carpal tunnel syndrome. But the chosen angle of immobilization has varied in the management of carpal tunnel syndrome. Wick catheter measurements of carpal tunnel pressures suggest that the neural position has less pressure and, therefore, greater potential to provide relief from symptoms.
KRUGER VL, KRAFT GH, et al (1991)
Stated that wrist splint at a neutral angle helps to decrease repetitive flexion and rotation, thereby relieving mild soft tissue swelling or tenosynovitis. Splinting is most effective when it is applied within three months of the onset of symptoms.
NERVE AND TENDON GLIDING EXERCISES
BAYSAL O, ERTEMK, YOLOGLUS, ALTAY Z, KAYHANA et al (2006)
Stated that combination of ultrasound therapy, splinting and exercises is a preferable and an efficacious treatment for patients with carpal tunnel syndrome.
ROZMARYN LM, et al (1998)
Used nerve and tendon gliding exercises in conservative treatment models to decrease adhesions developed in the carpal tunnel and regulate venous return in the nerve bundles. They reviewed more than 200 hands under consideration for carpal tunnel decompression. Altogether 71% of the patients who were not offered gliding exercises went forward to surgery; only 43% of the gliding exercise group was felt to require surgery.
SERADGE et al (1995)
Stated that intermittent active wrist and finger flexion-extension exercises reduce the pressure in the carpal tunnel.
SZABO et al (1994)
Showed that the relationship between median nerve and flexor tendon excursion was consistently linear. They suggested active finger motion of the median nerve and flexor tendons in the vicinity of the wrist to prevent adhesion formation even if the wrist is immobilized.
REMPEL D, MANOJLOVIC R, LEVINSOHN DG, et al (1994)
Stated that the median nerve movement is increased by nerve and tendon gliding exercises in the carpal tunnel and the flexor tendons excursion is increased in relative to one another.
TOTTEN AND HUNTER, et al (1991)
Proposed a series of exercises enhancing the gliding of the median nerve and tendon at the carpal tunnel for management of postoperative Carpal tunnel syndrome. They also suggested these exercises for non-operative Carpal tunnel syndrome.
LAMINA PINAR, SAIT ADA AND NEVIN GUNGOR ET AL
Stated that nerve and tendon gliding exercises included in conservative therapy approaches showed more rapid pain reduction and greater functional improvement in grip strength.
HANNAH RICE MYERS, et al
Stated that carpal tunnel exercises reduce the tension on the tendons in the tunnel and strengthen the weakened muscles of wrist and forearms. Even though nerve and tendon gliding exercises are effective when used alone, they have a greater effect when used along with other intervention such as splint. For people who are involving jobs with keeping their hands in a fixed position throughout the day such as typing secretaries, these exercises may help to prevent carpal tunnel syndrome from developing.
VISUAL ANALOGUE SCALE
POLLY E. BIJUR PHD, WENDY SILVER MA, E. JOHN GALLAGHER MD et al (2008)
Conducted to study to assess the reliability of the visual analogue scale (VAS) for acute pain measurement as assessed by the intraclass correlation coefficients (ICC) appears to be high. The results showed that the Visual analogue scale (VAS) is sufficiently reliable to be used to assess acute pain.
PAUL S. MYLES, MBBS, MPH, MD, FFARCSI, et al (1999)
Stated Visual analog scale (VAS) is a tool widely used to measure pain. A patient is asked to indicate his/her perceived pain intensity (most commonly) along a 100 mm horizontal line, and this rating is then measured from the left edge (VAS score). The visual analogue scale score correlates well with acute pain.
JOYCE, et al
Suggested that visual analogue scale and another scales have been compared in terms of sensitivity, distribution of responses and preferences. Results of these studies appear equal. The visual analogue scale has been described as superior in one study because it was more sensitivity than any other scale.
III. METHODOLOGY
3.1 STUDY DESIGN:
Pretest and Posttest Experimental group study design.
3.2 STUDY SETTING:
The study was conducted at Department of Physiotherapy, K.G.Hospital, Coimbatore.
3.3 STUDY DURATION:
3 weeks for each individual subject and the total duration was one year.
3.4 STUDY POPULATION:
Patients with Carpal tunnel syndrome referred to the Department of physiotherapy, K.G.Hospital, Coimbatore.
3.5 STUDY SAMPLE:
All patients with carpal tunnel syndrome who referred to Department of Physiotherapy, K.G. Hospital were selected. Among all patients, 20 patients who satisfied inclusive and exclusive criteria were selected and assigned into two groups, 10 of each by using Purposive Sampling method.
3.6 CRITERIA FOR SELECTION:
INCLUSIVE CRITERIA:
Age group above 30 years.
Both sexes.
Patients with mild to moderate unilateral carpal tunnel syndrome.
Patients with Positive Tinel sign, Phalens test and Digital compression test.
EXCLUSIVE CRITERIA:
Patients with severe carpal tunnel syndrome
Patients having thenar atrophy or denervation on electromyographic findings
Patients with a neuropathy other than carpal tunnel syndrome in the past year
Patient with history of steroid injection in carpal tunnel in the past 3 months
Patients had a prior carpal tunnel release
Cervical disc prolapse
Degenerative changes of cervical spine
Acute upper limb fractures
Wrist and fingers stiffness
Recent hand surgeries
Deqeurain’s disease
Pregnancy
Acute Infections of Wrist and Hand
3.7 Variables:
Dependent variable
Pain.
Independent variable
Visual analogue scale.
3.8 Orientation of subjects:
Before treatment all the patients were explained about the study and procedure to be applied and were asked to inform if they feel any discomfort during the course of the treatment. All the willing patients were asked to sign the consent form before the treatment.
3.9 OUTCOME MEASURES:
Pain.
3.10 OPERATIONAL TOOLS:
Visual analogue scale
3.11 STUDY PROCEDURE:
20 Patients with carpal tunnel syndrome were selected for this study after due consideration of inclusive and exclusive criteria. 20 patients were divided into 2 groups of 10 each.
Group A:
10 patients received ultrasound therapy, splint and exercises. Ultrasound therapy with parameters of 1 MHz pulsed mode, 1:4, 1 w/cm2 is given 15 minutes per day, five times per week. Custom made neutral volar splint is given at night and during day time. Exercises are nerve and tendon gliding exercises. During tendon-gliding exercises, the fingers are placed in five discrete positions. Those were straight, hook, fist, table top, and straight fist. During the median nerve-gliding exercise the median nerve was mobilized by putting the hand and wrist in six different positions. During these exercises the neck and the shoulder were in a neutral position and the elbow was in supination and 90 degrees of flexion. Each position was maintained for 5 seconds. Each exercise is repeated 10 times at each session, 5 sessions per day.
The total treatment duration is 3 weeks.
Group B:
10 patients received only Splint and Exercises.
Custom made neutral volar splint is given at night and during day time. Exercises are nerve and tendon gliding exercises. During tendon-gliding exercises, the fingers are placed in five discrete positions. Those were straight, hook, fist, table top, and straight fist. During the median nerve-gliding exercise the median nerve was mobilized by putting the hand and wrist in six different positions. During these exercises the neck and the shoulder were in a neutral position and the elbow was in supination and 90 degrees of flexion. Each position was maintained for 5 seconds. Each exercise is repeated 10 times at each session, 5 sessions per day.
The total treatment duration is 3 weeks.
3.12 STATISTICAL TOOLS:
Statistical analysis was done using Student t-test.
Paired ‘t’ test
Where,
n = Total number of subjects
SD = Standard deviation
d = Difference between initial and final value
= Mean difference between initial and final value.
(ii) Unpaired’t’ test:
To compare the pre test, post test values of both groups independent’t’ test is used.
Where,
n1 = Number of subjects in Group A.
n2 = Number of subjects in Group B.
= Mean of Group A
= Mean of Group B
s1 = Standard deviation of Group A.
s2 = Standard deviation of Group B.
S = Combined standard deviation
IV.DATA ANALYSIS AND INTERPRETATION
TABLE-1
VISUAL ANALOGUE SCALE FOR PAIN – GROUP A
PAIRED’t’ TEST
Mean values, mean differences, standard deviation and’t’ values of Visual Analogue Scale for Group A who underwent Ultrasound therapy, Splint, Nerve and Tendon gliding exercises.
S. NO
VAS
Improvement
‘t’ value
Mean
Mean difference
Standard deviation
1.
Pre test
5.60
3.90
0.70
39.0
2.
Post test
1.70
0.67
FIGURE-1
GRAPHICAL REPRESENTATION OF MEAN
VISUAL ANALOGUE SCALE FOR GROUP A
TABLE-2
VISUAL ANALOGUE SCALE FOR PAIN FOR GROUP B
PAIRED’t’ TEST
Mean values, mean differences, standard deviation and’t’ values of Visual Analogue Scale for Group B who underwent to Splint, Nerve and Tendon gliding exercises.
S. NO
VAS
Improvement
‘t’ value
Mean
Mean difference
Standard deviation
1.
Pre test
5.40
3.0
0.70
20.12
2.
Post test
2.40
0.52
FIGURE-2
GRAPHICAL REPRESENTATION OF MEAN
VISUAL ANALOGUE SCALE FOR GROUP B
TABLE-3
VISUAL ANALOGUE SCALE FOR PAIN
PRETEST VALUES OF GROUP A VERSUS GROUP B
UNPAIRED’t’ TEST
Mean, mean difference, standard deviation and unpaired’t’ test of pre test values of VAS between Group A and Group B
S. NO
VAS
Improvement
‘t’ value
Mean
Mean difference
Standard deviation
1.
Group A
5.60
0.20
0.70
0.64
2.
Group B
5.40
FIGURE-3
GRAPHICAL REPRESENTATION OF MEAN
VISUAL ANALOGUE SCALE FOR PAIN
PRETEST VALUES BETWEEN GROUP A AND B
TABLE-4
VISUAL ANALOGUE SCALE FOR PAIN
POSTTEST VALUES OF GROUP A VERSUS GROUP B
UNPAIRED’t’ TEST
Mean, mean difference, standard deviation and unpaired’t’ test of post test values between VAS for Group A and Group B
S. NO:
VAS
Improvement
‘t’ value
Mean
Mean difference
Standard deviation
1.
Group A
1.70
0.70
0.67
2.60
2.
Group B
2.40
0.52
FIGURE-4
GRAPHICAL REPRESENTATION OF MEAN OF VISUAL ANALOGUE SCALE OF GROUPS BETWEEN A AND B (POST TEST)
ANALYSIS OF RESULTS:
20 patients with carpal tunnel syndrome were divided into two groups. Group A received Ultrasound Therapy, Splint and Exercises and Group B received only Splint and Exercises. This study was carried out for 3 weeks for an individual subjects. Pain intensity was assessed by using visual analogue scale (VAS).
In this study, Statistical analysis was done by Student’t’ test. Paired’t’ test was used to find out the improvement within the group. Unpaired’t’ test was used to find out the difference between two groups.
PAIRED ‘t’ TEST:
GROUP A – ULTRA SOUND THERAPY, SPLINT AND EXERCISES
The calculated value for Group A was 39.0 which was greater than the tabulated ‘t’ value of 1.833 with 9 degrees of freedom at the level of significance of 5%. The result showed that there is significant effect of Ultrasound therapy, Splint and Exercises in reducing pain in patients with Carpal tunnel syndrome.
GROUP B – SPLINT AND EXERCISES ALONE
The calculated value for Group B was 20.12 which was greater than the tabulated ‘t’ value of 1.833 with 9 degrees of freedom at the level of significance of 5%. The result showed that there is significant effect of Splint and Exercises alone in reducing pain in patients with Carpal tunnel syndrome.
UNPAIRED ‘t’ TEST:
PRETEST VALUES:
The calculated pretest value was 0.64 which was lesser than the tabulated ‘t’ value of 1.734 with 18 degrees of freedom at 5% level of significance. The result showed that there is no significant difference between the effect of Ultrasound therapy, Splint and Exercises and Splint and Exercises alone in reducing pain in patients with Carpal tunnel syndrome.
POSTTEST VALUES:
The calculated posttest value was 2.60 which was greater than the tabulated ‘t’ value 1.734 with 18 degrees of freedom at 5% level of significance. The result showed that there is significant difference between the effect of Ultrasound therapy, Splint and Exercises and splint and Exercises alone in reducing pain in patients with Carpal tunnel syndrome.
V. DISCUSSION
This study aimed to find out the effect of ultrasound therapy in reducing pain in patients with carpal tunnel syndrome.
20 patients who satisfied inclusion and exclusion criteria were selected and assigned into 2 groups, 10 in each group.
Group A underwent ultrasound therapy, splint and exercises and Group B underwent splint and exercises alone for the period of duration of three weeks.
Statistical analysis was done by using Student’t’ test. The results showed that there was a significant difference between the effect of Ultra sound therapy, Splint and Exercises and Splint and Exercises alone in reduction of pain in patients with Carpal tunnel syndrome. Paired’t’ test concluded that there was a significant reduction in pain in ultrasound therapy, splint and exercises and splint and exercises alone. These results were supported by studies as follows.
Baysal O et al 2006 concluded that Combination of splinting, nerve and tendon gliding exercises and ultrasound therapy is a preferable and an effective treatment in patients with carpal tunnel syndrome.
Rashidy-Pour A, Bakhtiary AH, et al 2004; Compared the effect of ultrasound and laser treatment in mild to moderate idiopathic carpal tunnel syndrome patients. Ultrasound therapy was more effective than laser therapy for the treatment of carpal tunnel syndrome.
Ebenbichler GR, Resch KL, et al 1998. Compared Ultrasound therapy (1 MHz, 1.0w/cm2, pulsed mode 1:4, 15min/session) with sham ultra sound in patients with mild to moderate idiopathic carpal tunnel syndrome. Improvement was significantly more pronounced in actively treated than in sham treated wrists for both subjective symptoms and electroneurographic variables.
Lamina Pinar, Aysel Enhos, et al, Stated that nerve and tendon gliding exercises included in conservative therapy approaches demonstrated more rapid pain reduction and greater functional improvement in grip strength.
Akalin E, El Ã-, Senocak O, et al 2002 Compared the wrist splint alone with wrist with nerve and tendon gliding exercises for the efficacy of the treatment. They reported that significant improvement in clinical parameters, functional status scale and symptom severity scale in both groups. They also reported significant improvement only in pinch strength in the wrist with exercises compared with wrist splint alone.
Brininger Tl, Rogers Jc, et al stated that Fabricated customized neutral splint and nerve and tendon gliding exercises is more effective than wrist cock up splint and nerve and tendon gliding exercises in reducing symptoms and improving functional status in the treatment of carpal tunnel syndrome.
Totten and Hunter, et al 1991 proposed a series of exercises that enhances the median nerve gliding at the carpal tunnel in the management of postoperative Carpal tunnel syndrome. They also suggested these exercises for the management of non-operative Carpal tunnel syndrome.
El Hag M, Coghlan K, Chrismas P, et al 1985 stated that Ultrasound therapy elicits anti-inflammatory and tissue stimulating effects. Ultrasound therapy has the potential to accelerate normal resolution of inflammation. Ultrasound therapy may accelerate the healing process in damaged tissues. These mechanisms may explain our findings including pain relief, increased grip and pinch strength, improvement in functional status and symptom severity scale in carpal tunnel syndrome treated with ultra sound therapy.
Gerritsen AA, De Krom Mc, Struijs Ma, et al 2002 Immobilization of the wrist joint in a neutral position with a splint maximizes carpal tunnel volume and thereby pressure over median nerve is reduced.
Nakamichi and S. Tachibana, et al Conducted a study to analyse the motion of median nerve in patients with carpal tunnel syndrome and normal subjects. Results showed less sliding which indicates that physiological motion is restricted. This decrease in nerve mobility may be of significance in the pathophysiology of carpal tunnel syndrome.
Rempel D, Manojlovic R, Levinsohn DG. 1994 Stated that tendon and nerve gliding exercise may improve the relative median nerve excursion inside the carpal tunnel and the excursion of flexor tendons relative to one another. And also they stated that during the exercise, there may be redistribution of the point of maximal compression on the median nerve. This milking effect would promote venous return from the median nerve, thus decreasing the pressure inside the perinerium.
Seradge, et al 1995 stated that intermittent active wrist and finger flexion-extension exercises reduce the pressure in the carpal tunnel.
Rozmaryn LM, Dovelle S, Rothman ER et al 1998 Used nerve and tendon gliding exercises in conservative treatment models to decrease adhesions developed in the carpal tunnel and regulate venous return in the nerve bundles.
Ultrasound therapy treatment using pulsed mode accelerate healing process in damaged tissues, thereby produce pain relief, improved grip and pinch strength, functional status of carpal tunnel syndrome patients .
Wrist Splint maximizes the carpal tunnel volume and minimizes the pressure over median nerve. Wrist Splint prevents prolonged repetitive wrist flexion or extension, thereby reducing mild soft tissue swelling or relieving tenosynovitis.
Nerve and tendon gliding exercise are also used in non operative carpal tunnel syndrome. Exercises maximize the relative excursion of median nerve in carpal tunnel and flexor tendons relative to one another. Exercises produce milking effect which promotes venous return from median nerve thus decreasing pressure inside the perineurium.
Active nerve and tendon gliding exercises prevent adhesion formation and reduce pressure in the carpal tunnel.
Therefore added effects of ultrasound therapy to splint and exercises demonstrated pain reduction in patients with carpal tunnel syndrome.
VI. SUMMARY AND CONCLUSION
This study was conducted to find out the effect of ultrasound therapy in
reducing pain in patients with carpal tunnel syndrome.
20 patients were selected in the age group above 30 years after due consideration of inclusion and exclusion criteria. The patients were divided into 2 groups and named as group A and group B.
Group A received ultra sound therapy, splint and exercises and group B received only splint and exercises. This study was carried out for 3 weeks for an individual subjects.
Before and after 3 weeks of the study the outcome measures were recorded. Pain intensity was assessed by using Visual Analogue Scale (VAS).
Statistical analysis was done by Student’t’ test. Paired’t’ test was used to find out the improvement within the group. Unpaired’t’ test was used to find out the difference between two groups.
Based on the statistical analysis there was a significant difference between the effect of Ultra sound therapy, Splint and Exercises and only Splint and Exercises in reduction of pain in patients with Carpal tunnel syndrome.
This study concluded that Ultrasound Therapy, Splint and Exercises were effective in reducing pain in patients with Carpal tunnel syndrome than Splint and Exercises alone.
VII. LIMITATIONS AND RECOMMENDATIONS
The study was a short term study
The study has a small sample size
In this study, pain was only measured by visual analogue scale (VAS).
Outcome parameters such as Hand Grip and Pinch strength, Symptom severity scale, Function status scale, Static two point discrimination measurement, EMG findings (sensory and motor distal latency), and Levin’s self-administered questionnaire were used in further studies.
Studies aimed to compare out the effect of Ultrasound therapy with low laser therapy, carpal bone mobilization can be conducted for further reseasrch.
VIII.BIBLIOGRAPHY
1. David J. Magee, (III edition) Orthopaedic Physical Assessment, Saunders, Philadelphia (2002).
2. Susan B. O’sullivan, Thomas J. Schmitz. Physical Rehabilitation Assessment and Treatment (IV edition). Jaypee Brothers, New Delhi (2001).
3. Nichola J. Pretty and P. Moore. Neuromusculoskeletal Examination and Assessment. A Hand Book for Physiotherapist (I edition). Churchill Livingstone, Edinburgh (1998).
4. Roland C. Evans. Illustrated Orthopaedic Physical Assessment (II edition), Mosby St.Louis (2001).
5. Suresh war Pandey, Anil Kumar Pandey, Clinical Orthopaedic Diagnosis (II edition), Jaypee Brothers, New Delhi (2000).
6. Prakash P. Kotwala, Mayilvahanan Natarajan. Textbook of orthopaedics (I edition), Elsvier, New Delhi (2005).
7. Stuart B. Porter. Tidy’s Physiotherapy (XIII edition). Butterworth Steinmann, Edinburgh (2003).
8. Jayant Joshi and Prakash Kotwal. Essentials of Orthopaedics and Applied Physiology (I edition) Elsevier, NewDelhi (2000).
9. Wolf Schamberger. The Malignant Syndrome, Churchill Livingstone, Edinburgh (2002).
10. M.N. Natarajan Orthopaedics and traumatology (IV edition) M.N. orthopaedic hospital, Chennai (1994).
11. David J .Dandy, Dennis j. Edwards. Essential orthopaedics and trauma (III edition) Churchill livingstone, Edinburgh (2001).
12. Louis Solomon, David j. Warwick, Selva durai nayagam . Apley’s syste m of orthopaedics (VIII edition) Arnold co., Edinburgh (1997).
13. Downie Patricia. Cash textbook of orthopaedics and rheumatology for physiotherapists (I edition) Jaypee Brothers NewDelhi (1993).
14. William E.Prentice, Michael L. Voight. Techniques in Musculo Skeletal Rehabilitation, Mcgraw – Hill, Newyork (2001).
15. Robert A. Donotelli, Michael J. Wooden. Orthopaedic Physical Therapy (III edition) Churchill Livingstone, Newyork (2001).
16. Carrie M. Hall, Lorithein Brody. Therapeutic Exercise – Moving Toward Function. Lippincott Williams and Wilkins, Philadelphia (2005).
17. S. Brentz Brotzman , Kevin E. Wilk. Clinical Orthopaedic Rehabilitation (II edition) Mosby Philadelphia (2003).
18. Terry R Molole, Thomas G Mcpoil, Arthur J. Nitz. Orthopaedic and Sports Physiotherapy (II edition) Mosby st. Louis (1997).
19. Carolyn Kishner. Therapeutic Exercises Foundation and Techniques. Jaypee Brothers NewDelhi (1996).
20. John Ebnezar. Essentials of Orthopaedics for Physiotherapists (I Ed). Jaypee NewDelhi (2003).
21. Carolyn M Hicks. Research for Physiotherapists, Project Design and Analysis. Churchill Livingstone, Newyork (1995).
22. Elizabeth Domhold. Physical Therapy Research Principles and Applications. W .B. Saunders Company Philadelphia (1993).
23. Kothari C.R. Research Methodology, Methods and Techniques (II ed )
Vishva Prakashan, NewDelhi (2001).
24. R.S.N. Pillai, V. Bagavathi. Statistics Theory and Practice .S. Chand and Company Ltd., NewDelhi (1997).
25. Gerritsen AA, de Krom MC, Struijs MA et al. Conservative treatment options for carpal tunnel syndrome.
26. Totten PA, Hunter JM. Therapeutic techniques to enhance nerve gliding in thoracic outlet syndrome and carpal tunnel syndrome.
27. Bakhtiary AH et al Ultrasound and Laser therapy in the treatment of Carpal tunnel syndrome 2006.
28. Dawson DM. Entrapment Neuropathies of the Upper extremities.
29. Kruger V, Kraft G, Deitz J et al, Carpal tunnel syndrome: objectives measures and splint use.
30. Burke DT, Mchale M, Stewart GW et al. Splinting for Carpal tunnel syndrome.
31. Weiss AP, Sachar K, Gendreauu M et al. Conservative management of Carpal tunnel syndrome.
32. Slater RR Jr. Carpal tunnel syndrome, Current concepts.
33. Szumski AJ. Mechanism of pain relief as a result of therapeutic application of Ultra sound.
34. V Robertson, A Ward, J Low and A Reed. Electrotherapy Explained: Principles and practice.
35. Michelle Cameron. Physical agents in rehabilitation: From research to practice.
35. McGraw-Hill Medical; 3rd revised edition, By Prentice, William E. Ph.D. Therapeutic Modalities in Rehabilitation.
36. Virendra Kumar Khokhar. Helpline Electrotherapy for Physiotherapists.
37. M.Deena Gardiner. The Principles of Exercise Therapy
38.Elaine Ewing Fess,Karan Gettle. Hand and Upper Extremity Splinting: Principles and Methods.
39. Lundborg G, Dahlin LB. The pathophysiology of nerve compression. Hand Clin. May 1992;8(2):215-27.
39. Gelberman RH, et al. The carpal tunnel syndrome. A study of carpal canal pressures. J Bone Joint Surg Am. Mar 1981; 63(3):380-3.
40. Gelberman RH, et al. Tissue pressure threshold for peripheral nerve viability. Clin Orthop Relat Res. Sep 1983; (178):285-91.
41. Housang Seradge, MD, et.al. Poster exhibit, 1996 Annual Meeting, American Academy of Orthopaedic Surgeons.
42. Keir, PJ, et al DM. Pathomechanics of peripheral nerve loading. Evidence in Carpal tunnel syndrome. J Hand Ther 2005; 18:259.
43. Gerritsen, AA, Splinting for carpal tunnel syndrome: prognostic indicators of success. J Neurol Neurosurg Psychiatry 2003; 74:1342.
IX.APPENDIX
APPENDIX-I
ORTHOPAEDIC ASSESSMENT
SUBJECTIVE EXAMINATION:
Name: Date of Assessment:
Age:
Sex:
Occupation:
Address:
Chief Complaints:
History:
Present Medical History:
Past Medical History:
Drug History:
Surgical History:
Personal History:
Family History:
Socioeconomic History:
Psychological History:
Environmental History:
Prior Level of Activity:
Associated Problem:
Pain History:
Site:
Side:
Onset:
Duration:
Type:
Nature:
Frequency:
Aggravating Factor:
Relieving Factor:
Intensity: VAS Score 0_________________ 10
Vital Signs:
Temperature: Heart Rate:
Respiratory Rate: Blood Pressure:
OBJECTIVE EXAMINATION:
ON OBSERVATION:
Built:
Posture:
Attitude of Limbs:
Swelling:
Tropical changes:
Bony contours:
External appliances:
External devices:
ON PALPATION:
Tenderness:
Warmth:
Edema:
Pulse:
Muscle wasting:
ON EXAMINATION:
Range Of Motion:
REGION
ACTIVE
PASSIVE
RIGHT
LEFT
RIGHT
LEFT
Muscle tone:
Muscle power:
Muscle spasm:
Muscle tightness:
Muscle girth
Deep Tendon Reflexes:
Sensation:
Deformity:
Joint
Accessory movements:
End feel:
Functional Assessment:
Special Test:
Investigation:
DIAGNOSIS:
PROBLEM LIST:
AIMS:
MEANS:
FOLLOW UP:
APPENDIX-II
VISUAL ANALOGUE SCALE (VAS)
It is a subjective method to measure the level of Pain.
0_____________________________________________ 10
No Pain Severe Pain
VAS consists of 10 cm horizontal line with two end points, labeled as no pain and worst pain respectively. The subjects were instructed to place a mark on the 10 cm scale as per their level of pain perceived at that particular time.
The distance in centimeters from the lower limit to higher limit of VAS, as patient perceived was used as a numerical index to assess the severity of pain.
APPENDIX – III
PATIENT CONSENT FORM
Date:
This is to certify that, I_______________________________ totally agree to be subject for the project work “AN EXPERIMENTAL STUDY TO ANALYZE THE EFFECT OF ULTRASOUND THERAPY IN REDUCING PAIN IN PATIENTS WITH CARPAL TUNNEL SYNDROME” and I assure that I will not initiate or undergo any other treatment or concurrent exercise program during the course of this study.
I own all the responsibilities of my health condition, if any untoward development happened during the course of this study.
Signature of the Patient
Signature of the Witness
Signature of the Researcher
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