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  • Study: Manual Therapy Works as Well, And Sometimes Better, Than Surgery for Carpal Tunnel Syndrome

    In brief:

    • Study analyzed self-reported function and symptoms, pinch-tip grip, and cervical ROM among 100 women with CTS—half received surgery; half received multimodal manual therapy
    • Physical therapy group showed significant gains over surgery group at 1 month for function, symptoms, and pinch-tip grip; no improvement in cervical ROM.
    • By 6 months, both groups were reporting similar improvements; similarly at 1 year, there were few differences
    • Connection between manual therapy and cervical ROM for patients with CTS was not confirmed; authors think it's possible a different intervention (neurodynamic) may lead to improvements in ROM in this population
    • Authors believe early gains by physical therapy group make physical therapy preferable to surgery as a way to return patients to normal activities as quickly as possible

    Authors of a new study on carpal tunnel syndrome (CTS) say that when you toss out the splints, steroid injections, lasers, and other treatments often lumped in with physical therapy as part of a "conservative" approach and focus solely on a debate about surgery vs specific multimodal physical therapy, physical therapy makes a compelling case for itself.

    How compelling? Researchers found similar improvement in self-reported function and CTS symptom severity for both surgical and physical therapy patients after 1 year, but the physical therapy group reported more significant gains in the first month. That speedier gain early on is worth noting, researchers believe, because it allows these patients to return to work and other activities sooner than their peers who underwent surgery. Results were published in the Journal of Orthopaedic and Sports Physical Therapy (abstract only available for free).

    The study, conducted in Spain, focused on 100 women who had experienced CTS symptoms for at least a year including pain and paresthesia in the median nerve distribution, positive Tinel sign, and positive Phalen sign. Participants also underwent electrodiagnostic examination to verify deficits in sensory and motor median nerve conduction.

    Once accepted into the program, the women were randomly divided into 2 groups of 50: 1 group received endoscopic decompression and release of the carpal tunnel through surgery, and 1 group received 3 treatment sessions of manual therapies that targeted areas "anatomically related to potential entrapment of the median nerve (eg, shoulder, elbow, forearm, wrist, and fingers)," as well as the cervical spine (more on that later). The specific techniques included:

    • Soft tissue compression over the pectoralis minor muscle
    • Longitudinal stroke over the biceps muscle
    • Transversal stroke of the bicipital aponeurosis
    • Dynamic stroke of the pronator teres muscle
    • Stretching of the transverse carpal ligament
    • Stretching of the palmar aponeurosis
    • Manual compression of the lumbrical muscles
    • Lateral glides applied to the cervical spine
    • Longitudinal stroke over the scalene muscles
    • Posteroanterior nonthrust mobilization of the mid cervical spine
    • Transversal stretching of the costoclavicle spine

    Patients in the physical therapy group also received cervical spine exercises for stretching neck muscles, which they were encouraged to perform at home during the follow-up period as needed. Based on earlier studies by others, researchers hypothesized that patients with CTS were also experiencing limits on cervical range of motion and that manual therapy would show improvements in this area as well. Ultimately, the cervical work didn't result in any notable changes in cervical range of motion for the women in either group.

    But a different story surfaced when it came to improvement in self-reported function as measured through the Boston Carpal Tunnel Questionnaire (BCTQ), as well as pinch-tip grip force. The physical therapy group showed average 1-month gains that exceed those of the surgery group by nearly 1 point on the 5-point BCTQ scale. Pinch-tip grip force improvements also bettered the surgery group at the 1 month mark. When reassessed at 6 and 12 months, however, both groups posted similar scores on both assessments.

    "The findings of the current study have potential clinical implications and open new lines of research," authors write. "Because better short-term outcomes were found with manual therapy, patients may be able to return earlier to their activities of daily living and work when they receive manual therapy, compared to those who undergo surgery."

    While earlier studies tended to give surgery the edge over conservative treatments, those "conservative" approaches usually lumped in physical therapy with a host of ineffective treatments including splints, steroid injections, lasers, and transcutaneous electrical nerve stimulation. Authors of the current study say theirs is the first to make a clean comparison between surgery and well-defined multimodal manual therapy.

    As for the lack of change in cervical function, authors think there may still be a connection but that the interventions used in the research didn't provide "sufficient management of the neck impairments." Previous studies showing this connection employed neurodynamic interventions—something not used in the current study—and it's possible that had those interventions been used, improvements may have been gained, they write.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Comments

    • Somehow I remember doing a 3 hour presentation at the 1996 Combined Sections meeting in New Orleans on manual therapy for carpal tunnel syndrome. The presentation was not well received by one particular PT who proceeded to stand up and recite her credentials and multiple degrees, as if to validate what she was going to say. I think she may have been from the Philadelphia area but I'm not sure. She then recited the prestigious institution where she worked and the prestigious hand surgeons she worked with. She stated that they splinted and iced their patients and if that didn't work, they sent them to surgery. She strongly implied that manual therapy couldn't possibly work and proceeded to lay out 3 reasons why (all of which later research individually proved were incorrect). If that PT is still around and reads this, guess what? You were wrong then and more than 20 years later, someone finally got around to proving it. As a good friend of mine would say, "Empiricism adjusts the path of science behind it".

      Posted by Brian Miller on 3/9/2017 6:56 AM

    • I've had carpal tunnel surgery on both hands. One is a tad better but the L hand really bothers me. All five fingers are tingly, less so first thing in the morning but always worse as the day goes on. Doing any physical work like cleaning a window or weeding, holding a book to read, really makes the tingling worse. The doc thinks I have an impingement in the neck or shoulder or elbow. Might I be a good candidate for this manual therapy?

      Posted by Virginia Cizman on 5/23/2017 2:57 PM

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