Hazliza Razali¹, Naresh Bhaskar RAJ², Wan-Arfah N³, Zakaria Yusoff⁴, Vinodhkumar Ramalingam⁵

Author:

¹PhD student, Faculty of Health Sciences, Universiti Sultan Zainal Abidin, Gong Badak Campus, 21300 Kuala Nerus, Terengganu, Malaysia.

Co-Authors:

³Senior Lecturer,Faculty of Health Sciences, Universiti Sultan Zainal Abidin, Gong Badak Campus, 21300 Kuala Nerus, Terengganu, Malaysia.

⁴Orthopedic Surgeon, Department of Orthopaedic, Hospital Raja Perempuan Zainab, 15100 Kota Bharu, Kelantan, Malaysia.

⁵Senior Lecturer, Faculty of health and life sciences, INTI International University, Nilai, Malaysia

Corresponding Author:

²Dr.Naresh Bhaskar Raj, Senior Lecturer, Faculty of Health Science, Universiti Sultan Zainal Abidin (UniSZA), 21300 Terengganu, Malaysia. E-mail address: bnaresh@unisza.edu.my

ABSTRACT

Background of the study: Extracorporeal shock wave therapy (ESWT) has been reported as valuable and beneficial treatment for musculoskeletal disorder. Over the last few years, ESWT became more widely employed in clinical practice, with certain clinical studies confirming significant efficacy. Clinically, ESWT has been utilised to treat a variety of musculoskeletal and peripheral neuropathy disorders, including CTS. ESWT’s low energy was proven effective in mild to moderate CTS. The aim of the study is to analyse the effect of three physiotherapy intervention on symptom and hand functions in patients with carpal tunnel syndrome. Methodology: This study consisted of 52 male and female who had pain in their hands, either bilaterally or unilaterally. They were allotted into of three groups, Group A; received Ultrasound therapy (UST) combined with nerve and tendon gliding exercise,Group B; received Shock wave therapy (ESWT) combined with nerve and tendon gliding exercise and Group C; received only nerve and tendon gliding exercise, two times per week for four weeks. The outcome measure used was Boston Carpal Tunnel Questionnaire (BCTQ) to evaluate the symptom severity and functional status scale among the participants. The evaluation was performed at baseline, 2 weeks, 4 weeks and follow-up. Results: Repeated measure ANOVA shows significant improvement (p<0.005) in all comparison based on time. The overall improvement in Group B from baseline to follow-up was a reduction of 48.43% in the symptoms and 55.2% increase in the functions and was significant (p<0.005). Conclusion: This study concludes that the ESWT is an effective modality for idiopathic mild to moderate CTS. The beneficial effect of this non-invasive modality is safe and valuable to be used as one of physiotherapy modality in Malaysia.  Keywords: Carpal Tunnel Syndrome; Shock Wave Therapy; Ultrasound Therapy; Nerve and Tendon Gliding Exercise; Hand function; Idiopathic.

Received on 26th April  2022, Revised on 24th May 2022, Accepted on 28th May  2022, DOI:10.36678/IJMAES.2021.V08I02.005

Carpal Tunnel Syndrome (CTS) is a non-traumatic hand disorder caused by en-trapment of the median nerve as it travels through the wrist’s carpal tunnel¹. It’s a type of peripheral neuropathy that can be caused by a variety of things ^2,3.Mechanical stress, elevated pressure, and ischemia injury to the median nerve within the carpal tunnel are all factors in the pathophysiology of CTS⁴. The specific cause is unknown, however compression⁵and swelling of the median nerve in the carpal tunnel^6,7,8may be to blame.

CTS is more common in all nations^9,10 including Malaysia^9-12.There is no universally accepted gold standard for diagnosing CTS. A medical history and physical examination, with or without the use of diagnostic questionnaires, electrodiagnostic studies, MRI, and ultrasound, can be used to determine it^13,14,15. In the general population, the prevalence and incid-ence range from 0.6 percent to 14.4 percent, with women having a higher preva-lence than men^2,3,10.

There are three levels of CTS: mild, moderate, and severe¹⁶. The sensory component of the median nerve causes symptoms such as a loss of light and discriminative touch sensations at first¹⁷. In advanced cases, it damaged the motor component of the hand and upper limb, leading in a loss of grip and pinch strength^17,18.

Surgical and nonsurgical treatments are avail-able for CTS. For mild to moderate CTS, conservative treatment is often preferred whereas surgical decompression is a possibility for moderate to severe symptoms^19,20,21.

Several studies have found that conservative treatment is beneficial and appropriate for patients with mild to moderate CTS symptoms ^22,23,24. Ultrasound^25,26, laser^25,27, hand activiti-es²⁸, paraffin wax therapy²⁹, flexible wrist splints or kinesiotaping ³⁰, steroid injections²¹, night splints, oral steroids³¹, electromagnetic field therapy³²,workplace adaptability, and cup-ping  therapy ³³ are some of the treatments used Physiotherapy intervention is widely used as a noninvasive procedure and a conservative therapeuticchoice. Physiotherapy started as soon as feasible to avoid difficulties induced by decompression of the median nerve within the carpal canal ³⁴.

The main risk factors have been identified as mechanical, anatomical and physiological vari-ables. Gender, age (adult) obesity, and type of occupation are all major predictors, according to several studies, while secondary risk factors include carpal tunnel syndrome, metabolic causes and infection³⁵.

The consequences of CTS may include missed workdays, a change of career, and significant healthcare management costs. The patient with CTS must spend as much time away from work as they meet the symptoms as a result of persistent symptoms ³⁶. Extracorporeal shock wave therapy (ESWT) has been reported as a valuable and beneficial treatment for musculo-skeletal disorders in recent years, with certain clinical studies demonstrating significant eff-icacy.

Several examples of musculoskeletal injuries ^9,37 and peripheral neuropathy, such as CTS, have been successfully treated using ESWT. Patients with mild to severe CTS can benefit from ESWT, which is a noninvasive treatment and evidence based physical method³⁸. According to Seok and Kim (2013), the ESWT may be as effective as a local steroid injection in treating CTS symptoms³⁹.

There are two types of EWST in the therapeutic setting: focused EWST (fESWT) and radial ESWT (rEWST). The fESWT produces a lot of energy, which some patients can’t handle and may require a local anaesthetic^40,41. In other investigations, the ESWT’s low energy is expressed as rESWT ⁴¹. In treating CTS studies, rEWST has greater advantages than fESWT because to the energy dispersed over a large treatment region ⁴¹. It has both direct (physical) and indirect (biological) impacts on the tissue being treated ^37,42.

 The anti-inflammation ⁴³, pro-angiogenic, regenerative, and healing effects of ESWT on the mechanotransduction pathway ⁴⁴. In various research ^45,46 the cumulative effect of ESWT has been demonstrated, indicating that multiple sessions of ESWT may be more effective than a single treatment ⁴⁵. ESWT has been found to be effective in CTS of varied severity ⁴⁷ and improve symptoms, functional outcomes and electrophysiologic parameters.

The objective of this study is to determine the effects of different physiotherapy interventions on idiopathic CTS. To our knowledge, ESWT has still not been used and reported in clinical practise in Malaysia to treat CTS cases. The findings from this study could be used to better decide which parameters should be applied to treat CTS in Malaysia.

MATERIAL AND METHOD

Study design:

A randomized clinical trial study was conduct-ed.The sample size was calculated using G*Power 3.1.9.2. The sample size calculation using A priori with an effect size of 0.25, α error probability of 0.05 and power of 0.80 resulted in about 52 participants. Before participating in this study, the participants were given a thorough briefing and given written informed consent.

This study was conducted at Physiotherapy Units, Faculty of Health Sciences, Universiti Sultan Zainal Abidin (UniSZA) at Gong Badak Campus, Kuala Terengganu and Rehabilitation Center at Seberang Takir, Kuala Terengganu.

 Participants:

Initially, 75 CTS patients were referred to the Physiotherapy Unit, however only 60 participants were chosen because they met the criteria. They were chosen at random as they fulfilled the inclusion criteria. The inclusion criteria includeage 30 and 60 years old, having symptom (numbness, tingling, pain with or without weakness or at unilateral or bilateral hand), confirm diagnosis as CTS by doctor, mild to moderate symptoms, no thenar atrophy at affected hand, positive clinical provocative test (Phalen’s test, Tinel’s sign or Durkan’s test), never received any CTS intervention and not used splint.

The exclusion criteria included previous wrist trauma or surgery at affected hand, diagnosis as sensory and motor neuropathy due to other causes (example: Cervical stenosis, cervical spondylosis and etc.), underlying medical disorders (E.g.: Diabetes mellitus, renal failure, autoimmune disease, rheumatoid arthritis or hypothyroidism), pregnancy, open wound or skin condition at affected hand, require regular analgesic or anti-inflammatory drugs and  had steroid injection with current CTS symptom.

The randomisation technique was performed using research randomiser software to allocate the subjects into groups. Each group comprised of 20 subjects; two groups were designated as intervention groups (Group A and B), while the remaining were designated as control groups (Group C). Male and female participants with bilateral or unilateral pain in their hands took part in the study. Following the completion of the intervention period for four weeks, 8 participants withdrew from this study.

Outcome Measure: The outcome measure was conducted for baseline, 2-weeks, 4 weeks and follow up (4 weeks post-intervention).

Boston Carpal Tunnel Questionnaire: Levine et al., (1993) established the BCTQ as a self-administered outcome measure to quantify the intensity of symptoms and functional status of clients with CTS ⁴⁸. The original BCTQ was prepared in English and provided a standard severity and function measure for patients. The validity, reliability, and responsiveness of the BCTQ have lately been documented in other languages.

This study used the M-Boston Carpal Tunnel Questionnaire (M-BCTQ), which is a valid and reliable Malay version of the M-Boston Carpal Tunnel Questionnaire (M-BCTQ) ⁴⁹. BCTS is a disease-specific, patient-focused CTS instrum-ent that delivers important data from the patient’s perspective and may be used individually or in large groups ⁴⁹. It is easy to administer because it is quick and straightforward⁴⁹, it is recommended to be used in any kind of CTS research. The Symptom Severity Scale (SSS) is used to determine the severity of symptoms, whereas the Functional Status Scale (FSS) is used to determine a subject’s functional status.

The SSS features 11 questions with a five-point rating scale, whereas the FSS has eight things with a five-point rating scale for difficulty. Each scale produces a final score that varies from 1 to 5 (total of individual scores divided by number of elements). On a Likert scale, 1 indicates a low level of symptom (SSS) or a high level of difficulty (FSS), and 5 indicates a high level of symptom (SSS) and inability to function (FSS).

Intervention: They were instructed to perfo-rmed nerve and tendon gliding exercises developed by Totten and Hunter (1991)⁵⁰. The participants also obtained a brochure with instructions and illustrations describing the exercises. These exercises were presented by the physiotherapist and then performed by the patient with the supervision of the therapist.

Nerve gliding exercise: Each position will be maintained for 5 seconds before being repeated 10 times. The exercise required maintaining the fingers and hand in six different positions for six minutes^50,51.

1. With the wrist in neutral and the fingers and thumb in flexion (grasp)
2. With finger extension
3. With the wrist and fingers extended and the thumb in neutral 
4. With the wrist, fingers, and thumb extended
5. As the fourth position with the forearm in supination
6. As the fifth position and the other hand gently stretching the thumb

Tendon Gliding Exercise: During tendon gliding exercises, the fingers were placed in five distinct positions. Straight, hook, fist, tabletop, and straight fist these were techniques. Each position was sustained for a total of 7 seconds. All groups were instructed to perform 5 repetitions of the exercise and repeat for 3 sets of tendon gliding exercises twice a week for four weeks^24,52.

Ultrasound Therapy: Subjects in this group were treated with ultrasound therapy by Gymna Pulson 100. The machine was set to a frequency of 1 MHz, an intensity of 1.0 W/cm2, and a pulsed mode (1:4) with a 5 cm² focus transducer^25,29,53. The duration of the procedure was 5 minutes each session. During the procedure, the transducer is placed across the wrist carpal tunnel area from the wrist crease to the palmar region.

 The transducer moves in a circular motion, gently pressing on the affected area. A direct-contact method was utilised with a water-based gel as a coupling agent. Subjects must be in a comfortable position and have no experience of pain during the procedure. The subjects were then instructed to do Totten and Hunter’s nerve and tendon gliding exercises (1991)⁵¹. Exercise in the same manner as described in Nerve and tendon gliding exercise.

ESWT: The patients were treated with ESWT combined with standard hand exercise (nerve and tendon gliding exercise). They received 1000 shocks, 2 BAR (0.09 mj/mm²), and 3Hz by Zimmer Medizin System’s enPuls version 2.0 machine twice a week for four weeks. Shock wave therapy does not have a specific duration, but 1000 shocks take 5 minutes to complete in each session.The treatment was given by a qualified physiotherapist. The probe was held perpendicular to the patient’s palm throughout the procedure, and gel was used as a coupling agent. There was no need for extra anaesthetic or painkillers because the treatment was painless and safe⁵⁴.

The subjects were then instructed to do Totten and Hunter’s nerve and tendon gliding exercises (1991)⁵¹. Exercise in the same manner as described in Nerve and tendon gliding exercise.

Data Analysis: Descriptive analysis was used to establish the demographic data of the subjects as well as the mean value outcome measures for baseline, 2 weeks, 4 weeks, and follow-up (8 weeks). The normality of the data was checked using Shapiro-Wilk test. The assumptions for RM ANOVA were checked. The Repeated Measure ANOVA was performed to determine the time effect. The differences were considered significant at p<0.05.

RESULT

At the beginning of the study, sixty subjects (n=60) with hand treated (n=104) involved after fulfilling the inclusion criteria stated. However, during the 4 weeks of intervention period, 8 subjects withdrew from this study (Group A: n=3, Group B: n=2 and Control: n=3). Finally, the total of the subjects remain for data analysis of this study were n=52 and hand treated n=90. Majority of the subjects were female 73.1% while male with 26.9%. Table 1 shows the summary of the demographic data for the participants. In all comparison for outcome measures based on time, the results reveal a significant improvement (p<0.005).Descriptive analysis of SSS and FSS for the participants based on groups is presented in Table 1.

Repeated measure ANOVA within group analysis was applied followed by pairwise comparison with 95% confidence interval (CI) adjustment by Bonferroni correction to evaluated the SSS and FSS among the participants each group based on time (time effect) showed in Table 3.  In order to determine the treatment effect among the participants between the groups, repeated measure ANOVA between group analysis was applied followed by post-hoc multiple comparisons using Scheffe method was conducted on SSS (F-stat (df)=121.63(2), p-value <0.001) and FSS (F-stat(df)=103.41(2), p-value <0.001) of this study.  The detailed result was presented in Table 4.A profile plot was produced to interpret the interaction of three Physiotherapy interventions on SSS and FSS between the three different groups based on time. Therefore, the intervention of Group B (ESWT combined with nerve and tendon gliding exercise) shows decreasing level of SSS and increase FSS over time compared to other groups.

DISCUSSION

Numerous studies shown that the CTS is a common compression disease and debilitating disorder in ambulatory clinic visits in primary care^55,56. The syndrome is characterized by pain in the hand, numbness, and tingling in the distribution of the median nerve. The painful feelings may result in a reduction in grip strength and hand function⁴. If not treated, it can cause median nerve damage and as a result, loss of hand function⁵⁷.This present study used Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) as an outcome measurement to determine the effectiveness on symptom and hand function. Previously, several studies used the questionnaire for the measurement of the severity of symptoms and functional status due to reproducibility, internal consistency, and validity in patients with CTS^46,47. The used of this self-administer questionnaire is recommended in any types of CTS research due to quick and easy to administer⁵⁸.

 The SSS which has questions consists of 11 items assessing pain, paresthesia, numbness, weakness, nocturnal symptoms, and difficulty of grasping. The FSS contains eight items, which assess functional deficits in the following domains: writing, buttoning clothes, holding a book while reading, gripping a telephone handle, opening jars, performing household chores, carrying grocery bags, bathing, and dressing⁵⁹.

ESWT paired with hand exercise (nerve and tendon gliding exercise) enhanced SSS and FSS, in the current study. The results reveal a significant improvement (p<0.005) in all time comparisons. Several studies have found comparable findings, including this one, which demonstrated significant reductions in symptom and function after two or more ESWT sessions^46,47. In the treatment of CTS symptoms, one session of ESWT is as effective as a single corticosteroid injection³⁹.

As a result, clinical evidence suggests that many ESWT sessions are more effective than a single application⁴⁶. ESWT has been proven to have a cumulative impact in several studies⁴⁶. Both fESWT and rESWT have recently gained popularity as a safe and new treatment for CTS^39,40,47. After several tries, Murata et al. (2006)⁶⁰ discovered a cumulative effect on free nerve endings in rats with a longer lasting antinociceptive consequence. The cumulative effect of ESWT was established in a study by Ke et al., (2016)⁴⁶.

Repeated ESWT sessions could keep the analgesic benefits for at least four weeks, according to their findings. In contrast, a single session of ESWT has only a five-day efficacy against mechanical and thermal hyperalgesia. In mild to severe CTS, ESWT appears to activate a more analgesic and anti-inflammatory mechanism. They show in their study that repeated ESWT sessions may keep the analgesic effects for at least four weeks. A single session of ESWT, on the other hand, only has a five-day efficacy against mechanical and thermal hyperalgesia. For a mild to moderate CTS, ESWT appears to trigger a greater analgesic and anti-inflammation mechanism. In this study, the therapeutic benefit of ESWT for mild to moderate CTS was established. In previous research, low-energy ESWT was shown to improve pain and hand function in patients with mild to moderate CTS^61,62,63.

 In the current investigation, ESWT was found to considerably improve the symptom. Eight sessions of ESWT with pneumatic wave have been shown to offer good benefits for patients^47,64,65. However, there is currently no published evidence for using ESWT in CTS⁴⁷, and the test is not yet available in Malaysia.Gliding exercises for the nerves and tendons are a frequent exercise for CTS patients^24,28. These exercises have been utilised to manage both postoperative and conservative management⁶⁶.  

In order to improve the efficacy of conservative treatment for CTS, nerve and tendon gliding exercises were devised as a supplemental technique to traditional conservative treatment²⁸in the clinical environment. According to the findings, the ESWT was effective in treating mild to moderate symptoms. The ESWT improved symptom and function, according to the present study’s findings, which were backed up by several clinical trials. ESWT appears to be a safe and effective conservative treatment for relieving pain and impairment in CTS patients with no side effects^39,42,67.

Ethical clearance: There was no risk of conducting this study.Ethical approval for the study was granted by UniSZA Human Research Ethics Committee of Universiti Sultan Zainal Abidin (UHREC): UniSZA/UHREC/2019/108.

Conflicts of Interest: There is no conflict of interest to conduct this study.

Fund for the study: This is self funded study.

CONCLUSION

This result implies that the ESWT is an effective modality in treating mild to moderate CTS in a clinical setting in Malaysia. ESWT can be used to reduce the symptoms and improve the hand functions in patients with CTS.

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Citation:   Hazliza Razali, Naresh Bhaskar Raj, Wan-Arfah N, Zakaria Yusoff, Vinodhkumar Ramalingam (2022).  Effectiveness of Physiotherapy Interventions on Symptom Severity and Hand Function in Patients with Idiopathic CTS , ijmaes; 8 (2); 1287-1301