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Westenberg RF, DiGiovanni PL, Schep NWL, Eberlin KR, Chen NC, Coert JH. Does Revision Carpal Tunnel Release Result in Long-Term Outcomes Equivalent to Single Carpal Tunnel Release? A Matched Case-Control Analysis. Plast Reconstr Surg 2024; 153:746e-757e. [PMID: 37189245 DOI: 10.1097/prs.0000000000010682] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
BACKGROUND The aims of this study were to evaluate long-term patient-reported outcomes after revision carpal tunnel release (CTR); compare these outcomes with those of patients who had a single CTR and a comparable age, sex, race, type of initial surgery, and follow-up time; and assess which factors are associated with worse patient-reported outcomes after revision CTR. METHODS The authors retrospectively identified 7351 patients who had a single CTR and 113 patients who had a revision CTR for carpal tunnel syndrome between January of 2002 and December of 2015 at five academic urban hospitals. Of these 113 revision CTR cases, 37 patients completed a follow-up questionnaire including the Boston Carpal Tunnel Questionnaire (BCTQ), the Numerical Rating Scale for Pain Intensity, and satisfaction score. Those who completed the follow-up questionnaire were randomly matched to five controls (patients who had a single CTR) based on age, sex, race, type of initial surgery, and follow-up time. Of these 185 matched controls, 65 completed the follow-up questionnaire. RESULTS A linear mixed effects model using matched sets as a random effect showed that patients who had a revision CTR had a higher total BCTQ score, Numerical Rating Scale for Pain Intensity score, and a lower satisfaction score at time of follow-up than patients who had a single CTR. Multivariable linear regression showed that thenar muscle atrophy before the revision surgery was independently associated with more pain after revision surgery. CONCLUSION Patients improve after revision CTR, but generally have more pain, have a higher BCTQ score, and are less satisfied at long-term follow-up compared with patients who had a single CTR.
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Affiliation(s)
- Ritsaart F Westenberg
- From the Massachusetts General Hospital
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht
| | | | | | | | | | - J Henk Coert
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht
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Lusa V, Karjalainen TV, Pääkkönen M, Rajamäki TJ, Jaatinen K. Surgical versus non-surgical treatment for carpal tunnel syndrome. Cochrane Database Syst Rev 2024; 1:CD001552. [PMID: 38189479 PMCID: PMC10772978 DOI: 10.1002/14651858.cd001552.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
BACKGROUND Carpal tunnel syndrome (CTS) is a compression neuropathy of the median nerve at the wrist. Surgery is considered when symptoms persist despite the use of non-surgical treatments. It is unclear whether surgery produces a better outcome than non-surgical therapy. This is an update of a Cochrane review published in 2008. OBJECTIVES To assess the evidence regarding the benefits and harms of carpal tunnel release compared with non-surgical treatment in the short (< 3 months) and long (> 3 months) term. SEARCH METHODS In this update, we included studies from the previous version of this review and searched the Cochrane Neuromuscular Specialised Register, CENTRAL, Embase, MEDLINE, ClinicalTrials.gov and WHO ICTRP until 18 November 2022. We also checked the reference lists of included studies and relevant systematic reviews for studies. SELECTION CRITERIA We included randomised controlled trials comparing any surgical technique with any non-surgical therapies for CTS. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. MAIN RESULTS The 14 included studies randomised 1231 participants (1293 wrists). Eighty-four per cent of participants were women. The mean age ranged from 32 to 53 years, and the mean duration of symptoms from 31 weeks to 3.5 years. Trial sizes varied from 22 to 176 participants. The studies compared surgery with: splinting, corticosteroid injection, splinting and corticosteroid injection, platelet-rich plasma injection, manual therapy, multimodal non-operative treatment, unspecified medical treatment and hand support, and surgery and corticosteroid injection with corticosteroid injection alone. Since surgery is generally used for its long-term effects, this abstract presents only long-term results for surgery versus splinting and surgery versus corticosteroid injection. 1) Surgery compared to splinting in the long term (> 3 months) Surgery probably results in a higher rate of clinical improvement (risk ratio (RR) 2.10, 95% confidence interval (CI) 1.04 to 4.24; 3 studies, 210 participants; moderate-certainty evidence). Surgery probably does not provide clinically important benefit in symptoms or hand function compared with splinting (moderate-certainty evidence). The mean Boston Carpal Tunnel Questionnaire (BCTQ) Symptom Severity Scale (scale 1 to 5; higher is worse; minimal clinically important difference (MCID) = 1) was 1.54 with splint and 0.26 points better with surgery (95% CI 0.52 better to 0.01 worse; 2 studies, 195 participants). The mean BCTQ Functional Status Scale (scale 1 to 5; higher is worse; MCID 0.7) was 1.75 with splint and 0.36 points better with surgery (95% CI 0.62 better to 0.09 better; 2 studies, 195 participants). None of the studies reported pain. Surgery may not provide better health-related quality of life compared with splinting (low-certainty evidence). The mean EQ-5D index (scale 0 to 1; higher is better; MCID 0.074) was 0.81 with splinting and 0.04 points better with surgery (95% CI 0.0 to 0.08 better; 1 study, 167 participants). We are uncertain about the risk of adverse effects (very low-certainty evidence). Adverse effects were reported amongst 60 of 98 participants (61%) in the surgery group and 46 of 112 participants (41%) in the splinting group (RR 2.11, 95% CI 0.37 to 12.12; 2 studies, 210 participants). Surgery probably reduces the risk of further surgery; 41 of 93 participants (44%) were referred to surgery in the splinting group and 0 of 83 participants (0%) repeated surgery in the surgery group (RR 0.03, 95% CI 0.00 to 0.21; 2 studies, 176 participants). This corresponds to a number needed to treat for an additional beneficial outcome (NNTB) of 2 (95% CI 1 to 9). 2) Surgery compared to corticosteroid injection in the long term (> 3 months) We are uncertain if clinical improvement or symptom relief differs between surgery and corticosteroid injection (very low-certainty evidence). The RR for clinical improvement was 1.23 (95% CI 0.73 to 2.06; 3 studies, 187 participants). For symptoms, the standardised mean difference (SMD) was -0.60 (95% CI -1.88 to 0.69; 2 studies, 118 participants). This translates to 0.4 points better (95% CI from 1.3 better to 0.5 worse) on the BCTQ Symptom Severity Scale. Hand function or pain probably do not differ between surgery and corticosteroid injection (moderate-certainty evidence). For function, the SMD was -0.12 (95% CI -0.80 to 0.56; 2 studies, 191 participants) translating to 0.10 points better (95% CI 0.66 better to 0.46 worse) on the BCTQ Functional Status Scale with surgery. Pain (0 to 100 scale) was 8 points with corticosteroid injection and 6 points better (95% CI 10.45 better to 1.55 better; 1 study, 123 participants) with surgery. We found no data to estimate the difference in health-related quality of life (very low-certainty evidence). We are uncertain about the risk of adverse effects and further surgery (very low-certainty evidence). Adverse effects were reported amongst 3 of 45 participants (7%) in the surgery group and 2 of 45 participants (4%) in the corticosteroid injection group (RR 1.49, 95% CI 0.25 to 8.70; 2 studies, 90 participants). In one study, 12 of 83 participants (15%) needed surgery in the corticosteroid group, and 7 of 80 participants (9%) needed repeated surgery in the surgery group (RR 0.61, 95% CI 0.25 to 1.46; 1 study, 163 participants). AUTHORS' CONCLUSIONS Currently, the efficacy of surgery in people with CTS is unclear. It is also unclear if the results can be applied to people who are not satisfied after trying various non-surgical options. Future studies should preferably blind participants from treatment allocation and randomise people who are dissatisfied after being treated non-surgically. The decision for a patient to opt for surgery should balance the small benefits and potential risks of surgery. Patients with severe symptoms, a high preference for clinical improvement and reluctance to adhere to non-surgical options, and who do not consider potential surgical risks and morbidity a burden, may choose surgery. On the other hand, those who have tolerable symptoms, who have not tried non-surgical options and who want to avoid surgery-related morbidity can start with non-surgical options and have surgery only if necessary. We are uncertain if the risk of adverse effects differs between surgery and non-surgical treatments. The severity of adverse effects may also be different.
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Affiliation(s)
- Vieda Lusa
- Tampere University Hospital, Wellbeing Services County of Pirkanmaa, Tampere, Finland
| | - Teemu V Karjalainen
- Department of Surgery, Hospital Nova, Wellbeing Services County of Central Finland, Jyväskylä, Finland
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Melbourne, Australia
| | - Markus Pääkkönen
- Turku University Hospital, Wellbeing Services County of Southwest Finland, Turku, Finland
| | - Tuomas Jaakko Rajamäki
- Department of Hand Surgery, Tampere University Hospital, Wellbeing Services County of Pirkanmaa, Tampere, Finland
| | - Kati Jaatinen
- Hospital Nova, Wellbeing Services County of Central Finland, Jyväskylä, Finland
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Straatman LN, Lukacs MJ, Carlesso L, Grewal R, Lalone EA, Walton DM. A systematic review of the psychometric properties of pressure pain detection threshold in evaluating mechanical pain threshold in people with hand or wrist injuries. J Hand Ther 2023; 36:845-859. [PMID: 37778878 DOI: 10.1016/j.jht.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 11/16/2022] [Accepted: 06/09/2023] [Indexed: 10/03/2023]
Abstract
PURPOSE The aim of this study was to conduct a systematic review of the psychometric properties of Pressure Pain Detection Threshold (PPDT) measures in people with hand or wrist injuries. STUDY DESIGN AND METHODS MEDLINE, Embase, and CINAHL databases were searched to identify eligible studies evaluating psychometric properties of PPDT in samples composed of at least 50% of people with hand or wrist injury. The Consensus-based Standards for the Measurement of Health Instruments' risk of bias checklist was used to critically appraise the included studies, and qualitative synthesis was performed by pooling the results of all studies that presented the same measurement property using Grading of Recommendations, Assessment, Development, and Evaluation. RESULTS From 415 studies, 11 relevant studies were identified. Of the 11 studies, four hand or wrist injuries were represented; carpal tunnel syndrome, distal radius fractures, osteoarthritis, and complex regional pain syndrome. Intra-rater reliability was considered sufficient (intraclass correlation coefficient 0.64-0.94), with small reported standard error of the mean values (5.3-39.2 kPa). Results of validity and responsiveness could not be synthesized due to heterogeneity. Risk of bias for reliability and measurement error was assessed as very good or adequate, whereas validity and responsiveness were doubtful or inadequate. Overall quality of evidence was low or very low for all measurement properties. CONCLUSIONS Inconsistent results and low quality evidence provide little confidence in the overall measurement properties of PPDT in a hand or wrist injury population. No criterion standard for pain further highlights complexities around pain measurement such that the results obtained from PPDT measures in clinical practice cannot be compared to a gold standard measure.
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Affiliation(s)
- Lauren N Straatman
- Department of Health and Rehabilitation Sciences, Western University, London, Ontario, Canada; Department of Mechanical and Materials Engineering, Western University, London, Ontario, Canada; Bone and Joint Institute, Western University, London, Ontario, Canada.
| | - Michael J Lukacs
- School of Physical Therapy, Western University, London, Ontario, Canada; Bone and Joint Institute, Western University, London, Ontario, Canada
| | - Lisa Carlesso
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Ruby Grewal
- Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Hospital, London, Ontario, Canada
| | - Emily A Lalone
- Department of Mechanical and Materials Engineering, Western University, London, Ontario, Canada; Bone and Joint Institute, Western University, London, Ontario, Canada
| | - David M Walton
- Department of Health and Rehabilitation Sciences, Western University, London, Ontario, Canada; School of Physical Therapy, Western University, London, Ontario, Canada; Bone and Joint Institute, Western University, London, Ontario, Canada
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Fernández-de-las-Peñas C, Fuensalida-Novo S, Nijs J, Basson A, Plaza-Manzano G, Valera-Calero JA, Arendt-Nielsen L, de-la-Llave-Rincón AI. Carpal Tunnel Syndrome: Neuropathic Pain Associated or Not with a Nociplastic Condition. Biomedicines 2023; 11:1744. [PMID: 37371839 PMCID: PMC10296499 DOI: 10.3390/biomedicines11061744] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/14/2023] [Accepted: 06/15/2023] [Indexed: 06/29/2023] Open
Abstract
Carpal tunnel syndrome (CTS) has been traditionally classified as primarily a neuropathic condition with or without pain. Precision medicine refers to an evidence-based method of grouping patients based on their susceptibility to biology, prognosis of a particular disease, or in their response to a specific treatment, and tailoring specific treatments accordingly. In 2021, the International Association for the Study of Pain (IASP) proposed a grading system for classifying patients into nociceptive, neuropathic, or nociplastic phenotypes. This position paper presents data supporting the possibility of subgrouping individuals with specific CTS related-pain into nociceptive, neuropathic, nociplastic or mixed-type phenotypes. Carpal tunnel syndrome is a neuropathic condition but can also be comorbid with a nociplastic pain condition. The presence of extra-median symptoms and the development of facilitated pain processing seem to be signs suggesting that specific CTS cases can be classified as the nociplastic pain phenotype. The clinical responses of therapeutic approaches for the management of CTS are inconclusive. Accordingly, the ability to identify the predominant pain phenotype in patients with CTS could likely be problematic for producing efficient treatment outcomes. In fact, the presence of a nociplastic or mixed-type pain phenotype would explain the lack of clinical effect of treatment interventions targeting the carpal tunnel area selectively. We propose a clinical decision tree by using the 2021 IASP classification criteria for identifying the predominant pain phenotype in people with CTS-related pain, albeit CTS being a priori a neuropathic pain condition. The identification of a nociplastic-associated condition requires a more nuanced multimodal treatment approach to achieve better treatment outcomes.
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Affiliation(s)
- César Fernández-de-las-Peñas
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, 28922 Alcorcón, Spain; (S.F.-N.); (A.I.d.-l.-L.-R.)
- Center for Neuroplasticity and Pain (CNAP), SMI, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, DK-9220 Aalborg, Denmark;
| | - Stella Fuensalida-Novo
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, 28922 Alcorcón, Spain; (S.F.-N.); (A.I.d.-l.-L.-R.)
| | - Jo Nijs
- Pain in Motion Research Group (PAIN), Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, 1050 Brussels, Belgium;
- Chronic Pain Rehabilitation, Department of Physical Medicine and Physiotherapy, University Hospital Brussels, 1090 Brussels, Belgium
- Unit of Physiotherapy, Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden
| | - Annalie Basson
- Department of Physiotherapy, University of the Witwatersrand, Office 23, Khanya Block-West, 7 York Road, Parktown 2193, South Africa;
| | - Gustavo Plaza-Manzano
- Department of Radiology, Rehabilitation and Physiotherapy, Complutense University of Madrid, 28040 Madrid, Spain; (G.P.-M.); (J.A.V.-C.)
- Grupo InPhysio, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
| | - Juan A. Valera-Calero
- Department of Radiology, Rehabilitation and Physiotherapy, Complutense University of Madrid, 28040 Madrid, Spain; (G.P.-M.); (J.A.V.-C.)
- Grupo InPhysio, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
| | - Lars Arendt-Nielsen
- Center for Neuroplasticity and Pain (CNAP), SMI, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, DK-9220 Aalborg, Denmark;
- Department of Gastroenterology & Hepatology, Mech-Sense, Clinical Institute, Aalborg University Hospital, DK-9000 Aalborg, Denmark
- Steno Diabetes Center North Denmark, Clinical Institute, Aalborg University Hospital, DK-9000 Aalborg, Denmark
| | - Ana I. de-la-Llave-Rincón
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, 28922 Alcorcón, Spain; (S.F.-N.); (A.I.d.-l.-L.-R.)
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Dahlin LB, Perez R, Nyman E, Zimmerman M, Merlo J. Carpal Tunnel Syndrome and Ulnar Nerve Entrapment Are Associated with Impaired Psychological Health in Adults as Appraised by Their Increased Use of Psychotropic Medication. J Clin Med 2022; 11:jcm11133871. [PMID: 35807165 PMCID: PMC9267822 DOI: 10.3390/jcm11133871] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/16/2022] [Accepted: 06/28/2022] [Indexed: 02/05/2023] Open
Abstract
We aimed to study psychological health, as approximated by the use of psychotropic drugs, in a population diagnosed and surgically treated for carpal tunnel syndrome (CTS) or ulnar nerve entrapment (UNE), or both, also considering the demographic and socioeconomic factors of the individuals. Linking data from five large national registers, use of psychotropics (at least one dispensation during the first year after the surgery or the baseline date) was examined in around 5.8 million people 25–80 years old residing in Sweden 2010. Among these individuals, 9728 (0.17%), 890 (0.02%) and 149 (0.00%) were identified as diagnosed and surgically treated for CTS, UNE, or both, respectively. As much as 28%, 34% and 36% in each group, respectively, used psychotropic drugs, compared with 19% in the general population. Regression analyses showed a general higher risk for use of psychotropics related to these nerve compression disorders, to higher age, being a woman, and having low income or low occupational qualification level. Individuals born outside of Sweden had a lower risk. We conclude that surgically treated individuals with a nerve compression disorder have an increased risk of impaired psychological health. Caregivers should be aware of the risk and provide necessary attention.
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Affiliation(s)
- Lars B. Dahlin
- Department of Translational Medicine—Hand Surgery, Lund University, 20502 Malmö, Sweden;
- Department of Hand Surgery, Skåne University Hospital, 20502 Malmö, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, 58183 Linköping, Sweden;
- Correspondence:
| | - Raquel Perez
- Unit for Social Epidemiology, Department of Clinical Sciences (Malmö), Faculty of Medicine, Lund University, 20502 Malmö, Sweden; (R.P.); (J.M.)
| | - Erika Nyman
- Department of Biomedical and Clinical Sciences, Linköping University, 58183 Linköping, Sweden;
- Department of Hand Surgery, Plastic Surgery and Burns, Linköping University Hospital, 58183 Linköping, Sweden
| | - Malin Zimmerman
- Department of Translational Medicine—Hand Surgery, Lund University, 20502 Malmö, Sweden;
- Department of Hand Surgery, Skåne University Hospital, 20502 Malmö, Sweden
| | - Juan Merlo
- Unit for Social Epidemiology, Department of Clinical Sciences (Malmö), Faculty of Medicine, Lund University, 20502 Malmö, Sweden; (R.P.); (J.M.)
- Center for Primary Health Research, Region Skåne, 20502 Malmö, Sweden
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Hoogendam L, Bakx JAC, Souer JS, Slijper HP, Andrinopoulou ER, Selles RW. Predicting Clinically Relevant Patient-Reported Symptom Improvement After Carpal Tunnel Release: A Machine Learning Approach. Neurosurgery 2022; 90:106-113. [PMID: 34982877 DOI: 10.1227/neu.0000000000001749] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 08/21/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Symptom improvement is an important goal when considering surgery for carpal tunnel syndrome. There is currently no prediction model available to predict symptom improvement for patients considering a carpal tunnel release (CTR). OBJECTIVE To predict using a model the probability of clinically relevant symptom improvement at 6 mo after CTR. METHODS We split a cohort of 2119 patients who underwent a mini-open CTR and completed the Boston Carpal Tunnel Questionnaire preoperatively and 6 mo postoperatively into training (75%) and validation (25%) data sets. Patients who improved more than the minimal clinically important difference of 0.8 at the Boston Carpal Tunnel Questionnaire-symptom severity scale were classified as "improved." Logistic regression, random forests, and gradient boosting machines were considered to train prediction models. The best model was selected based on discriminative ability (area under the curve) and calibration in the validation data set. This model was further assessed in a holdout data set (N = 397). RESULTS A gradient boosting machine with 5 predictors was chosen as optimal trade-off between discriminative ability and the number of predictors. In the holdout data set, this model had an area under the curve of 0.723, good calibration, sensitivity of 0.77, and specificity of 0.55. The positive predictive value was 0.50, and the negative predictive value was 0.81. CONCLUSION We developed a prediction model for clinically relevant symptom improvement 6 mo after a CTR, which required 5 patient-reported predictors (18 questions) and has reasonable discriminative ability and good calibration. The model is available online and might help shared decision making when patients are considering a CTR.
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Affiliation(s)
- Lisa Hoogendam
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Rehabilitation Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Hand and Wrist Center, Xpert Clinics, Eindhoven, the Netherlands
| | - Jeanne A C Bakx
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Rehabilitation Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Hand and Wrist Center, Xpert Clinics, Eindhoven, the Netherlands
| | | | - Harm P Slijper
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Hand and Wrist Center, Xpert Clinics, Eindhoven, the Netherlands
| | | | - Ruud W Selles
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Rehabilitation Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Núñez-Cortés R, Cruz-Montecinos C, Torres-Castro R, Tapia C, Püschel TA, Pérez-Alenda S. Effects of Cognitive and Mental Health Factors on the Outcomes Following Carpal Tunnel Release: A Systematic Review and Meta-analysis. Arch Phys Med Rehabil 2021; 103:1615-1627. [PMID: 34861234 DOI: 10.1016/j.apmr.2021.10.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/10/2021] [Accepted: 10/18/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To determine the effects of the cognitive and mental health factors on the outcomes after carpal tunnel release (CTR). DATA SOURCES Embase, PubMed/MEDLINE, Web of Science, Cumulative Index to Nursing and Allied Health, and Cochrane Central Register of Controlled Trials databases from inception to August 14, 2021. STUDY SELECTION Randomized controlled trials and observational studies of patients with CTR were included. The included studies aimed to determine the effect of the cognitive (catastrophic thinking, kinesiophobia, self-efficacy) or mental health factors (symptoms of anxiety and depression) on the outcomes at least 3 months post CTR. DATA EXTRACTION Two independent reviewers performed data extraction and assessed the risk of bias. Data were extracted using a standardized protocol and reporting forms. The risk of bias of the included studies was assessed using the Quality in Prognosis Studies risk-of-bias tool. Random-effects models were used for meta-analysis. DATA SYNTHESIS A total of 15 studies involving 2599 patients were included in this systematic review. The majority of studies indicate a significant association between the cognitive or mental health factors and outcomes after CTR. Quantitative analysis showed a moderate association of symptoms of depression on symptom severity (n=531; r=0.347; 95% CI, 0.205-0.475; P≤.0001), function (n=386; r=0.307; 95% CI, 0.132-0.464; P=.0008), and pain (n=344; r=0.431; 95% CI, 0.286-0.558; P≤.0001). In general, the risk of bias in the included studies was low. CONCLUSIONS This systematic review and meta-analysis showed that symptoms of depression have a moderate association with symptom severity, function, and pain after CTR. Symptoms of anxiety, catastrophic thinking, and self-efficacy are also important indicators of poor postsurgery outcomes. Physicians, physical therapists, and occupational therapists should consider evaluating these variables in patients undergoing CTR.
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Affiliation(s)
- Rodrigo Núñez-Cortés
- Department of Physiotherapy, Physiotherapy in Motion Multispeciality Research Group (PTinMOTION), University of Valencia, Valencia, Spain; Department of Physical Therapy, Faculty of Medicine, University of Chile, Santiago, Chile; International Physiotherapy Research Network (PhysioEvidence), Barcelona, Spain
| | - Carlos Cruz-Montecinos
- Department of Physiotherapy, Physiotherapy in Motion Multispeciality Research Group (PTinMOTION), University of Valencia, Valencia, Spain; Department of Physical Therapy, Faculty of Medicine, University of Chile, Santiago, Chile; Division of Research, Devolvement and Innovation in Kinesiology, Kinesiology Unit, San José Hospital, Santiago, Chile
| | - Rodrigo Torres-Castro
- Department of Physical Therapy, Faculty of Medicine, University of Chile, Santiago, Chile; International Physiotherapy Research Network (PhysioEvidence), Barcelona, Spain
| | - Claudio Tapia
- Department of Physical Therapy, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Thomas A Püschel
- Ecology and Evolutionary Biology Division, School of Biological Sciences, University of Reading, Reading, United Kingdom; Primate Models for Behavioural Evolution Lab, Institute of Cognitive and Evolutionary Anthropology, School of Anthropology, University of Oxford, Oxford, United Kingdom
| | - Sofía Pérez-Alenda
- Department of Physiotherapy, Physiotherapy in Motion Multispeciality Research Group (PTinMOTION), University of Valencia, Valencia, Spain.
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8
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Liew BXW, de-la-Llave-Rincón AI, Arias-Buría JL, Ortega-Santiago R, Fernández-de-Las-Peñas C. Understanding the Psychophysiological Mechanisms Related to Widespread Pressure Pain Hyperalgesia Underpinning Carpal Tunnel Syndrome: A Network Analysis Approach. PAIN MEDICINE 2021; 22:2708-2717. [PMID: 34343327 DOI: 10.1093/pm/pnab241] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Current evidence suggests that carpal tunnel syndrome (CTS) involves widespread pressure pain sensitivity as manifestion of central sensitization. This study aimed to quantify mechanisms driving widespread pressure pain hyperalgesia in CTS by using network analysis. DESIGN Cross-sectional. SETTING Urban hospital. SUBJECTS 120 women with CTS who participated in a previous randomized clinical trial. METHODS Pain intensity, related-function, symptom's severity, depressive levels, and pressure pain threshold (PPTs) over median, radial and ulnar nerves, the cervical spine, the carpal tunnel, and the tibialis anterior were collected. Network analysis was used to quantify the adjusted correlations between the modelled variables, and to determine the centrality indices of each variable (i.e., the degree of connection with other symptoms in the network). RESULTS The estimated network showed several local associations between clinical variables and the psychophysical outcomes separately. The edges with the strongest weights were between PPT over the median and radial nerves (ρ: 0.34), function and depressive levels (ρ: 0.30), and PPT over the carpal tunnel and tibialis anterior (ρ: 0.29). The most central variables were PPT over the tibialis anterior (the highest Strength centrality), and PPT over the carpal tunnel (the highest Closeness and Betweenness centrality). CONCLUSIONS This is the first study to apply network analysis to understand the multivariate mechanisms of individuals with CTS. Our findings support a model where clinical, depression, and widespread pressure pain sensitivity are connected, albeit within separate clusters. Clinical implications of current findings, such as developing treatments targeting these mechanisms, are also discussed.
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Affiliation(s)
- Bernard X W Liew
- School of Sport, Rehabilitation and Exercise Sciences, University of Essex, Colchester, United Kingdom
| | - Ana I de-la-Llave-Rincón
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Spain
| | - José L Arias-Buría
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Spain
| | - Ricardo Ortega-Santiago
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Spain
| | - César Fernández-de-Las-Peñas
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Spain
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Spectral Clustering Reveals Different Profiles of Central Sensitization in Women with Carpal Tunnel Syndrome. Symmetry (Basel) 2021. [DOI: 10.3390/sym13061042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Identification of subgroups of patients with chronic pain provides meaningful insights into the characteristics of a specific population, helping to identify individuals at risk of chronification and to determine appropriate therapeutic strategies. This paper proposes the use of spectral clustering (SC) to distinguish subgroups (clusters) of individuals with carpal tunnel syndrome (CTS), making use of the obtained patient profiling to argue about potential management implications. SC is a powerful algorithm that builds a similarity graph among the data points (the patients), and tries to find the subsets of points that are strongly connected among themselves, but weakly connected to others. It was chosen due to its advantages with respect to other simpler clustering techniques, such as k-means, and the fact that it has been successfully applied to similar problems. Clinical (age, duration of symptoms, pain intensity, function, and symptom severity), psycho-physical (pressure pain thresholds—PPTs—over the three main nerve trunks of the upper extremity, cervical spine, carpal tunnel, and tibialis anterior), psychological (depressive levels), and motor (pinch tip grip force) variables were collected in 208 women with clinical/electromyographic diagnosis of CTS, whose symptoms usually started unilaterally but eventually evolved into bilateral symmetry. SC was used to identify clusters of patients without any previous assumptions, yielding three clusters. Patients in cluster 1 exhibited worse clinical features, higher widespread pressure pain hyperalgesia, higher depressive levels, and lower pinch tip grip force than the other two. Patients in cluster 2 showed higher generalized thermal pain hyperalgesia than the other two. Cluster 0 showed less hypersensitivity to pressure and thermal pain, less severe clinical features, and more normal motor output (tip grip force). The presence of subgroups of individuals with different altered nociceptive processing (one group being more sensitive to pressure pain and another group more sensitive to thermal pain) could lead to different therapeutic programs.
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Scalise V, Brindisino F, Pellicciari L, Minnucci S, Bonetti F. Carpal Tunnel Syndrome: A National Survey to Monitor Knowledge and Operating Methods. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18041995. [PMID: 33670831 PMCID: PMC7922196 DOI: 10.3390/ijerph18041995] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/09/2021] [Accepted: 02/12/2021] [Indexed: 11/21/2022]
Abstract
The aim of this article was to investigate the knowledge, management, and clinical practice of Italian physiotherapists concerning patients with carpal tunnel syndrome (CTS). A national cross-sectional survey consisted of 24 questions was administered from December 2019 until February 2020. A Chi-squared independence test was run to study any difference between subgroups of the sample and responses to the questionnaire. Five hundred and eight respondents completed the survey. Most respondents (n = 225/508; 44.3%) are under 29 years old, female (n = 256/508; 50.4%) and have been working as physiotherapists for less than 5 years (n = 213/508; 41.9%). Most of respondents correctly knows about the cause (n = 455/508, 89.6%), main signs and symptoms of CTS (n = 415/508, 81.70%) and administer education, manual therapy, myofascial techniques and therapeutic exercises (n = 457/508, 89.88%). Three hundred and sixty-four (71.68%) respondents were aware of the influence of psychosocial factors on the patient’s outcomes. The survey showed greater adherence to evidences by physiotherapists holding a master’s degree. The results are mostly comparable with other surveys structured all over the world on the same topic. Italian physiotherapists management of the CTS was not always in line with current evidence. Interventions such as education, manual therapy, therapeutic exercise, nerve and tendon glide techniques are widely used, while the orthotic is only offered by half of the sample.
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Affiliation(s)
- Valentina Scalise
- Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, I-00133 Rome, Italy; (V.S.); (F.B.); (S.M.); (F.B.)
| | - Fabrizio Brindisino
- Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, I-00133 Rome, Italy; (V.S.); (F.B.); (S.M.); (F.B.)
- Department of Medicine and Health Science “Vincenzo Tiberio”, University of Molise, I-86100 Campobasso, Italy
| | - Leonardo Pellicciari
- Neurorehabilitation Research Laboratory, IRCCS San Raffaele Pisana, I-00166 Rome, Italy
- Correspondence: or ; Tel.: +39-32-8568-2656
| | - Silvia Minnucci
- Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, I-00133 Rome, Italy; (V.S.); (F.B.); (S.M.); (F.B.)
| | - Francesca Bonetti
- Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, I-00133 Rome, Italy; (V.S.); (F.B.); (S.M.); (F.B.)
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Clinical Significance and Diagnostic Value of Pain Extent Extracted from Pain Drawings: A Scoping Review. Diagnostics (Basel) 2020; 10:diagnostics10080604. [PMID: 32824746 PMCID: PMC7460462 DOI: 10.3390/diagnostics10080604] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 08/13/2020] [Accepted: 08/17/2020] [Indexed: 01/11/2023] Open
Abstract
The current scoping review aimed to map current literature investigating the relationship between pain extent extracted from pain drawings with clinical, psychological, and psycho-physiological patient-reported outcome measures in people with pain. Electronic databases were searched for cross-sectional cohort studies that collected pain drawings using digital technology or a pen-on-paper approach and assessed for correlations between pain extent and clinical, psychological or psycho-physical outcomes. Data were extracted by two different reviewers. The methodological quality of studies was assessed using the Newcastle–Ottawa Quality Assessment Scale. Mapping of the results included: 1, description of included studies; 2, summary of results; and 3, identification of gaps in the existing literature. Eleven cross-sectional cohort studies were included. The pain disorders considered were heterogeneous, ranging from musculoskeletal to neuropathic conditions, and from localized to generalized pain conditions. All studies included pain and/or pain-related disability as clinical outcomes. Psychological outcomes included depression and anxiety, kinesiophobia and catastrophism. Psycho-physical measures included pressure or thermal pain thresholds. Ten studies were considered of high methodological quality. There was heterogeneity in the associations between pain extent and patient-reported outcome measures depending on the pain condition. This scoping review found that pain extent is associated with patient-reported outcome measures more so in patients presenting with musculoskeletal pain, e.g., neck pain or osteoarthritis, rather than for those with neuropathic pain or headache.
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Fernández-de-las-peñas C, Arias-Buría JL, Ortega-Santiago R, De-la-Llave-Rincón AI. Understanding central sensitization for advances in management of carpal tunnel syndrome. F1000Res 2020; 9:F1000 Faculty Rev-605. [PMID: 32595941 PMCID: PMC7308881 DOI: 10.12688/f1000research.22570.1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/05/2020] [Indexed: 12/27/2022] Open
Abstract
Carpal tunnel syndrome is the most common nerve compression disorder of the upper extremity, and it is traditionally considered a peripheral neuropathy associated with a localized compression of the median nerve just at the level of the carpal tunnel. Surgery and physiotherapy are treatment approaches commonly used for this condition; however, conflicting clinical outcomes suggest that carpal tunnel syndrome may be more complex. There is evidence supporting the role of peripheral nociception from the median nerve in carpal tunnel syndrome; however, emerging evidence also suggests a potential role of central sensitization. The presence of spreading pain symptoms (e.g. proximal pain), widespread sensory changes, or bilateral motor control impairments in people presenting with strictly unilateral sensory symptoms supports the presence of spinal cord changes. Interestingly, bilateral sensory and motor changes are not directly associated with electrodiagnostic findings. Other studies have also reported that patients presenting with carpal tunnel syndrome exhibit neuroplastic brainstem change supporting central sensitization. Current data would support the presence of a central sensitization process, mediated by the peripheral drive originating in the compression of the median nerve, in people with carpal tunnel syndrome. The presence of altered nociceptive gain processing should be considered in the treatment of carpal tunnel syndrome by integrating therapeutic approaches aiming to modulate long-lasting nociceptive barrage into the central nervous system (peripheral drive) and strategies aiming to activate endogenous pain networks (central drive).
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Affiliation(s)
- César Fernández-de-las-peñas
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Spain
- Cátedra Institucional en Docencia, Clínica e Investigación en Fisioterapia: Terapia Manual, Punción Seca y Ejercicio Terapéutico, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
| | - José L Arias-Buría
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Spain
- Cátedra Institucional en Docencia, Clínica e Investigación en Fisioterapia: Terapia Manual, Punción Seca y Ejercicio Terapéutico, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
| | - Ricardo Ortega-Santiago
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Spain
- Cátedra Institucional en Docencia, Clínica e Investigación en Fisioterapia: Terapia Manual, Punción Seca y Ejercicio Terapéutico, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
| | - Ana I De-la-Llave-Rincón
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Spain
- Cátedra Institucional en Docencia, Clínica e Investigación en Fisioterapia: Terapia Manual, Punción Seca y Ejercicio Terapéutico, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
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Plaza-Manzano G, Delgado-de-la-Serna P, Díaz-Arribas MJ, Rodrigues-de-Souza DP, Fernández-de-Las-Peñas C, Alburquerque-Sendín F. Influence of Clinical, Physical, Psychological, and Psychophysical Variables on Treatment Outcomes in Somatic Tinnitus Associated With Temporomandibular Pain: Evidence From a Randomized Clinical Trial. Pain Pract 2020; 21:8-17. [PMID: 32419303 DOI: 10.1111/papr.12919] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/26/2020] [Accepted: 05/11/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To assess the influence of clinical, psychological, and psychophysical variables on treatment outcomes after application of exercise combined with education with/without manual therapy in people with tinnitus associated with temporomandibular disorder (TMD). METHODS A secondary analysis of a clinical trial was performed investigating the effectiveness of including cervico-mandibular manual therapy into an exercise combined with education program in 61 subjects with TMD-related tinnitus. Clinical outcomes including tinnitus severity and tinnitus-related handicap were assessed at 3 and 6 months post-intervention. Patients were assessed at baseline for clinical (tinnitus severity, tinnitus-related handicap, quality of life), physical (range of motion), psychological (depression), and psychophysical (pressure pain thresholds [PPTs]) variables that were included as predictors. RESULTS The regression models indicated that higher scores of tinnitus severity at baseline predicted better outcomes 3 and 6 months post-intervention (explaining 13% to 41% of the variance) in both groups. Higher scores of tinnitus-related handicap at baseline predicted better outcome of tinnitus-related handicap (45% variance) in the manual therapy with exercise/education group. Lower PPTs over the temporalis muscle at baseline predicted poorer clinical outcomes (10.5% to 41% of the variance) in both groups. Other predictors were sex and quality of life (6.7% variance) in the manual therapy group and PPTs over the masseter muscle (5.8% variance) in the exercise/education group. CONCLUSION This study found that baseline tinnitus severity and localized PPT over the temporalis muscle were predictive of clinical outcomes in individuals with TMD-related tinnitus following physical therapy. Other predictors (eg, sex, quality of life) were less influential.
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Affiliation(s)
- Gustavo Plaza-Manzano
- Department of Radiology, Rehabilitation and Physiotherapy, Universidad Complutense de Madrid, Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, Madrid, Spain
| | | | - María J Díaz-Arribas
- Department of Radiology, Rehabilitation and Physiotherapy, Universidad Complutense de Madrid, Madrid, Spain
| | | | - César Fernández-de-Las-Peñas
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón Madrid, Spain.,Cátedra Institucional en Docencia, Clínica e Investigación en Fisioterapia: Terapia Manual, Punción Seca y Ejercicio Terapéutico, Universidad Rey Juan Carlos, Alcorcón, Spain
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Wolny T, Linek P. Long-term patient observation after conservative treatment of carpal tunnel syndrome: a summary of two randomised controlled trials. PeerJ 2019; 7:e8012. [PMID: 31720121 PMCID: PMC6844241 DOI: 10.7717/peerj.8012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/08/2019] [Indexed: 01/04/2023] Open
Abstract
Background Physiotherapy of carpal tunnel syndrome (CTS) involves manual therapy based on neurodynamic techniques. Until now, two randomized controlled trials have shown that immediately after therapy, CTS patients who received neurodynamic techniques had significant improvement in nerve conduction, pain, symptom severity (SSS), functional state (FSS), muscle strength (MS) and two-point discrimination (2PD). However, long-term effects seem to be more important, as they are the only ones that can significantly improve the patient's health and influence economic and social costs. Thus, the objective of this study was to evaluate the long-term (six months) effects of neurodynamic techniques in the conservative treatment of CTS patients. Methods Carpal tunnel syndrome patients (107) from two previously published randomised clinical trials were observed for six months after the treatment based on neurodynamic techniques. Results The sensory conduction velocity, motor conduction velocity, and motor latency were not subject to statistically significant changes within six months after therapy (p > 0.05). In both groups, there was further pain reduction (p < 0.05). In Group B, the symptom severity improved significantly (p < 0.05), while the functional status in both groups remained unchanged (p > 0.05). In both groups, there was muscle strength improvement (p < 0.05). Two-point discrimination remained unchanged six months after the therapy. Conclusion The use of manual therapy based on neurodynamic techniques maintains the beneficial effects 6 months after therapy in CTS patients.
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Affiliation(s)
- Tomasz Wolny
- Institute of Physiotherapy and Health Sciences, Musculoskeletal Elastography and Ultrasonography Laboratory, The Jerzy Kukuczka Academy of Physical Education, Katowice, Poland
| | - Pawel Linek
- Institute of Physiotherapy and Health Sciences, Musculoskeletal Elastography and Ultrasonography Laboratory, The Jerzy Kukuczka Academy of Physical Education, Katowice, Poland
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