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1st Mar

2017

Manual Therapy Found Equally Effective as Surgery for Carpal Tunnel Syndrome

Fresh off the press, a new Spanish research study showed encouraging results for people with carpal tunnel syndrome (CTS). One hundred women with diagnosed CTS were randomly allocated to either a manual therapy or a surgery group. The outcome was measured with self-rated hand function assessed with a CTS questionnaire, pinch-tip grip strength, neck range of motion, and a questionnaire for symptom severity. Measurements were taken at baseline, 1, 3, 6, and 12 months after the last treatment.

Manual therapy was performed by experienced manual physical therapists, and all physicians were experienced hand surgeons. The manual physical therapy consisted of various soft tissue mobilization techniques addressing muscles and fascia along the course of the median nerve (and related nerve structures) from the neck, down the arm, to the hand, as well as joint mobilization to the neck. Patients were instructed in self-stretching exercises to the neck. Treatments were administered once a week for three weeks.

At one month after treatment, the manual therapy group scored significantly better on measurements, compared to the surgery group. At the 6 and 12 month intervals, results were essentially identical between the two groups.

The authors made the valid point, that carpal tunnel syndrome typically is not just a local median nerve compression disorder in the wrist, but a more complex condition involving nerve sensitization and often secondary tissue changes elsewhere in the arm and neck, which therefor in physical therapy are best treated with a comprehensive manual therapy approach, as used in this study. More research data have been reported in recent years, which have shown that manual physical therapy can produce essentially equally good results as surgery. This study revealed that results at 6 and 12 months were very much comparable in terms of self-rated function, symptom severity, and pinch-tip grip strength.

The authors acknowledged that results in the manual therapy group could have been even better, if participants had received more than three weekly sessions. However, this was not tested in this study.

After analyzing the manual therapy methods used in this study, I would like to make the following comments:
Soft tissue mobilization techniques were appropriate and comprehensively applied. Cervical spine mobilization can be instrumental in reducing pain and muscle guarding both locally in the neck and peripherally in the arm and hand. I would have chosen slightly different, and in my opinion, more effective mobilization techniques. No nerve gliding mobilization was performed, although we know that quite frequently this condition presents with reduced nerve gliding capacity in the upper extremity, with painful nerve tension signs. Such nerve gliding techniques, including self-performed at home, could have further enhanced the patients’ progress. I would also have modified the neck stretches performed at home, and added a few gentle dynamic exercises. Finally, I agree with the authors that three weekly visits is likely insufficient, to get optimal results. Four to 6 sessions, spread out over 6-8 weeks, would likely yield consistently better outcomes.

The results of this study are important and encouraging, since most people would like to avoid having surgery, as long as long-term good results can be achieved by conservative means. Studies such as this have been missing until recently, which is why manual physical therapy for CTS is often not suggested by physicians. I hope that more physicians, including surgeons, will become aware of studies such as this one, which was published in a major, and well respected physical therapy journal, and hopefully will also be referenced in papers published in major medical journals in the near future.

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