Effect of exercise on nerve conduction study of Carpal tunnel syndrome patients
Sahoo J. K1*, Joshi A. G2, Sahoo K. N3
1Assistant Professor, Department of Physiology, KIMSDU, Karad, Maharashtra, India, 415539.
2Professor, Department of Physiology, KIMSDU, Karad, Maharashtra, India, 415539.
3Associate Professor, Department of Prosthetics and Orthotics, KIMSDU, Karad, Maharashtra India, 415539.
*Corresponding Author E-mail: jksahoo1980@gmail.com
ABSTRACT:
Background: Carpal tunnel syndrome is the most common entrapment neuropathy of the median nerve at the wrist. In general population CTS is known to be a very common disease and the prevalence of CTS is estimated to be 2.7% as confirmed by clinical and electrophysiological findings. Typical symptoms of CTS are tingling, numbness and parasthesia in thumb, index, middle finger and radial half of ring finger which is often exaggerated at night. Previously research studies have been done on pain control, grip strength, wrist function. Very little research work has been done on effect of exercise on NCS of CTS patients. So the aim of the study is to find the short term (6weeks) effects of exercise on NCS of CTS patients. Methodology: Bilateral sensory and motor nerve conduction studies were carried out in 50 CTS patients before and after 6weeks of exercise. Exercise treatment was given to patients under the guidance of trained physiotherapist. Clinical examination was also done after 6 weeks. RMS machine from Chandigarh was used. Statistical analysis was done by INSTAT- 3.6 software. Result: DML, DML (diff.) DSL, DSL (diff.) showed significant decrease after 6 weeks of exercise in symptomatic (Rt.) hand, but no significant difference was found in SCV, CMAP, SNAP of median nerve. Whereas in Lt. hand only DML (diff.) between median and ulnar nerve showed significant change. There was also improvement in clinical signs and symptoms and pain scale. Conclusion: It was concluded that exercise treatment for 6 weeks under the proper guidance of trained physiotherapist showed significant improvements in clinical as well as electrophysiological parameters in symptomatic hands. So, exercise treatment can be suggested as choice of treatment for CTS patients.
KEYWORDS: Sensory nerve conduction, Motor nerve conduction, Carpal tunnel syndrome, Exercise.
INTRODUCTION:
Typical symptoms of CTS are tingling, numbness and parasthesia in thumb, index, middle finger and radial half of ring finger which is often exaggerated at night3,4.
A study from south India accounted 7% of CTS patients with peripheral nerve disorders and 84% of entrapment neuropathies referred for electro diagnostic evaluation. Early diagnosis of CTS may help to plan the treatment in early stage before structural damage to median nerve occurs. The results of electro diagnostic studies have been found to be highly sensitive and specific5.
Several treatments like carpal tunnel release surgery, medicinal treatment, exercise, and splints for CTS have been suggested. Several research studies have been done to see the effect of exercise on pain control, grip strength, wrist function. Very little research work has been done on NCS of CTS patients. So the present research work is planned to study the effects of exercise on NCS of CTS patients.
AIM AND OBJECTIVES:
1 To study the clinical findings (phalen’s test, tinel’s sign, pain scale) before and after exercise treatment.
2 To study the electrophysiological findings DML, DML (diff.), DSL, DSL(Diff.), SCV SNAP, CMAP before and after exercise treatment.
3 Comparision of clinical and the electrophysiological findings before and after exercise treatment.
MATERIALS AND METHODS:
50 clinically diagnosed CTS patients both male and female in the age Group 30-80 years referred to dept. Of Physiology for electro diagnosis were included in the study. Bilateral sensory and motor nerve conduction studies were carried out in clinically diagnosed patients of CTS to find out electro physiologic changes in median nerve conduction. Sample size was 50.
Following parameters were studied for electro diagnosis of CTS.
Motor conduction study:
· Distal motor latency of Median and ulnar nerve
· Motor conduction velocity.
· Amplitude of compound muscle action potential.
· Difference between distal motor latencies of median and ulnar nerves.
Sensory conduction Study:
· Distal sensory latency of Median and ulnar nerve
· Sensory conduction velocity
· Amplitude of sensory nerve action potential.
· Difference between distal sensory latencies of median and ulnar nerves.
Inclusion criteria:
Patients having Tingling, numbness, pain in palm more than 4weeks with or without phalen’s test positive or Tinels sign positive6.
Exclusion criteria:
Patients having open wounds on hand and all the conditions where nerve conduction is contraindicated.
For recording sensory and motor nerve conduction, surface metal electrodes were used. For recording motor conduction of Median nerve, recording electrode was placed close to the motor point of Abductor Pollicis Brevis and reference electrode 3cm distal to it at first metacarpo phalangeal joint. A supramaximal stimulus was given at wrist and at elbow near volar crease of brachial pulse.
For recording motor conduction of Ulnar nerve, recording electrode was placed close to the motor point of Abductor Digiti Minimi and reference electrode 3cm distal to it at fifth metacarpophalangeal joint. A supramaximal stimulus was given at wrist and at elbow in cubital tunnel behind medial epicondyle. For ulnar nerve stimulation at elbow arm position was maintained at 1350.
Same distance was kept between stimulating and recording electrodes for both median and ulnar nerves at wrist so that distal latencies of Median and Ulnar nerves could be compared1.
For orthodromic sensory conduction of median nerve, surface recording electrode was placed 3cm proximal to distal wrist crease and reference electrode at 3cm proximal to recording electrode. For stimulation ring electrodes were fixed on second digit.
For orthodromic sensory conduction of ulnar nerve, recording electrode was placed 3cm proximal to distal palmer crease and reference electrode at 3cm proximal to recording electrode. For sensory stimulation ring electrodes were fixed on fifth digit. Cathode was placed at first interphalangeal joint and anode at 3cm distal to cathode. 20 supramaximal stimuli were delivered and average was recorded. Laboratory temperature was maintained between 21o C to 230C1.
Institutional ethical committee approval (Ref. No. KIMSDU/IEC/2/2013) was taken for the study. Written consent of patients was taken before study. Recorder and Medicare System (RMS) machine from Chandigarh was used. After initial completion of NCS and clinical examination, patients were again evaluated after 6 weeks.
EXERCISE THERAPY FOR CTS7-11
1. Pulsed Ultra Sound at the Carpal tunnel
2. Low TENS over the wrist and hand
3. Passive manual mobilization of wrist, intercarpal, carpo metacarpal joint of hand.
4. Wrist and hand active exercises (10 repetitions for each joint)
· Free exercise of wrist and hand
· Towel exercise
· Exercise in wrist mover
· Practicing various grips
For assessment of severity of pain following pain scale was used12
1. Very mild 4.Severe
2. Mild 5. Very Severe
3. Moderate
Statistical Analysis:
INSTAT-3.6 version Software was used. Unpaired T test was applied to study the differences for various parameters studied. Mean and SD were calculated. The difference was considered to be highly significant (P < 0.001) and significant (P < 0.05).
RESULT:
Table: 1 Comparison of electrophysiological parameters of Right hand before and after 6 weeks of exercise
|
Parameters (N=50) |
Before |
After |
‘P’ value |
Remark |
||
|
Mean |
SD |
Mean |
SD |
|||
|
DML (Median) |
4.273 |
0.905 |
3.578 |
0.635 |
P<0.05 |
Significant |
|
DML (Diff.) |
1.746 |
0.802 |
1.247 |
0.623 |
P<0.001 |
Significant |
|
CMAP |
8.786 |
3.864 |
10.650 |
3.244 |
P>0.05 |
Not significant |
|
DSL (median) |
3.495 |
1.053 |
2.983 |
0.866 |
P<0.05 |
Significant |
|
DSL (diff) |
1.211 |
0.862 |
0.828 |
0.578 |
P<0.05 |
Significant |
|
SCV (median) |
38.547 |
10.611 |
38.256 |
12.033 |
P>0.05 |
Not significant |
|
SNAP |
12.410 |
9.308 |
12.907 |
8.576 |
P>0.05 |
Not significant |
Table-2: Comparision of electrophysiological parameters of Left hand before and after 6 weeks of exercise
|
Parameters (N=50) |
Before |
After |
‘P’ value |
Remark |
||
|
Mean |
SD |
Mean |
SD |
|||
|
DML(Median) |
4.324 |
1.272 |
3.875 |
1.018 |
P>0.05 |
Not significant |
|
DML(Diff.) |
1.869 |
1.283 |
1.232 |
0.862 |
P<0.01 |
Significant |
|
CMAP |
11.598 |
5.532 |
12.784 |
4.623 |
P>0.05 |
Not significant |
|
DSL (median) |
3.239 |
0.873 |
2.793 |
0.936 |
P>0.05 |
Not significant |
|
DSL (diff) |
1.011 |
0.655 |
0.842 |
0.596 |
P>0.05 |
Not significant |
|
SCV (median) |
40.013 |
12.040 |
38.188 |
13.636 |
P>0.05 |
Not significant |
|
SNAP |
13.764 |
10.241 |
13.252 |
9.517 |
P>0.05 |
Not significant |
Table-3: clinical tests and pain scale before and after exercise treatment
|
Clinical tests |
No. of patients Pre-exercise |
No. of patients Post- exercise |
|
|
Phalen’s test (+) |
44(Rt.) and 24 (Lt.) |
20(Rt.) and 18 (Lt.) |
|
|
Tinel’s test (+) |
41(Rt.) and 37(Lt.) |
15(Rt.) and 25(Lt.) |
|
|
Pain Scale |
Severe-30 Moderate-20 |
Very mild-2, mild-11 moderate-31, severe-6 |
|
Table -4 showing percentage of clinical improvement
|
|
Clinical signs |
% Improvement |
|
|
Right |
Left |
||
|
Exercise |
Phalen’s test |
54.5% |
25% |
|
Tinel’s sign |
63.4% |
32.4% |
|
|
Pain scale |
Before |
After |
|
|
Severe-60% Moderate-40% |
Very mild-4%, Mild-22% Moderate-62%, Severe-12% |
||
Comparison of electrophysiological parameters of Rt. Hand before and after 6 weeks of exercise Treatment showed significant decrease in DML(P<0.05), DML (diff.) (P<0.05), DSL(P<0.05), DSL(diff.) (P<0.05), but no significant difference was found in SCV (P>0.05), CMAP (P>0.05), SNAP(P>0.05) of median nerve (Table-1). Whereas in Lt. hand there was no significant change in DML(P>0.05), DSL(P>0.05), DSL(diff.) (P>0.05), SCV(P>0.05) and also no significant difference was found in amplitude of CMAP and SNAP of median nerve. But only significant difference was found in DML (diff.) between median and ulnar nerve. (Table-2).
When the clinical evaluation was done before and after exercise treatment (Table-3) it was observed that Phalen’s test was positive in 44 patients (Rt. hand), 24 patients (Lt. hand) before while after exercise for 6 weeks 20 patients showed positive Phalen’s test on Rt. Hand and 18 patients on Lt. hand. Tinel’s sign was positive in 41 patients (Rt. hand), 37 patients (Lt. hand) before but after exercise treatment only 15 patients showed positive Tinel’s sign on Rt. hand and 25 patients on Lt. hand. For Pain scale 30 patients showed severe pain and 20 patients moderate pain. After exercise treatment pain scale was reduced to severe (6), moderate (31), mild (11), and very mild (2). Table-4 shows percentage of clinical improvement. Phalen’s test was improved to 54.5% in Rt. Hand and 25% in Lt. hand, Tinel’s sign improved to 63.4% in Rt. Hand and 32.4% in Lt. hand. Pain scale was also improved so much. So our findings indicate that after 6weeks of exercise treatment except SCV, amplitude of CMAP and SNAP, all the electrophysiological parameters were improved on symptomatic hand, where as in Non-symptomatic hand only DML difference was improved. But there was improvement in clinical signs and symptoms and pain scale.
DISCUSSION:
Carpal tunnel syndrome is caused by compression of median nerve at the wrist and symptoms usually confined to the lateral aspect of the palm, thumb and the next three fingers. In the nonsurgical treatment corticosteroid injections, NSAIDs, immobilisation by splinting can be used to reduce pain and tingling sensation13. But the effect of drugs and splint shows short term result. Long term outcomes are poor. Drugs may have also side effects. In our study majority of our CTS patients were female. Different mode of exercises were done by the patients under the guidance of trained physiotherapist for 6 weeks. Our study showed that after 6 weeks of exercise there was significant decrease in DML, DML(diff.), DSL, DSL(diff.), but no significant difference was found in SCV, CMAP, SNAP, of median nerve of symptomatic Rt. hand whereas in Lt. hand. Only significant difference was found in DML (diff.) between median and ulnar nerve. Our result is different from other study.
Thomas et al. (1993) studied the effects of exercise on carpal tunnel syndrome for 8weeks and concluded that no significant difference was found in nerve conduction latency between control and CTS group. Significant differences were found in grip strength suggesting that exercise group may have benefited physiologically14.
Won-gyu Yoo etal. (2015) studied the effect of 3 exercises (release, wrist flexor stretching, wrist extensor stretching,) in a 40yr old right hand dominant presented with cts, with pain, progressive tingling and numbness. They concluded that pressure pain threshold decreased after 1st session, further decreased after 2nd session and the phalen’s test and tinel’s sign became less positive13.
Clifford JC et al (1994) studied the influence of provocative dynamic exercises on nerve conduction study in 3 groups. control, patients with clinically CTS but normal NCS, patients with clinically CTS but abnormal NCS. They found that there was significant decrease in DSL difference but no increase in DSL. So they concluded that provocative wrist exercise add diagnostic value to the regular electrodiagnostic evaluation15.
Yeong-Dong Park et al (2017) studied the effect of taping therapy for carpal space expansion on electrophysiological change in 20 female CTS patients in age group of 40-60rs.They found that DML was decreased, SNCV of median nerve was faster after 4 weeks. No significant difference was found in SNAP and CMAP16.
Compression of median nerve at wrist produces sensory loss on palmar aspect of the first through the third digits. Forced flexion or extension of the wrist commonly exacerbates the sensory symptoms. Motor symptoms and signs can develop with severity of mononeuropathy but the sensory symptoms predominate, especially early in the course17. In our study we have seen the effects after 6 weeks because it is the minimum time required for myelination of nerve fibers. So further large scale and long term study is required to get improvement in other electrophysiological parameters.
CONCLUSION:
In our study it was found that effect of exercise improves sensory as well as motor latency, latency difference after 6 weeks of exercise. Phalen’s and tinel’s sign became less positive. Pain scale was also improved. So it was concluded that after various mode of exercise treatment for 6 weeks improves clinical as well as electrophysiological parameters.
ACKNOWLEDGEMENT:
The authors are thankful to vice chancellor, Dean and HOD, Physiology KIMSDU, Karad for providing laboratory and hospital facilities to carry out this research work.
FUNDING SUPPORT:
KIMSDU, Karad
CONFLICT OF INTEREST:
There is No conflict of interest.
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Received on 02.07.2020 Modified on 13.08.2020
Accepted on 15.09.2020 © RJPT All right reserved
Research J. Pharm. and Tech. 2021; 14(8):4157-4160.
DOI: 10.52711/0974-360X.2021.00719