Rajiv Gandhi University of Health Sciences,
Karnataka, Bangalore
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1. / Name of the candidate and address (in block letters) / JOSHI SHRUTI KAMLESH,Dr. M. V. SHETTY COLLEGE OF PHYSIOTHERAPY,
VIDYA NAGAR, KULOOR,
MANGALORE-575013
2. / Name of the Institution / Dr. M. V. SHETTY COLLEGE OF PHYSIOTHERAPY
3. / Course of study and subject / MASTER OF PHYSIOTHERAPY IN
MUSCULO SKELETAL DISORDERS AND SPORTS PHYSIOTHERAPY.
4. / Date of admission / 12 JULY 2013
5. / Title of the Topic / A STUDY TO ASSESS THE EFFICACY OF NERVE MOBILIZATION IN FEMALES SUFFERING FROM CARPAL TUNNEL SYNDROME.
6. / Brief Resume of the Intended Work
6.1) Introduction and Need of the Study:
Carpal tunnel syndrome (CTS) is one of the most common peripheral neuropathies. It affects mainly middle aged women. In majorities of the patients, the exact cause and pathogenesis of CTS is unclear. CTS account for approximately 90% of all entrapment neuropathies. It is due to entrapment of median nerve in carpal tunnel at the wrist.
The risk of CTS is high in occupations involving exposure to high pressure, high force, repetitive work, and vibrating tools.1 Vibration may cause direct injury to the peripheral nerves resulting in the classic symptoms of CTS include nocturnal pain associated with tingling and numbness and burning sensation in the distribution of median nerve in the hand1,2,3 Involving median nerve distribution (first 3 digits and median half of the fourth finger) along with the deep aching pain in the wrist.2,4
The prevalence of CTS is estimated around 1% in the general population and 5% to 15% among workers in activities where there is use of repetitive flexion an extension of wrist, intense gripping of hands.5 Women are considerably more prone to this disorder in the ratio of 3:1 to about 10:1.4 CTS are bilateral in up to 87% of patients clinically and approximately 50% through Neurophysiological testing.2,6 In Carpal tunnel, the median nerve lies immediately beneath the Palmaris longus tendon and anterior to the flexor tendon. Conditions which decreases the tunnel’s size, or swell the structures contained within it, compress the median nerve against the transverse ligament bounding the tunnel’s roof. Such circumstances can arise traumatically, congenitally, or due to systematic or inflammatory effects.3,7 It is now widely accepted that exposure to hand – arm vibration and exposure to a combination of repetitive hand use and the use of hand force may be causal agents.8
CTS affects several classes of sensory receptors required for grasp control, .i.e., mechanoreceptors of the skin as well as muscle, joint and tendon receptors of intrinsic hand muscles. Much less is known about the role of other classes of receptors in hand muscles, tendons and joints for grasp control. CTS may challenge the ability to co-ordinate intrinsic and extrinsic muscles acting on a digit, hence affect force co-ordination across digits. Instruments used to asses hand grip is the dynamometer, which measures the hand grip strength, the individual is able to perform besides verifying the hand and upper limb strength, the hand grip strength can be used as an indicator of a general strength status, being used hence in physical fitness tests, it is also provided an index of functional integrity of upper extremity.9
Physical therapy modalities, although they are often used, in patients with CTS but results show only benefits in the short term. Nerve mobilization is one of the treatment methods for peripheral neuropathy, and it involves very specific movements to restore and adequate level of flexibility to nervous system in vertebrae, upper extremity & lower extremity.10 Maitland claims that the nerve mobilization technique helps to mitigate the pain transmitted by nerve fibres which is related to inflammation & dysfunction of nerve tissue and that it reduces nerve compression & friction in the nerve by increasing the compliance of peripheral nerves.11,12.
Need of the study.
Carpal tunnel syndrome (CTS) is the most common peripheral neuropathy in the upper limb, but its treatment was conservative therapies such as neural mobilization is controversial.13 Researchers suggests the need to re-examine the application of nerve mobilization with the use of more homogeneous study design and pathologies with addition, it should standardise the nerve mobilization intervention used in the study.14
Some studies says, there is use of repetitive flexion & extension of the wrist intense gripping of the hands and incorrect wrist flexion when using heavy machineries or hand tools, considered to be the risk factors for CTS. A need was identify to check the efficacy of neural mobilization in females having CTS, since CTS is more prevalent than men with the ratio of 3:1, F: M.15
Research Question:
Will there be significant difference in VAS and grip strength following the application of nerve mobilization on females with CTS.
Hypothesis:
Research Hypothesis: There will be significant difference in VAS and grip strength following the application of nerve mobilization on females with CTS .i.e. carpal tunnel syndrome.
Null hypothesis: There will be no significant difference in VAS and grip strength following the application of nerve mobilization on females with CTS
.6.2) REVIEW OF LITERATURE:
Marieli Araujo Rossoni Margoli, Josineie Gresele Coradine, et al. did a study on nociceptive & histomorphometric evaluation of nerve mobilization and they concluded that there were no changes in nerve regeneration histological and nociceptive sensation, delaying the proliferation of the number of axons in G3.13
Ton A R Schreuders, Marij E Roebroeck, et al. did the study on measurement errors in grip & pinch force measurements in patient with hand injuries using hand held dynamometer for hand grip they conclude that according to the ICC values obtained in their study, the reliability of grip & pinch force measurements is excellent.15
Missok Ha,Youngmin Son, et al. did the study on the effect of median nerve mobilization & median nerve self mobilization on median motor nerve conduction velocity. Their analysis of the results showed that the physical therapist’s application of MNM was more effective than self- MNM at increasing nerve conduction velocity.12
P Yazdapanah, S Aramesh, A Mousavizadeh, et al. did a prevalence study and severity of carpal tunnel syndrome in women and concluded that although the prevalence of CTS in Iranian pregnancy is higher than non pregnancy conservative treatment is safe and more effective.2
Wei Zhang, Jamie A. Johnston, Mark A. Ross, et al. did the study an effects of CTS on adaptation of multi digit force to object weight for whole hand manipulation and interpret that these behavioral deficits are resulting from impaired nerve function (slowing of sensory nerve conduction velocity axonal loss such impairment may account for patients reduced ability to perform accurate sensor motor memories of previous manipulation, or represent learned compensatory strategy to maximize grasp stability.9
Keith T Palmer, did a study on the role of occupational factors in CTS. In this study, the review focuses on the role of occupational factors in caution of CTS and factors that can mitigate risk areas of uncertainly, debate and research interest are emphasized were relevant.16
Chili Lati, Lori C. Guthrie, et al. did the comparative study of the construct validity & sensitivity to change of the VAS & a modified rating scale as measured of patient global assessment in RA. They concluded that although the rating scale with marker states was designed to be a more descriptive instrument than the VAS, both instruments had comparable validity & consistency among patients in their study. Their result provides reassurance that VAS can accurately identify patient’s assessment.17
Somaiah Aroori, Roy AJ Spence, conducted a systematic literature review on carpal tunnel syndrome. They concluded that occupational CTS is uncommon and it is essential to exclude all other causes particularly the intrinsic factors such as obesity before attributing it to occupation. The risk of CTS is high in occupations involving exposure to high pressure, high force, repetitive work, and vibrating tools. The diagnosis of CTS should be based on symptoms and signs and nerve conduction studies.1
Jane F Thomsen, Fred Gerri and Isam Atroshi, did a systemic literature review and states that there is insufficient epidemiological evidence that computer work causes CTS.8
Richard F. Ellis, B. Phty, et al. on nerve mobilization performed a systemic review of randomized control trial with an analysis of therapeutic efficacy and they conclude that nerve mobilization is advocated for treatment of aerodynamic dysfunction. A majority of these studies conclude a positive therapeutic benefit from using neural mobilization. However, in consideration of their methodological quality, qualitative analysis of these studies revealed that there is only limited evidence to support the use of nerve mobilization.14
David L Nordstrom, Robert A Vierkant, et al did a study on risk factors for CTS in general population and concluded that CTS is work related disease, although some important measures of occupational exposure, include keyboard use, were by a weight gain of about six pounds increases the risk of disease 8% requires explanation.3
Bruna Formentao Araujo1, Cassiane Merigo do Nascimento1, et al did a study on Assessment of hand grip strength after neural mobilization and in this study it is suggested that further investigations on the topic should be carried out including with non-crossed studies, to guide the activity of physiotherapists who use this technique, not only as cure but also prevention and performance improvement.18
6.3) OBJECTIVE OF STUDY:
1) To check the efficacy of nerve mobilization in females with CTS.
2) To assess the grip strength along with VAS.
7. / MATERIALS AND METHODS:
MATERIALS: Hand grip dynamometer and visual analogue scale.
7.1) STUDY DESIGN:
Experimental design
7.2 DEFINITION OF THE STUDY SUBJECTS :
Females in the age group of 35- 44 of years will be recruited for the study.
7.2 II INCLUSION AND EXCLUSION CRITERIA:
Inclusion Criteria:
§ Only female workers are included in the study2,4
§ Age group 35- 44 years
§ Subjects with CTS certified by the physician
§ Females have been working minimum 2-3hrs a day.16
§ Pain, tingling sensation, and all the symptoms of CTS present in females.1,2,3
Exclusion Criteria:
§ Surgeries of hand and wrist joint .
§ Any associated nerve injuries with upper extremity
§ Fractures involving lower end of the radio- ulnar and in & around the wrist joint.
§ Rheumatoid Arthritis
§ Skin conditions in and around the wrist joint
§ Ganglions or tumour involving the upper extremity
§ Herpes zoster involving the upper extremity
§ Keloids and scars in and around the wrist joint
§ Any other abnormalities in and around hand & wrist will be excluded.
7.2 III STUDY SAMPLE DESIGN, METHOD, SIZE:
Sample design and method :
Purposive sampling technique.
Sample size:
30 female subjects suffering from CTS will be selected.
7.2 IV FOLLOW UP:
Subjects who have completed the study will be assessed for pain and hand grip using VAS and hand dynamometer after 10session of the intervention.
7.2 V PARAMETERS USE FOR COMPARISION AND STATISTICAL TESTS :
Collective data will be analyzed with paired‘t’ test.
7.2 VI DURATION OF STUDY:
Duration of the study will be 12 months.
7.2 VII METHODOLOGY:
In the study, female subjects suffering from CTS would be selected. Subjects would be explained about the procedure before application of the technique. Pre and post assessment of VAS and hand grip strength would be taken for analyzing the improvement, effectiveness and reliability of the technique on the subjects with CTS.
Subject’s position: In the oblique supine position; head is near the therapist.
Therapist’s position: At the edge of the couch, perpendicular to the subject.
Procedure: Therapist with his ASIS depresses the subject’s shoulder, then subject’s arm is abducted to 10 degree, thumb is abducted, and one hand of the therapist is on the subject’s medial side of forearm & other hand on the subject’s palm and passively gives mild extension to the wrist. Now, for mobilizing nerve with grading, apply grading in wrist extension. The nerve mobilization will be maintained for 15 seconds followed by 10 seconds of break. This will be repeated for three times in one session.
7.3) Does the study require any investigations to be conducted on patients or other human or animal if so please describe briefly?
Yes, Hand held dynamometer and VAS.
7.4) Has ethical clearance been obtained from your institution in case of 7.3.
Yes
List of References:
1. Somaiah Aroori, Roy AJ Spence. Carpal tunnel syndrome. Ulster Med J 2008; 77 (1) 6-17.
2. P Yazdanpanah,S Aramesh,A Mousavizadeh, et al. Prevalence and severity of carpal tunnel syndrome in women. Iranian J Publ Health2012; 41(2):105-110. Randall LB, Ralph MB, Leighton C et al. Physical Medicine & Rehabilitation. Elsevier Saunders, Philadelphia, 2007, 3rd edition, pp.:1079-80.
3. David L Nordstrom, Robert A Vierkant, et al. Risk factors for carpal tunnel syndrome in a general population. Occupational and environmental Medicine 1997; 54:734-740.
4. Randall LB, Ralph MB, Leighton C et al. Physical Medicine & Rehabilitation. Elsevier Saunders, Philadelphia, 2007, 3rd edition, pp.:1079-80.
5. C. U. Pereira, A. F. Carvalho, M. F. Carvalho, et al.“Tratamento conservador da s’ındrome do t’unel do carpo,” Arquivos Brasileiros de Neurocirurgia, 2005, vol. 24.
6. Padua L, Pauda R, Nazzaro M, Tonali P. Incidence of bilateral symptoms in carpal
tunnel syndrome . Hand Surg, 1998, 23B, pp: 603-06.
7. Croft, P., AJ Hochberg, MC. Soft tissue rheumatism In: Silman. Editors, Epidemiology of the Rheumatic Diseases. Oxford University Press; Oxford: 1993. p. 399-408.
8. Jane F Thomsen, Fred Gerr and Isam Atroshi. Carpal tunnel syndrome and the use of computer mouse and keyboard: A systematic review.BMC Musculoskeletal Disorders 2008, 9:134.
9. Wei Zhang, Jamie A. Johnstone, Mark A. Ross,et al. Effects of carpal tunnel syndrome on adaptation of multi digit forces to object weight for whole- hand manipulation. Force coordination and adaptation in CTS,2011,6(11).
10. Butler DS: Mobilization of the nervous system; London: Churchill Livingstone, 1991, pp 147-159.
11. Maitland GD: the slump test: examination and treatment. Aust J Physiother, 1985, 31: 215-219.
12. Missok HA, Youngmin Son, et al. Effect of median nerve mobilization and median nerve self-mobilization on median motor nerve conduction velocity. J. Phys. Ther. Sci. 24:801-804, 2012.
13. Marieli Araujo Rossoni Marcioli, Josineia Gresele Coradini, et al. Nociceptive and histomorphometric evaluation of neural mobilization in experimental injury of median nerve. The scientific world journal, 2013,volume 2013.
14. Richard F. Ellis, B. Phty, et al. Neural mobilization: A systematic review of randomized controlled trials with an analysis of therapeutic efficacy. The Journal of manual & manipulative therapy2008; 16 (1):8-22.
15. Ton AR Schreuders, Marij E Roebroeck, et al. Measurement error in grip and pinch force measurements in patients with hand injuries. PHYS THER. 2003; 83:806-815.
16. Professor Keith T Palmer. Carpal tunnel syndrome: the role of occupational factors.Res Clin Rheumatol.2011,25(1):15-29
17. Chili Lati, Lori C. Guthrie, et al. Comparison of the construct validity and sensitivity to change of visual analogue scale and modified rating scale as measures of patient global assessment in rheumatoid arthritis. J Rheumatol. 2010 April; 37(4): 717-722.
18. Bruna Formentao Araujo, Cassiane Merigo do Nascimento, et al. Assessment of hand grip strength after neural mobilization. Rev Bras Med Esporte2012: Vol.
19. Katz JN, Simmons BP. Clinical practice. Carpal tunnel syndrome. N Engl J Med
2002; 346(23):1807-12.
20. Eversmann w w Jr. Entrapment and compression neuropathies. In:Green DP, editor.Operative hand surgery, New York: Churchill
Livingstone; 1993; 2 :1341 – 85.
21. Omer GE, Jr. Median nerve compression at the wrist. Hand Clin
1992;8(2):317-24.