Carpal Tunnel Syndrome (CTS) has long been a thorn in the side of the Workers’ Compensation system. Associated with repetitive motions of the upper extremity, there has long been an argument over occupational causality. Regardless of causality, the economic and social burden of the condition, significantly impacting days absent from work and increasing overall medical costs cannot be denied.
Patients with CTS can be managed either conservatively or surgically. Conservative approaches are usually attempted first and typically combines a treatment plan of splinting, steroid injections and Physical Therapy. If conservative treatment fails or is slow to show benefit, surgery may be attempted. Recently the efficacy of surgery has been debated. A current analysis of the available research only demonstrated a slightly better outcome in pain reports and functional outcomes in surgical patients. Previous studies were limited as the conservative treatments used were typically local to the hand (ultrasound, stretches, splinting, etc.). Although CTS is a mostly considered a local peripheral neuropathy , recent evidence suggests that Physical Therapy should focus on a more complex approach since there is more central nervous system involvement than once thought in CTS.
The authors (Fernandez-de-las Penas, et al) of a new study in the Journal of Orthopaedic and Sports Physical Therapy (JOSPT) performed a randomized clinical trial to compare the effectiveness of manual Physical Therapy versus surgery in improving cervical range of motion, pinch grip strength, symptom severity, and self-reported function in women with CTS.
Patients in the Physical Therapy group were treated with manual Physical Therapy, stretching exercises and education. The manual therapy and exercises focused on the entire upper extremity up to the cervical spine, most specifically targeting the median nerve, which is the nerve entrapped in CTS. Manual interventions included joint mobilizations and soft tissue mobilization techniques.
After completing the study at a 12 month follow up, the authors concluded that manual Physical Therapy and surgery had similar effectiveness for improving self-reported function, symptom severity, and pinch-tip grip force on the symptomatic hand in women with CTS.
The authors concluded that manual therapy treatment of the cervical spine and potential areas of entrapment of the median nerve are a worthy alternative to surgical intervention in CTS. As a practicing Orthopedic Manual Therapist I can attest to this. I have also had numerous occasions where I treat a post-surgical CTS patient and have to go back and perform all of the manual therapy interventions of the upper extremity and cervical spine anyway to get the patient back to full function. Surgical release of CTS releases the local pressure at the wrist, but if the median nerve is entrapped further up the chain to the cervical spine, this is often not enough to get the patient full relief and return to function.
This is yet another study that demonstrates that conservative care can be as effective as surgery when looking at long term outcomes. This study did have limitations as the subjects were all women from the same hospital system. More studies will need to be performed on a broader population in the future.
These types of studies should be considered in medical decision making and utilization review determinations. We often times do not give conservative care enough time to help before determining the patient needs surgery. In the case of CTS there are frequently no opportunities for conservative care to work at all, a positive diagnosis may go right to surgery.
Another important note is that the Physical Therapists performing the interventions in this study were all very experienced manual Physical Therapists with over 10 years of experience in manual therapy. The old version of local conservative care: splinting, modalities, injections and wrist stretches should be questioned for their adequacy. As in other similar studies, conservative care is most effective when being performed by an experienced orthopedic manual therapist. If you or one of your patients is experiencing CTS or another musculoskeletal condition – make sure you are seeing a Physical Therapist that is committed to evidence based care including manual therapy interventions.
If you would like more information please contact Results Physiotherapy at https://resultspt.com/request-an-appointment. To see more about the study listed in this article visit http://www.jospt.org/doi/abs/10.2519/jospt.2017.7090?code=jospt-site for the abstract.
