Carpal Tunnel Syndrome was first described by Sir James Paget in 1854 but the term was coined by Moeirisch. It is a syndrome of compression neuropathy of median nerve at the wrist. Carpal Tunnel Syndrome results in considerable discomfort and pain, limitation of activities of daily living, loss of sleep and work disability. (Levine et al., 1993). Twenty percent of symptomatic subjects with symptoms of pain, numbness, nocturnal parasthesia and tingling sensation in the hand would be expected to have Carpal tunnel syndrome based on the clinical examination and electro physiologic testing.
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CARPAL TUNNEL SYNDROME IN PREGNANCY
Carpal tunnel Syndrome is more frequent in pregnancy because the systemic process increases the extra capsular fluid retention by the hormone Prolactin and produce soft tissue swelling in the later stages (third trimester) of their pregnancies. The Carpal Tunnel Syndrome can thus be produced by compression or swelling of the median nerve in its synovial sheath (Gelberman et al., 1981; Snell, 2000; Szabo, 1989; Primal Pictures, 2001; Rempel et al., 1999).
Many therapies have been advocated for treating the carpal tunnel syndrome including Mobilizations, nerve gliding, tendon gliding, etc. Therefore the presence study was focused on the Effect of Nerve and Tendon gliding Exercises in the functional recovery of the carpal tunnel syndrome during pregnancy.
Tendon gliding Exercises were mostly performed at the end range of motion at small amplitude are performed at the limit of available motion and stressed into the tissue resistance. These exercises are thought to relieve pressure on the median nerve and stretch the carpal ligaments, which also helps decrease pressure. They are also thought to help blood flow out of the carpal tunnel, which can help decrease fluid pressure.
Pregnant Women with pain and swelling in the wrist for at least 1 month.
Pregnant women with both unilateral and bilateral carpal tunnel syndrome.
Pregnant women with age group between 25years and 32years.
Non-pregnant women with carpal tunnel syndrome.
Pregnant women having other complications like hypothyroidism, diabetes that may lead to carpal tunnel syndrome.
Any other trauma related injuries in hand.
MATERIALS AND METHODS
Nerve and Tendon Gliding Exercises.
Functional Status Scale for measuring functional activity.
Nerve and Tendon Gliding Exercise programme will be effective in the treatment of carpal tunnel syndrome during pregnancy.
There may not be any significance between the nerve and tendon gliding exercise programme and carpal tunnel syndrome during pregnancy.
The aim of this study is to determine from the available evidence the effectiveness of Nerve and Tendon gliding exercises programme in carpal tunnel syndrome during pregnancy using Functional Status Scale for performance and Symptom Severity Scale for wrist pain.
A total of 20 patients having carpal tunnel syndrome during pregnancy are selected to find out the effectiveness of nerve and tendon gliding exercises on them.
The duration of study per patient – 4 weeks
Treatment session – 10 minutes per session / 2settings
Treatment per week – 7 days
DURATION OF STUDY: 6 months
Relief of pain and swelling in hand.
An improvement in the functional ability of hand.
Awareness is created for the working pregnant women especially with computers, typewriters, cake decorators, postal workers, dentists, and dental technicians virtually, who use their hands and wrists repetitively.
Avoiding the severity of median nerve injury, which may lead to claw hand if unnoticed.
Sir James Paget first described carpal Tunnel Syndrome in 1854 but Moeirisch coined the term. It is a syndrome of compression neuropathy of median nerve at the wrist. INTRODUCTION:
Carpal Tunnel Syndrome results in considerable discomfort and pain, limitation of activities of daily living, loss of sleep and work disability. (Levine et al., 1993).
The Carpal Tunnel’s floor is made up of the 8 tiny wrist bones. Its roof is a thick ligament called the transverse carpal ligament. 9 tendons pass through this tunnel. 4 of the 9 tendons bend the tips of the finger, another 4 of the 9 tendons bend the middle joints of the finger, and the 9th tendon bends the thumb tip.
The median nerve passes through this tunnel. When there is swelling or if there is thickening of the ligament the nerve gets pinched or compresses. With enough compression carpal tunnel symptoms occur. If the compression is severe or occurs over a longer period of time the nerve may change shape and flatten causing some permanent damage.
Carpal Tunnel Syndrome occurs due to many causes like
CARPAL TUNNEL SYNDROME IN PREGNANCY
Carpal tunnel Syndrome (CTS) is more frequent in pregnancy because the systemic process increases the extra capsular fluid retention by the hormone Prolactin and produce soft tissue swelling in the later stages (third trimester) of their pregnancies. The Carpal Tunnel Syndrome can thus be produced by compression or swelling of the median nerve in its synovial sheath (Gelberman et al., 1981; Snell, 2000; Szabo, 1989; Primal Pictures, 2001; Rempel et al., 1999).
CTS have been recognized as a common complication of pregnancy (Heckman&Sassard, 1994). The pathophysiology of pregnancy related CTS (PRCTS) has been mostly attributed to redistribution of fluids (Ekman-Ordeberg et al., 1987; Wand, 1990; Pauda et al.,2001).
Signs And Symptoms
1.Pain that shoots from the hand up the arm as far as the shoulder.
2.Tingling in the hands during the day or the night that disrupts sleep and limits the ability to grasp objects with the hands.
3.Weak feeling in the hands, and the inability to pick up small objects.
4. The feeling that the hands are swollen, even if they do not appear to be so.
5.Burning numbness and tingling sensation in the thumb and first three fingers.
6.Weakness in the muscle at the base of the thumb, near the palm.
Motor weakness will be seen in abductor pollicis brevis, flexor polices brevis and opponens policis brevis. Passive flexion or hyperextension of the affected hand at the wrist for more than one minute may worsaen symptoms.(Phalen.G.S.,1966). Percussion of the median nerve at the wrist causes paresthesis of the digits (Steward.J.D.,1978).
1.Splinting the wrist in a neutral position.
2.Avoiding the activities which causes pain if possible
3.Tendon and nerve gliding exercises.
5.Elevating the arm or flicking
7.Ultrasound, icing, as pain relieving modality etc.
Non operative treatment s is more effective in early stageas such as NSAIDS and local corticosteroids injections.If the probl;em is severe surgery is made to release the carpal tunnel.
Harrington etal suggested surveillance criteria for carpal tunnel syndrome should be pain or parasthesia or sensory losss in the median nerve distribution and one of the following:
Tinel’s sign positive
Phalens test positive
Nocturnal exacerbation of symptoms
Motor loss with wasting of the abductor pollicis brevis
Abnormal nerve conduction studies.
Nocturnal and exertonal dyesthesias in the radial half of the palm occur in 10% to 25% of pregnant women. When the carpal tunnel syndrome occurs, the symptoms area more often bilateral. Onset of symptoms is typical during the third trimester. Because of itas trnsient nature carpal tunnel syndrome during pregnancy is best treated by using conservative measures, such as tendon and nerve gliding exercises. That subsequent pregnanciesaraae frequently associated with repeated episodes of carpal tunnel syndrome confirms the association of carpal tunnel syndrome and pregnancy.
Tendon gliding and median nerve-gliding exercises are two types of exercises that may help with carpal tunnel syndrome. These exercises are thought to relieve pressure on the median nerve and stretch the carpal ligaments, which also helps decrease pressure. They are aolso thought to help blood fow out of the carpal tunnel, which can help decrease fluid pressure.
Fist Flexion Exercises
Fist Flexion Exercises(also known as tendon gliding exercises) move your fingers through five positions while your wrist stays in a neutral position(meaning it is not bend). To perform this exercise, do the following:
1.Start with your fingers straight.
2.Make a hook fist and then return to a straight hand.
3.Make a straight fist and then return to a straight hand.
4.Make a full fist andthen return to a straight hand.
Hold each positons for seven seconds amd do 10 repetitions. Repeat three times to five timeas a day.
Median Nerve Gliding Exercises
For median nerve gliding exercises ou move yout thumb through 6 positi0nswhile your wrist stays a neutral position. To perform this exercise, do the following:
1.Begin by making a fist with your wrisat in the neutral position.
2.Straigthen your fingers anad thumb.
3.Bend your wrist back and move your thumb away from your palm
4.Turn your wrist palm up
5.Use your other hand to gently pull uyout thumb farther away from your palm.
Hold each position for seven seconds, and do five repetitions. Repeat three ti five times a day.
Effectiveness of the Tendon and nerve gliding exercises used as conservative treatment approachesd in relieving the symptoms of the carpal tunnel syndrome during pregnancy.(Lamia Pinar, Asgel Enhos et al.,)
Carpal tunnel syndrome is a condition caused by compression of median nerve within the carpal tunnel leads to sensory changesover the lateral side of the hand and muscle weakness in thenar eminence, results in pain, numbness and tingling of fingers. It usually occurs in the third trimester of pregnancy.
Aim of Study
“A STUDY OF EFFECTIVENESS OF NERVE AND TENDON GLIDING EXERCISES AS TREATMENT APPROACH TO CARPAL TUNNEL SYNDROME DURING PREGNANCY.”
The aim of this study is to determine from the available evidence the effectiveness of Nerve and Tendon gliding exercises programme in carpal tunnel syndrome during pregnancy using Functional Status Scale for performance and Visual Analogue scale for wrist pain.
There may not be no significance between the nerve and tendon gliding exercise programme and carpal tunnel syndrome during pregnancy.
Nerve and Tendon Gliding Exercise programme will be effective in the treatment of carpal tunnel syndrome during pregnancy.
Review of literature
1.Lamia Pinar, Asgel Enhos et.al
Conducted an experiment study on total of 26 patients with caroal tunnel syndrome were divided into two groups. In one group the volar splint were applied and trained to modify their functional activities in accordance witrh conservative treatment. In group two tendon gliding exercises were continued for 4 weeks with numeric rating scale and Gonuiometry. It comcluded that group two reported excellent results in pain reduction and functional improvement than gropup one.
Conducted an experimental study on carpal tunnel syndrome with a total of 28 patients with 36 hands of CTS, which were divided into two groups, with 14 patients each. One group was treated with nerve and tendon gliding exercises along with custom made neutral volar splint, and another group was treataed with only neutral volar splint for 4 weeks continuously. Patientas satisfaction was invesatigated during the follow up ranging from 5-11 month, with a mean of 8 month. The study explained that, of those patients who performed nerve and tendon gliding exercise with wearing custom made neutral volar splint, 93% reported good results, and of those patients who have only wearing neutral volar splint, 72% reported good results. American Journal of Physical Medicine Rehabilitation, 2002, Feb;81(2), Pp:108-13).
3.Rosemaryn .L.M., et.al.,(1998)
Conducted an experimental study on carpal tunnel syndrome with 240 hands, from 197 patients. They were divided into two groups. Patients in both groups were treated with standard conservative methods, and those in one group were also treated with a program of nerve and tendon gliding exercise of those who did not perform the nerve and tendon gliding exercise, 71.2% underwent surgery compared with only 43.0% of patients who did perform them. Patient in experimental group, who did not undergo surgery were interviewed at an average follow-up time of 23 months (range, 14-38 months), of these 53 patients, 47(89%) responded to this detailed interview of those 47, who responded, 70.2% reported good or excellent results, 19.2% remained symptomatic, and 10.6% were non-complaint.(Journal of Hand Therapy, 1998, Jul-Sep:11(3),171-9).
the purpose of the study was to evaluate the usefulness in conservative treatment of carpal tunnel syndrome. 40 Patients aged 30-72 years, with unilateral CTS cofirmed by EMG examination were included. The patients were divided into 3 groups based on clinical symptoms according to Whitley. The character of pain, its frequency and intensity (VAS Scale) were determined using parameter. Decrease in pain was observed by the usae of VAS. (Rock Akad Med Bialmyst, 2005:50-suppi:196-8).
the study was designed to assess the efficacy of a proposed new and unique programme relative to treatment. The patients diagnosed as CTS were compared to control to a control population showing no symptoms. Prior to undergoing treatment and following completion of the treatment programme. Results indicate that individuals with CTS had significantly lower values in strength, ROM, and slower task performance than did the control;ratings of pain anad distress were also significantly higher than the control groups. Analysis of the post treatmaent cases revealed statistically significant improvements in several measures of up to statistically significant improvements in several measure of up to 25% over post treatment values. Significant improvement was also shown to several ROM measures of upto 22%. Finally, a significant reduction of 15% pain and distress ratings was demonstrated in the post treatment cases. (Journal of Manipulative Physical Therapy, 1994 (May);17(4):246-249).
Conducted a comparative study between the responsiveness of Visual analogue scale and McGill pain questionnaire. Measures in 75% patients and concluded that the VAS was a better tool than the McGill pain questionnaire for measuring pain in clinical practise.
7.O.Baysal, Z.Altay et.al
Conducted a study in 28 female patient with clinical and electrophysiologic evidence of bilateral carapal tunnel syndrome. They were divided into two groups. Group 1 received tendon gliding exercise with splinting. Group 2 received splinting with ultrasound for a period of 4 weeks with Visual analogue scale and Functional status scale.
8.Bringer TL.,Roger IC et.al
conducted a randomized trial in totoal of 61 patients with carpal tunnel syndrome. They were divided into four groups. Group 1 received neutral wrist and MCP exercise group. Group 2 received neutral wrist MCP exercise along with splint. Group 3 received wrist cock-up exercise and Group 4 received wrist cock-up exercise and tendon gliding exercise along with splintas perfoarmed 3 times a day. The tool used to asses the function is functional Status Scale and Symptom Severity Scale. There was significant effect in Group4.
9. Sonodyn, Sieman(2000)
Conducted an experiment on study of 16 patients. They was treataed with Ultrasound for a period of 4 weeks and the pain was assessed. In this, 88% reported good reasult and reduction pain was assessed by using Visual Analogue Scale.
10. Davis.P.T.,et. al., (1998)
Conducted an experimental study to compare the efficiency of conservative management care with chiropractic care in treatment of carpal tunnel syndrome. The group with 9 week of treatment and a 1 month follow-up interview. 96 eligible patients with symptoms were conformend by clinical exam and nerve conduction studies. Conservative treamtment included mobilization of carpal bone, soft tissues, joints (three treatment per week for 2 wee, two treatment per week for 3 week, and one treatment per week for 4 wek). Main outcomes measures were pre and post assessment of self reported physical and mental distress, nerve-conduction studies, results show that there was significant improvement in perceived function and comfort, neve conductuion and finger sensation. (Journal of Manipulative Physiotherapy, 1999 June;22(55);348-9)
11. FD Burke, J Ellis, H McKenna, M J Bradley(2003)
Carpal Tunnel syndrome of mild to moderate severity can often be effectively treated in a primary care environment. Work space modifications wrist splints tendon and nerve gliding exercises are of benefit and useful for symptomatic women in the third trimester of pregnancy.
12.Shaafi Sh*, Naimain Sh*, Iromlou H*, Sayyah Melli M**
A convenience sample of 90 pregnant women (30 women from each trimester) were referred from Al-Zahra Hospital of the electrodiagnostic ward of examined clinically and then by electroneurodiagnostic tests.There were suspected symptoms of CTS in 45 patients. The most frequent symptom and sign were hands paresthesia(34%) and positive tinel and phalen sign(each22%). CTS was definite diagnosis in 15 women(16.6%) by electroneurodiagnostic studies. Mild bilateral involvement was seen in 73.3% of patients. There was a meaningful relationship between CTAS and trimester that 26.6% of patients were at third trimester. Also there was a meaningful relation to age. The CTS was more frequent in ilder women.
13.BaumannF, Karlikaya G, Yuksel G, Citci B, Kose G, Tireli H(2007)
Pregnant women in the third trimesater (n=69) and age-matched non-pregnant women (n=40) asymptomatic for CTS were included in the studyNerve conductn studies of themedian and the ulnar nerves across the carpal tunnel were bilaterally performed with the standard techniques. All the median sensory nerve conduction studies performed from the ring finger and palmar region to the wrist. Median sensory nerve latencies from palmar branches to wrist were significantly longer in the pregnant group.(p<0.01) than in non pregnant group(p<0.05). sensory nerve action potential amplitudes recorder in the palmar region were smaller in the pregnant groups(45.1V) than in the control group(56.5V).
Conducted an experimental study to evaluate the effectiveness of non surgical treatment for carpal tunnel syndrome versus a placebo or other non-surgical control interventions in improving clinical outcome. Twenty ine trials involving 884 people were included. In one trial involving 21 people carpal bone mobilization significantly improved symptoms after three weeks, (weighted mean difference is -1.43;95% confidence interval is 2.19 to -0.67), compared to no treamtment. Current evidence shows significant short term bebefit from carpal bone mobilization. (Cochrane Databasae syst Rev.2003;(1):CD003219).
MATERIALS AND METHODOLOGY
MATERIALS AND METHODOLOGY
MATERIALS AND METHODOLOGY
FUNCTIONAL STATUS SCALE
Quasi experimental study with Pre Vs.Post test design.
The 10 samplings were selected from Retna
Global Hospital, Trichy and Thanthai Roever College of Physiotherapy, perambalur. A total number of 10 subjects were diagnosed as symptomatic Carpal Tunnel syndrome during pregnancy at age group of years was selected by Quasi-experimental purposive random sampling method after giving due consideration to inclusion and exclusion criteria.
The study was conducted at Outpatient Physiotherapy Department in Thanthai Roever College of Phsiotherapy, Perambalur, Rathna Global Hospital, EMG Laboratory in PG Studies under the supervision of concerned authority.
The study was conducted for a period of 4 weeks.
Pregnant women with pain and swelling in the wrist for 1 month.
Both unilateral and bilateral involvement.
Age 25 years and 32 years.
Non pregnant women with carpal tunnel syndrome.
Pregnant women having other complications like hypothyroidism, diabetes which may lead to carpal tunnel syndrome.
Any other trauma related injuries.
Abnormal X-Ray of the wrist.
Gained surgical of symptoms.
History of steroid injection into the carpal tunnel.
A.VISUAL ANALOGUE SCALE(VAS)
The VAS Scale is the valid and reliable measurement tool for pain.It is used to measure the pain response that the patient experience before and after nerve and tendon gliding exercises of median nerve.
VAS Scale consists of 10cm horizontal line with two ends labeled as no pain(0) and severe pain(10), the patient will mark a point on the line, which corresponds to the intensity of pain what theyexperience.
B.FUNCTIONAL STATAUS SCALE(FSS)
Functional Status Scale was used to measure the functional disability offhand. It consists of six items of questionnaire (writing, buttoning of clothes, holding a book while reading, household, carrying grocery bags, bathing and dressing).
06-12 -No difficulty
13-18 -Mild difficulty
19-24 -Moderate difficulty
25-29 -cannot do at all due to hand or wrist symptoms.
A total of 10 subjects with symptomatic carpal tunnel syndrome during pregnancy was selected randomly with due consideration to inclusion an exclusion criteria
A brief demonstration was given about tendon and nerve gliding techniques for the patient.
Pre test data and post taest data was collected with VAS and FSS Scale. The results were recorded.
The subjects weare given nerve and tendon gliding exercises.
The results of post test of the same parameter was recorded and compared.
The statistical tool used in this study were paired t-test.
âˆ‘t-test was used to find out the statistical significance between Pre and Post test values of tendon and nerve gliding exercises and VAS pain response and FSS Scale response before and after treatment.
FORMULA: PAIRED T-TEST
d =Difference between the Pre Test Vs post Test
d= Mean difference
n=Total number of subjects
Visual Analogue scale
Pre Test Post Test
Functional Status Scale
Pre Test Post Test
DATA ANALYSIS AND INTERPRETATION
DATA ANALYSIS AND INTERPRETATION
This chapter deals with the analysis and interpretation of the Data’s collected from 10 patients with carpal tunnel syndrome during pregnancy and the effect of nerve and tendon gliding exercises aas a treatment approach to carpal tunnel syndrome during pregnancy by comparing the VAS Scale for pain response and FSS for functional ability.
The table II shows the mean value, mean diference, standard deviation and paired t value between pre and post test value of Visual Analogue Scale for patientas whao have been subjected to tendon anad nerve gliding exercises.
Paired t value
It explains the paired t value of pre and post test value was 13.28 at 0.05 level of significance which was greate than the tabulated t value 2.26. This showed that there was a statistical significant difference between pre versus post test. The pre test mean was 7.9 the post test mean waas3.4 and the difference was 4.5 which showed that there was a reduction in Visual Analogue Scale score in post test values in which the recovery of selected samples in response to intervention.
THEREFORE THE STUDY IS REJECTING THE NULL HYPOTHESIS AND ACCEPTING THE ALTERNATE HYPOTHESIS.
Visual analogue scale: Pretest VS Post test
Functional Status Scale: Pre test Vs Post Test
Table III representas the mean values,mean difference, standard deviation and paired t value of Functional Status Scale who have been subjected to tendon and nerve gliding exercises.
Paired t value
It explains the paired t value of pre versus post sessions awas 17.7 at 0.05 level of significance which was greater than the tabulated t value 2.26. this showed that there was a statistical significant difference between the pre and post test resultas. The pr tesat ment was 27.1, the post test ment was 14.6,and the difference was 12.5 which showed that there was a reduction in functional status scale score in post test values in which recovery of the selected samples in response to intervention.
Thrrefore the study is rejecting the null hypothesis and accepting the alternate hypothesis.
The aim of the study was to determine the effect of tendon and nerve gliding excercises in reducing the pain and improving the functional ability of hand in patient with carpal tunnel syndrome during pregnancy.
Carpal tunnel syndrome is most common and significant of all nerve entrapment syndromes (Phalen.G.S. 1972). It causes 20% of all compression syndromes especially in the third trimester of pregnancies.
A total number of 10 subjects of age group of 25-32 years were selected for the study. Visual Analogue Scale for pain and Functional Status Scale for functional ability were taken as parameters to measure the affliction of patients. Pre test data has collected for the subjects and computed.
They were subjected to tendon and nerve gliding exercises for 4 weeks. The result of post teat of same parameter was recorded for comparison after 4 weeks of treatment. The paired t test was used to compare the pre VS post test results of subjects.
Caarpal tunnel syndrome is a common condition among people who do repetitive wrk all day lke punching keys on computer or cash register or even pressing on the strings of a violin. Pregnant women are also susceptible to carpal tunnel syndrome even if they do not type or play msic all day. The studies have shown that one out of four pregnant women complains of the syndrome usually in the second or third trimester of pregnancy when fluid retention in the aarms and hands is more likely to put pressure on the nerve that leads to the hands anad fingers.
The nervous system is normally under some pressure and tension. If the tension is breaked there results some movement(Millesi.et.al.1972).
Dackowicz . A.,, conducted an study to evaluate the usefulness in conservative treatment of the carpal tunnel syndrome.
According to Butler neural tissue requires movement to promote healing and restoration of optimum mechanical properties.Decreased neural mobility and adverse mechanical tension in nervous system can generate pain.(Butler and Elvey 1978).
Mchellan and Swash in 1976 noted that wrist and fingers extensor wil move the median nerve at wrist 2 or 4 times more than the middle of the upper arm.
According to Asgel Enhos tendon requires movement to promote functional ability.
Rosmaryn and Asgel Enhos said that the decreased tendon gliding in nervous system can generate pain. Rosmaryn proposed that radicular pain might be mobilizing the involved nerve.
The mechanical respose is tendon movement in the cross sectional shape and viscoelastic function.
So the treatment of tendon Gliding Exercise mah normalize the pressure gradient around the nervous system and releases the tendon thus reducing pain improving functional ability.
The objective of the study was to determine from the available evidence the effectiveness of tendon and nerve gliding exercises programmed in reducing pain and of increasing the functional ability in the carpal tunnel syndrome during pregnancy.
To conduct the study, the total number of 10 carpal tunnel pataients during pregnancy with both unilateral and bilateral involvement at the age group 25 to 32 years, who were suitable for inclusive criteria was selected by Quasi – experimental purposive random sampling technique and informed consents were obtained from subjects individually.
The pre and post test of VAS and FSS were conducted and recorded before and after treatment programmed for 4 weeks of nerve and tendon gliding exercises inmcarpal tunnel syndrome during pregnancy.
The paired t test is used to compare the pre and post test values of nerve anad tendon gliding exercises and the pain and functional ability are computed by the VAS and FSS Scale.
In the analysis and interpretation of the data based on the Visual Analogue Scale for pain the paired t- test value (13.28), which was greater than the tabulated paired t test val
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