Myofascial Release on Electrophysiological Measures of Pregnant Women With CTS
Condition: Carpal Tunnel Syndrome
MeSH terms: Carpal Tunnel Syndrome; Syndrome
Study type: Interventional
Phase: Phase 4

Summary: 
      Objective: To explore the effect of myofascial release on electrophysiological and clinical
      measures of pregnant women with carpal tunnel syndrome (CTS).

      Design: Randomized controlled trial. Methods: Thirty pregnant women had CTS, their age ranged
      from 25-35 years, were randomized into two equal groups. The control group only wore a
      natural wrist splint during sleeping for 4 weeks, while the study group received a myofascial
      release in addition to wearing a natural wrist splint during sleeping for 4 weeks. All
      pregnant women in both groups were evaluated pre and post-treatment through median nerve
      distal motor latency (DML) and Boston carpal tunnel questionnaire (BCTQ) to assess pain,
      numbness & tingling sensation severity and hand function.
    

Detailed description: 
      Design This study was designed as a prospective, randomized, controlled trial. The Research
      Ethical Committee of the Faculty of Physical Therapy, Cairo University approved this study.
      The study was conducted between May 2013 and April 2014.

      Participants A sample of thirty pregnant women were recruited from the Obstetric Out-patient
      Clinic, El-Sahel Teaching Hospital, Cairo, Egypt. To be included in the study, the
      participants were chosen pregnant women at early of the third trimester complaining from
      idiopathic CTS (pain, numbness and tingling of the hand), which was confirmed by
      electrophysiological examination (i.e. delayed median DML < 3.9 msec) as well as positive
      Phalen's test. Pregnant women having bilateral and unilateral CTS affection participated but
      the dominant hand data only were enrolled in this study. Their ages ranged from 25 to 35
      years old, their body mass index (BMI) did not exceed 34 Kg/m2 and their gravidity number
      ranged from 1 to 3 times. The participants were excluded if they had other predisposing
      causes for CTS and/or neuromuscular diseases that might affect median nerve transmission such
      as diabetes mellitus, pre-eclampsia, rheumatoid arthritis, previous CTS symptoms, acute hand
      trauma, cervical spondylosis, previous surgeries in the forearm involving the median nerve,
      peripheral neuropathy and pronator teres syndrome. All pregnant women did not receive any
      physical or medical therapy for treating CTS complains and had no serious medical problems as
      pacemaker and heart diseases that might interfere with electrophysiological testing.

      Randomization Informed consent was signed by each participant after explaining the nature,
      purpose, and benefits of the study, informing them of their right to refuse or withdraw at
      any time, and about the confidentiality of any obtained data. The pregnant women were
      randomly assigned into two equal groups (control group and study group), a computer-based
      randomization program. No dropping out of subjects from the study after randomization.

      Interventions Participants were randomly assigned into; Control group composed of fifteen
      pregnant women who only wore a natural wrist splint during sleeping for 4 weeks. Study group
      composed of fifteen pregnant women who received a myofascial release in addition to wearing a
      natural wrist splint during sleeping for 4 weeks.

      Neutral wrist splint A neutral wrist splint was worn by all pregnant women in both groups
      daily at night, only all through the study time (4 weeks). This neutral wrist splint was used
      to keep the wrist in a straight position (neutral position) and to prevent the extreme wrist
      motion (flexion and extension) while sleeping.

      Myofascial release technique

      Each pregnant woman in the study group received myofascial release technique, 3 sessions/week
      for 4 weeks. The position of treatment was long sitting with the back fully supported, the
      dominant palm and forearm exposed and rested comfortably. Myofascial release technique was
      divided into two parts:

        -  First part; Myofascial wrist retinaculum (Transverse carpal ligament) release: The
           physical therapist placed her fourth and fifth fingers of both hands between the
           pregnant woman's fourth and fifth fingers and first and second fingers of the palmar
           surface and extension of the pregnant woman's wrist was introduced. The Physical
           therapist's thumbs overlie the lateral and medial attachments of the wrist flexor
           retinaculum and transverse distraction to the retinaculum was applied until relaxation
           of the soft tissue or release of the restriction was achieved (for about 30 seconds)
           then relaxation time was about 10 seconds. 15 repetitions were made in each session,
           three sessions per week for four weeks.

        -  Second part; Interosseous membrane and forearm muscles myofascial release (Bilateral
           thumb pressure technique): Gentle force was applied ventrally on the forearm through 2
           hands grasping the pregnant woman's distal forearm with the thumbs contacting the
           anterior aspect of the forearm muscles and interosseous membrane while the index fingers
           grasping the posterior aspect of the forearm to engage the soft tissues cephalad until a
           barrier of tissue motion was reached and hold for about 30 seconds then relaxation time
           was about 10 seconds. 15 repetitions were made in each session, three sessions per week
           for four weeks Outcome Measures

      Median nerve DML:

      It was done for all the pregnant women in both groups before participation in this study to
      confirm their diagnosis of CTS and also after the end of the treatment.

      Each pregnant woman in both groups was asked to evacuate her bladder to be more relaxed and
      then she was informed about the aim and steps of the test while she was seated on a wooden
      chair and her back was supported. The dominant forearm was in supinated position, rested on
      the examining table and the elbow joint held slightly flexed. The pregnant woman's body
      temperature was measured with an oral mercury thermometer and if it was normal, the test
      procedure was carried out and also the room temperature was adjusted at 22 °C, which
      controlled by an air conditioner as median nerve DML could be affected by the pregnant woman
      temperature as well as the room temperature.

      Before electrode placement, the areas used for recording, stimulating or ground points were
      cleaned by alcohol to clean the skin to decrease its resistance. Further reduction of
      impedance was obtained by using conducting gel on the surface of the recording electrodes.

      Then, the electromyography was calibrated and the parameters of the apparatus were adjusted
      as follows: Time base at 5.0 milliseconds/division, the sensitivity at 4000.0 volts/division
      and the intensity according to the site of stimulation; it was about 7 mA at the wrist
      stimulation and 12 mA for the elbow stimulation [7].

      After the end of the previous preparation, the active recording electrode was placed on the
      motor point of the abductor pollicis brevis muscle and the reference recording electrode on
      the tip of the thumb. They were fixed to the hand by adhesive plaster straps. The bipolar
      stimulating electrode was placed above the wrist joint between the tendons of palmaris longus
      and the flexor carpi radialis muscles on the course of the median nerve, with the negative
      pole distal toward the active recording electrode, and the positive pole proximal to
      stimulate the median nerve. The ground electrode was placed on the distal wrist crease midway
      between the stimulating and recording electrodes, 7 mA was used at wrist stimulation.

      Then, the bipolar stimulating electrode was placed in the cubital fossa, just medial to the
      biceps tendon, with the negative pole distal toward the active recording electrode, and the
      positive pole proximal. The recording electrodes were applied at the same locations as in
      recording at wrist level. 12 mA was used at elbow stimulation.

      BCTQ:

      It was self-applied and evaluated the severity of symptoms and the functional status of
      patients with CTS. It had comprehensive framework, good validity, reliability and
      responsiveness in the hands of the researchers [8]. The questionnaire compromised two scales,
      a symptoms severity scale (SSS) and a functional status scale (FSS). The SSS evaluated
      symptoms regarding severity, frequency and time. The FSS evaluated how the syndrome affects
      daily life. Questions concerning SSS composed of 11 questions addressing: Pain intensity
      during day time and night time, time of pain during the day, dormancy, weakness, tingling
      sensation at night, frequency of that night tingling sensation and skill. Each question had
      five answers numbered from 0 point (no symptoms) to 4 points (most severe). Questions
      concerning FSS consisted of daily activities that were performed by most individuals and were
      commonly affected by CTS. The patients rated their ability to perform the activity on a scale
      that ranged from 1 point (no difficulty with the activity) to 5 points (cannot perform the
      activity at all). The overall score for the FSS was the mean of the ratings on the daily
      activities. This questionnaire was performed before and after treatment for both groups.
    

Intervention name(s): Study group; Control group
Intervention type(s): Combination Product; Device
Intervention description(s): Each pregnant woman in the study group received myofascial release technique, 3 sessions/week for 4 weeks. a myofascial release in addition to wearing a natural wrist splint during sleeping for 4 weeks.
Myofascial wrist retinaculum (Transverse carpal ligament) release.
• Second part; Interosseous membrane and forearm muscles myofascial release (Bilateral thumb pressure technique).; A neutral wrist splint was worn by all pregnant women in both groups daily at night, only all through the study time (4 weeks). This neutral wrist splint was used to keep the wrist in a straight position (neutral position) and to prevent the extreme wrist motion (flexion and extension) while sleeping.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Participant)
Primary purpose: Treatment