Rajiv Gandhi University Of Health Sciences

Rajiv Gandhi University Of Health Sciences,
Karnataka, Bangalore
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1
2
Name of the Candidate and
Address
Name of the Institution
MR. SANDEEP.P.H
S/O HARISH.P.N
#3978, NEAR HAMPI CIRCLE,
VIJAYNAGAR II STAGE
MYSORE
J S S COLLEGE OF PHYSIOTHERAPY
JSS HOSPITAL CAMPUS,
RAMANUJA ROAD,
MYSORE – 570004
MASTER OF PHYSIOTHERPY
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Course of Study and Subject
4
Date of admission to the
course
PHYSIOTHERAPY IN
NEUROLOGICAL AND PSYCHOMATIC
DISORDERS
17-06-2009
TITLE OF THE TOPIC
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A COMPARITIVE STUDY ON THE EFFECT OF KINESIOTAPING AND
CONVENTIONAL PHYSIOTHERAPY IN CARPAL TUNNEL SYNDROME.
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Brief resume of the intended work
6.1) INTRODUCTION.
Carpal tunnel syndrome (CTS) is a constellation of the paresthesias, numbness and muscle
weakness in the hand caused when the median nerve gets compressed or impinched at the
wrist1
The condition was first noted in medical literature as early as the 20th century and the term
“carpal tunnel syndrome” was coined in 1939.2The pathology was identified by physician Dr.
George S. Phalen of the Cleveland Clinic after working with a group of patients in the 1950s
and 1960s2. CTS became widely known among the general public in the 1990s because of the
rapid expansion of office jobs3.
CTS
is caused due to various reasons like repetitive stress injury, trauma, pregnancy,
rheumatoid arthritis, hypothyroidism, obesity, multiple myeloma, amyloidosis, acromegaly,
mucopolysaccharidoses and idiopathic4
The narrowing of the carpal tunnel due to a musculoskeletal imbalance between over and under
used muscles of the hand and forearm is the most prevalent cause for carpal tunnel syndrome.
Once the carpal tunnel begins to collapse in on itself, by any form of repetitive or static
extension such as typing, writing, grasping, etc, friction of the flexor tendons against the carpal
bones, median nerve and blood vessels causes irritation, inflammation and increased swelling of
the structures within the carpal tunnel .
In normal hands, the average interstitial pressure within the tunnel is 2.5 mm Hg with maximum
pressure elevations in wrist extension or flexion well below 32 mm Hg 5
If the pressure becomes higher and/or more sustained, swelling of the nerve bundle can occur
within the endoneurium, The endoneural edema alone interferes with nerve function due to
alterations in the local ionic environment of the axons 7
Increased canal interstitial pressure has a direct mechanical effect on axonal transport, with
outcomes suggesting that persistent compression at 20 mm Hg results in a reduction of
orthograde fast axonal transport with reductions in orthograde slow transport at 30 mm Hg 8.
Destruction of the epineurium and endoneurium with a dense, fibrous scar tissue is the final
result9.
The magnitude of oedema formation and subsequent nerve conduction blockage is related to the
magnitude and duration of the compression occuring due to obstruction of venous return in the
epineural or perineural vascular plexuses, leading
to venous congestion, hyperemia and
circulatory slowing 6
According to the Bureau of Labor statistics (2007-08), CTS accounted for “1.7%” of work
place related conditions in private industries that resulted in lost work. Recent researches have
shown that the incidence of CTS may be as high as “3.7%” in general population, with a higher
incidence in individuals who practice repetitive wrist maneuvers &30 percent of computer
professionals who complained of hand paresthesias.10 Incidence of carpal tunnel syndrome is
highest in women over the age of 30.11
Carpal tunnel syndrome can be treated either conservatively or surgically. Conservative
treatment comprises of various electrical modalities like laser, ultra sound, tens, exercises like
nerve and tendon gliding exercise, Kinesio taping , carpal tunnel splints and anti inflammatory
drugs. Open carpal tunnel release and endoscopic carpal tunnel release techniques are
commonly used surgical intervention.
The electrical modalities and nerve and tendon gliding exercise will assist in decreasing the
pain, inflammatory process and assist in tendon and nerve gliding which has been restricted.
Kinesio taping is one of the newer approaches in treating the carpal tunnel syndrome. It uses a
correction technique to lift the skin creating a space in the area of inflammation or pain to
improve lymph or vascular movement, The movement of taped skin and soft tissue creates a
massaging
effect that
promotes
lymph
and blood flow decreasing
pressure on
mechanoreceptors and thus pain and oedma. Sensory receptors in the skin also act on ascending
and descending neurologic pathways to decrease pain and assist in control of muscle tension
via Golgi tendon input12.
Surgical interventions are opted only in severe cases of CTS as the complications like soreness
of operated areas, permanent loss of grip strength, infection, damage to nerves and blood
vessels and scar tissue formation deter people from opting this form of treatment13, 14.
NEED OF THE STUDY
The conservative treatment relies heavily on splinting, whose basic principle is to give rest to
inflamed segment by inhibiting movements which restricts their daily routine work at home &
work place. This in turn leads to muscle atrophy, disturbed sleep, uncomfortable sensation and
holds hand in a certain positon with no particular therapeutic action15.
Kinesio taping will not only allow the segment to move without hampering his daily routine
work but also provides therapeutic benefits like, reducing oedema, inflamation, pain and to relax
over used muscle and stimulate weak muscles.
This study is an attempt to evaluate the efficacy of kinesio taping as an adjunct in the treatment
of CTS and as a replication of carpal tunnel splints.
HYPOTHESIS
EXPERIMENTAL HYPOTHESIS: Treatment using kinesio taping with conventional
therapy shows significant difference in pain, grip strength and distal nerve latency in patients
with CTS
NULL HYPOTHESIS: Treatment using kinesio taping with conventional therapy does not
shows significant difference in pain, grip strength and distal nerve latency in patients with CTS
6.2) REVIEW OF LITERATURE:
1.
Maryylynn A Jacobs’s et al: In there published book mentioned that usage of kinesio taping
for carpal tunnel syndrome uses a correction techniuqe to lift the skin, creating a space in the
area of inflamation or pain to improve lymph and vasular movement. Where the target tissue
was retinacular ligament and material used was two inch wide “I” cut tape. Taping was done by
positioning the hand in tolerable wrist extension, applying the correction tape with all the
stretch taken out of center and applied directly down onto the area over transverse carpal
ligament. Move the wrist into relaxed flexion and apply the ends without tension.Tape may be
applied either volar/ dorsal aspect of wrist depending on response of patient. Patient
experienced changes in symptoms over 24 hour period.12
2. Darren
Hancock, DC, CKTI : In his article mentioned that application of kinesio taping on
carpal tunnel syndrome causes changing in tension of skin tissue lifting it to increase lyphatic
drainage and act as an correction technique.Taping was done by extending palm up, place base
of “X” strip on inside of wrist. Extend one tail toward base of thumb & other toward base of
little finger , extend wrist adding light to moderate stretch to all but last one or two inchs.extend
opposite tails toward inner & outer side of elbow joint adding light to moderate stretch to all
but last 1-2 inches. Wrap “I” strip around the wrist, adding light stretch to tape over back of
wrist & no stretch to tape over inside of wrist.16
3.
Wen-Dien Chang, Jih_huah Wu, et al 2008: Studied the theraputic effects of 830nm diode
laser on pain, functional ability and grip strength in CTS. 36 patients were randomly divided
into two groups. Group A received laser treatment (10 hz, 50%duty cycle, 60mW, 9.7J/cm2 at
830nm) Group B received sham laser treatment for 2 weeks. Results shows that stastically
significant differences(p<0.05) were found in group treated with laser on VAS, grip strength
and functional assessments at 2 week follow up.17
4.
Th. Rappl, Ch. Laback, et al: Evaluated the effect of low level laser therapy in mild &
moderate CTS monitored by EMG & VAS recordings. 72 patients with cts were evalated and
divided into two groups. Group A were treated with LLLT (wave length 830nm, 400 mW, and
3J/point) over carpal tunnel or trigger or accupuncture points, Group B received a red light pen.
Results suggest that LLLT can be recommende in mild, moderate CTS.18
5. Shooshtari SM, Badiee V et al: Conducted a study to find out the effect of low level laser
on pain, hand grip strength, median nerve latency in CTS. 80 patients with CTS were randomly
assigned into 2 groups. Group A underwent laser therapy over the carpal tunnel area (9-11
jouls/cm2) , Group B received sham laser therapy. Results showed significant improvement in
pain intensity, hand grip and decrease in nerve latency after 15 sessions (P<0.001).19
5.
Naeser MA, HahnKA et al: The purpose of this study was to examine the effect of TENS
with laser on 11 patients of CTS. Patients received real and sham treatment series in a
randomized order.real treatments used red beam laser (contious wave, 15mW, 632.8nm) on the
afected hand and micro amps tens on affected wrist. Results showed significant decreases in
pain score and median nerve sensory latency after the real treatment series but not after sham
treatment series.20
6.
Pinar, lamia et al: Conducted a study to investigate the effectiveness of nerve and tendon
gliding exercises in combination with conservative treatment in patients of CTS. 26 patients
with CTS were divided into 2 groups. Group A recevied ultra sound, tens and night splint were
as group B patients received same treatment with addition of nerve and tendon gliding exercise
for 4 weeks. Results showed significant improvement in both groups, when the 2 groups were
compared group B showed more rapid pain reduction, greater functional improvement especially
in grip strength (p<0.05). 21
7.
Rozmaryn LM, Dovelle S et al: Evaluated the effect of nerve and tendon gliding exercises
and the conservative management of carpal tunnel syndrome. In the study 197 subjects
presenting for treatment of CTS were divided into 2 groups.Patients in both groups were treated
by standerd physitheraputuc conservative methods, and those in one group were treated with a
program of nerve & tendon gliding exercises. Results showed a significant improvement in
subjects treated with nerve and tendon gliding exercise who were interviewed at an average
follow up time of 23 months.22
6.3) Objectives of the study:
1. To evaluate the effectiveness of kinesio taping in patients with carpal tunnel syndrome on
pain, grip strength and distal latency during nerve conduction velocity studies.
2. To evaluate the effectiveness of conventional physiotherapy in patients with carpal tunnel
syndrome on pain, grip strength and distal latency during nerve conduction velocity
studies.
3. To compare the effectiveness of kinesio taping with conventional physiotherapy on carpal
tunnel syndrome on pain, grip strength and distal latency during nerve conduction velocity
studies.
Materials and Method
7.1) Study design:
Experimental study
Pre test _Post test
Source of study: Department of physiotherapy, JSS Hospital, Mysore.
7.2) (I) Definition of study subjects: Subjects diagnosed with Carpal Tunnel Syndrome who
are referred from various deparment of J.S.S Hospital Mysore.
(II) Inclusion and exclusion criteria:
Inclusion Criteria
•
Both male & female subjects.
•
Age group 20-50 years.
•
Positive Phalens & Drunkans test.
•
Unilateral CTS.
Exclusion Criteria
•
Patients having cervical spondylosis with radiculopathy.
•
Rheumatoid arthritis.
•
Post steroid injected patients.
•
Post traumatic cases like colle’s fracture, fracture scaphoid
•
Subjects with bilateral CTS.
( III ) Study sampling design, method and size
Sample design: Simple random sampling
Method of collection of data: Personal structural interview
Sample size: 30 subjects
(Vi) Duration of study: 2weeks
(V) Materials required:
•
RMS EMG EP MARK 2 with all standard accessories.
•
Kinesio tape.
•
Prometheus M infrared 904nm laser apparatus.
•
Aquasonic conducting gel.
•
Measuring inch tape
•
‘Base line’Hand dynamometer
(IV) Follow up: 2 weeks after the course of treatment.
(vii) METHODOLOGY:
Patients will be included in the study after the initial assessment and informed consent is
obtained. Subjects who fulfil the inclusion criteria will be assigned into 2 groups based on
simple random sampling. As all the subjects under go a thorough evaluation comprising of
pain intensity, grip strength, distal latencies & nerve conduction velocities before & after the 2
week trial period.
Subjects in both the Group’s received infrared laser (Impulse frequency 4000Hz, Impulse
power 9mW, 904nm), TENS (50 hz, accupunctue mode 15 minutes), and nerve and tendon
gliding exercise. Group ‘B’ subjects will be given kinesio taping in addition to the
electrotherapy treatment, which will be applied daily after course of treatment where the target
tissue will be the retinacular ligament and material used was two-inch wide “I” cut tape. Taping
will be done by positioning the hand in tolerable wrist extension, the correction tape will be
applied with all the stretch taken out of centre and applied directly down onto the area over
transverse carpal ligament.Wrist is moved into relaxed flexion and applied the ends without
tension. Tape was applied either volar/ dorsal aspect of wrist depending on response of patient.
Outcome measures:
•
Visual analog scale(VAS)
•
Grip strength measured by ‘Baseline’ hand dynamometer.
•
Nerve conduction studies.
Statistics: The data obtained will be analyzed using ANOVA and Pearson’s Co-relational
design. The level of significance will be kept at p<0.05.
7.3)
Does the study require any investigations or interventions to be conducted on
patients or other Human or animal?
Yes
7.4)
Has ethical clearance been obtained from your institution in case of 7.3?
Yes.
List of References:
1. Stevan J Macabe “Carpal tunnel syndrome what is it? How to treat?” 2007:1-2.
2. Kao SY. "Carpal tunnel syndrome as an occupational disease". The Journal of the
American Board of Family Practice / American Board of Family Practice 16 (6) 2003:
533–42.
3. Sternbach G. "The carpal tunnel syndrome". J Emerg Med, 1999; 17: 519–23.
4. Survey by National Institute of Neurological Disorders and Stroke 2007-08.
5. Gelberman RH, Hergenroeder PT, Hargens AR, et al. The carpal tunnel syndrome: A
study of carpal tunnel pressures. J Bone Joint Surg [Am]. 1981; 63A:380-3.
6. Eversmann WW Jr. Entrapment and compression neuropathies. In Green DP (Ed):
Operative Hand Surgery Ed 2. New York, Churchill Livingstone, 1993 p 1341-45.
7. Rydevik B, Lundborg G. Permeability of intraneural microvessels and perineurium
following acute, graded experimental nerve compression. Scand J Plast Reconst Surg.
1977; 11:179-87.
8. Dahlin LB, McLean WG. Effects of graded, experimental compression on slow and fast
axonal transport in rabbit vagus nerve. J. Neurol Sci. 1986; 72:19-30.
9. Sunderland S. The nerve lesion in carpal tunnel syndrome. J Neurol Neurosurg
Psychiatry. 1976; 39:615-26.
10. Stevens JC, Witt JC, Smith BE, Weaver AL. The frequency of carpal tunnel syndrome
in computer users at a medical facility. Neurology 2001; 56: 1568-70.
11. Book on Carpal tunnel syndrome and its management by Stanley J. Swierzewski, III,
M.D. 2005.
12. Marylyn A Jacobs, Noelle M. Austin .Splinting the hand & upper extremity: principle
and process 2002; 280-81.
13. Thoma A,Veltri K, Haines T, Duku E. "A meta-analysis of randomized controlled trials
comparing endoscopic and open carpal tunnel decompression". Plast Reconstr Surg 2004; 114
(5): 1137–46.
14. Chow JC, Hantes ME. "Endoscopic carpal tunnel release: thirteen years' experience with the
Chow technique". J Hand Surg [Am] 2002; 27 (6): 1011–8.
15. Dr Clyde Morgan “Carpal solution and its effects”, chiropractor Olathe U.S.A.
16. Darren Hancock. “Principle: The kinesio taping method”2004.
17. Wen-Dien
Chang,
Jih_huah
Wu,Joe-air
Jiang,
Cun
–Yu
Yeh,Chien_Tsung
Tsai ;“Carpal tunnel syndrome treated with a diode laser” American journal of physical
therapy 2008.
18. Th. Rappl, Ch. Laback, St Quasthoff, M.Auer- Grumbach, and R.Gumpert; “Low level
laser therapy in mild and moderate CTS- a double blind, Randomized study”, Archive
of physical medicine and rehabilitation.2002:17.
19. Shooshtari SM, Badiee V, Amanollahi AH, and Grami MT; “The effects of low leval
laser in clinical out come & neurophysiological results of CTS” Archive of physical
medicine and rehabilitation.2008:48(5):229-231.
20. Naeser MA, HahnKA and Branco KF; “Carpal tunnel syndrome pain treated with low
level
laser and
microamperes
TENS”
Archive
of physical
medicine
and
rehabilitation.2002:83; 978-89.
21. Pinar, Lamia, Enchos Aysel, Ada Sait. “Effectiveness of nerve and tendon gliding
exercise in combination with conservative management of CTS” Journal Advances in
therapy. 2005:22:467-75.
22. Rozmaryn LM, Dovelle S, RothamanER, Gorman K. “Nerve and tendon gliding
exercise &and the conservative management of CTS” Archive of physical medicine and
rehabilitation.2006
9
Signature of the candidate
10
Remarks of the guide
11
Name and Designation of
11.1
Guide
11.2
Signature
11.3
Co-guide (if any)
MR. SANDEEP.P.H
Proposal is unique & relevant
Hence Recommended
A.V.SUNISH
PRINCIPAL, J.S.S. COLLEGE OF
PHYSIOTHERAPY, MYSORE
NA
11.4
Signature
11.5
Head of Department
A.V.SUNISH
HOD, DEPT. OF PHYSIOTHERAPY
J.S.S.COLLEGE, MYSORE
11.6
12
Signature
12.1 Remarks of the Chairman and
Principal
Recommended
A.V.SUNISH
PRINCIPAL, J.S.S. COLLEGE OF
PHYSIOTHERAPY, MYSORE
12.2 Signature