Rajiv Gandhi University Of Health Sciences,
Karnataka, Bangalore
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1 / Name of the Candidate andAddress /
MR. SANDEEP.P.H
S/O HARISH.P.N#3978, NEAR HAMPI CIRCLE,
VIJAYNAGAR II STAGE
MYSORE
2 / Name of the Institution / J S S COLLEGE OF PHYSIOTHERAPY
JSS HOSPITAL CAMPUS,
RAMANUJA ROAD,
MYSORE – 570004
3 / Course of Study and Subject / MASTER OF PHYSIOTHERPY
PHYSIOTHERAPY IN
NEUROLOGICAL AND PSYCHOMATIC DISORDERS
4 / Date of admission to the course / 17-06-2009
5 / TITLE OF THE TOPIC
A COMPARITIVE STUDY ON THE EFFECT OF KINESIOTAPING AND CONVENTIONAL PHYSIOTHERAPY IN CARPAL TUNNEL SYNDROME.
6 / 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.