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Is manual therapy based on neurodynamic techniques effective in the

treatment of carpal tunnel syndrome? A randomized controlled trial

Article  in  Clinical Rehabilitation · January 2019

DOI: 10.1177/0269215518822114

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Jose Miranda Tomasz Andrzej Wolny

Universidad Peruana de Ciencias Aplicadas (UPC) Akademia Wychowania Fizycznego im. Jergo Kukuczki w Katowicach
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Paweł Linek
The Jerzy Kukuczka Academy of Physical Education
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822114
letter2019
CRE0010.1177/0269215518822114Clinical RehabilitationLetter to the Editor
Letter to the Editor
Is manual therapy based on
neurodynamic techniques
effective in the treatment of
carpal tunnel syndrome?
A randomized controlled trial
To the Editor
We have read with great interest the article by T
Wolny et al., “Is manual therapy based on neurody-
namic techniques effective in the treatment of carpal
tunnel syndrome? A randomized controlled trial.”
This article presents manual therapy as a promising
treatment for carpal tunnel syndrome. Nevertheless,
we consider that there are certain questionable
aspects of the study, specifically those related to the
ethical basis for the usage of placebos.
Within the ethical premises of clinical trials, all
the participants must receive the best treatment pos-
sible as suitable comparator against the experimen-
tal intervention. In this case, we have two groups of
patients with clinical features and electrophysiologi-
cal changes which confirm the diagnosis of carpal
tunnel syndrome. However, only the intervention
arm received treatment, while the other group only
received a placebo. The use of a placebo is only jus-
tified when there are no other evidence-based proven
available therapies.1 There are systematic reviews
and meta-analyses that prove the effectiveness of
several treatments for carpal tunnel syndrome,2,3
including non-steroidal anti-inflammatory drugs
(NSAIDs), corticosteroids, physiotherapy, and
surgery.4,5 Therefore, any experimental intervention
in patients with carpal tunnel syndrome associated
with electrophysiological changes must be com-
pared with other interventions that have demon-
strated effectiveness, making the use of placebo a
very questionable strategy.
There are some additional aspects that deserve
comments. The article only mentions 103 patients as
the population for this study, while the protocol
(ACTRN12617000672358) registered in ANZCTR,
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had a final sample size of 350 patients. The reason
for this must be clarified in order to assess the pos-
sibility of a selection bias. In addition, clinical trials
usually have one or two well-defined outcomes, but
this trial has six main outcomes, of which one (nerve
conduction velocity) is not significant. In fact, the
article does not define the main electrophysiological
parameter to be evaluated as primary outcome. This
may confuse the reader regarding treatment effect.
Finally, we consider that both secondary outcomes
(cylindrical and pincer grips) should be analyzed
and compared evaluating the magnitude and signifi-
cance of differences found.
In conclusion, the article presents a promising
technique for the treatment of carpal tunnel syn-
drome. Nevertheless, we must always consider the
ethical basis for the use of placebo in clinical trials,
assuring that the control group receives the best
treatment available, and compare it with the inter-
vention that will be evaluated.
José Miranda-Medina and Mateo Barba Cavigiolo
Escuela de Medicina, Universidad Peruana de
Ciencias Aplicadas (UPC), Lima, Peru
Alonso Soto
Doctorado en Ciencias de la Salud, Universidad
Peruana de Ciencias Aplicadas (UPC), Lima, Peru
Departamento de Medicina, Hospital Nacional
Hipólito Unanue, El Agustino, Peru
Corresponding author:
José Miranda-Medina
Escuela de Medicina, Universidad Peruana de
Ciencias Aplicadas (UPC), Prolongación
Primavera 2390, Lima 15023, Peru.
Email: u201312835@upc.edu.pe
2 Clinical Rehabilitation 00(0)
References
1. Millum J and Grady C. The ethics of placebo-controlled
trials: methodological justifications. Contemp Clin Trials
2013; 36(2): 510–514.
2. Mooar PA, Doherty WJ, Murray JN, et al. Management
of carpal tunnel syndrome. J Am Acad Orthop Surg 2018;
26(6): e128–e130.
3. Raizman NM and Blazar PE. AAOS appropriate use cri-
teria: management of carpal tunnel syndrome. J Am Acad
Orthop Surg 2018; 26(6): e131–e133.
4. Huisstede BM, van den Brink J, Randsdorp MS, et al.
Effectiveness of surgical and postsurgical interventions
for carpal tunnel syndrome: a systematic review. Arch
Phys Med Rehabil 2018; 99(8): 1660.e21–1680.e21.
5. Shi Q, Bobos P, Lalone EA, et al. Comparison of the
short-term and long-term effects of surgery and nonsur-
gical intervention in treating carpal tunnel syndrome: a
systematic review and meta-analysis. Hand. Epub ahead
of print 1 July 2018. DOI: 10.1177/1558944718787892.
Response to the letter
The study (ACTRN 12617000672358) was
approved by the Bioethics Committee and all
patients gave written consent to participate. The
research was conducted in accordance with the
guidelines of the Declaration of Helsinki, and
after the experiment, appropriate treatment was
immediately given to both control and placebo
groups. The average waiting time for physiother-
apy from the National Health Service in Poland
(where the study was performed) is usually much
longer than 10 weeks. Thus, the patients included
in the study ultimately received treatment
quicker than they usually would in Poland, and
in our opinion, patients were not “denied effec-
tive treatment” through involvement in this
study.
With regard to other remarks, the registered pro-
tocol consisted four groups: (1) neurodynamic
techniques treatment; (2) placebo; (3) no treatment,
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patients; and (4) no treatment, healthy volunteers.
For the first study,1 103 patients participated in the
final analysis, whereas other 150 patients were
involved in the second study analysis.2 Data from
healthy volunteers have not been published. It is
unfounded to remark that there was no statistical
significance after the applied therapy with regard to
nerve conduction assessment. Significant improve-
ments occurred in the assessment of both sensory
conduction velocity and motor latency. There were
no changes in the motor conduction velocity because
it was within the normal range. Finally, cylindrical
and pincer grips were analyzed in the study (the sec-
ond paragraph in the “Result” section1).
T Wolny, PhD
Department of Kinesiotherapy and Special
Methods in Physiotherapy, The Jerzy Kukuczka
Academy of Physical Education in Katowice,
Katowice, Poland.
Email: t.wolny@twreha.com
Pawel Linek, PT, PhD
Department of Kinesiotherapy and Special
Methods in Physiotherapy, The Jerzy Kukuczka
Academy of Physical Education in Katowice,
Katowice, Poland.
Email: linek.fizjoterapia@vp.pl
References
1. Wolny T and Linek P. Is manual therapy based on neu-
rodynamic techniques effective in the treatment of carpal
tunnel syndrome? A randomized controlled trial. Clin
Rehabil. Epub ahead of print 11 October 2018. DOI:
10.1177/0269215518805213.
2. Wolny T and Linek P. Neurodynamic techniques versus
“sham” therapy in the treatment of carpal tunnel syn-
drome: a randomized placebo-controlled trial. Arch Phys
Med Rehabil 2018; 99(5): 843–854.