ae ao CY PF AYA eH DOF A Vevae tv we 2 et tee pe SN ee oe COLLEGE OF PHYSIOTHERAPY, PANDIT BHAGWAT DAYAL SHARMA UNIVERSITY OF HEALTH SCIENCES, ROHTAK Proforma of application for the approval of subject of thesis for MPT (Neurology) examination 1, Name of the candidate 2. Father's Name 3. Address of Candidate 4. Name of the Un Graduated versity from which 5. Year and Month of passing BPT examination 6. Date of joining MPT course 7. Proposed subject of thesis 8. Facilities for work on the subject Sharma PGIMS, Rohtak 1. Detailed scheme according to which 10. Name and Address of the Supervisor 11, Name and Address of Co-supervisor Total no. of pages: 1-33 Aasha Sh. Rambilash Verma College of Physiotherapy Pt. B. D, Sharma PGIMS, Robtak PL. B. D. Sharma PGIMS, Rohtak December 2018 1* April 2022 To evaluate the effectiveness of sealene and pectoralis minor muscle stretching exercises in patients with carpal tunnel syndrome. All facilities exist at Pt. B.D. Plan attached Suman Assistant Professor College of Physiotherapy Pt. B. D. Sharma PGIMS, Rohtak Dr. Surekha Dabla Senior Professor Head of department of Neurology Pt. B.D, Sharma PGIMS, Robtak \3 SignalYe-afCandidatefe y ie hh fr ag EMRE S God ¢ / Ge ¥ u fe fests G4Uous ¢ cud me ES eS SO fi CERTIFICATE OF SUPERVISORS We certify that all the facilities for the study on the subject of thesis “To evaluate the cffectiveness of scalenc and pectoralis minor muscle stretching exercises in patients with carpal tunnel syndrome.” exists in this institute and will be provided to the candidate (Aasha) in pursuance of her plan of thesis. J will guide the candidate in her study and will see that the data being included in the theses is genuine and the work is being done by the candidate herself. Ota $ | Dr. Surekha Dabla Suman Assistant Professor Senior professor College of Physiotherapy Head of department neurology Pt, B, D, Sharma PGIMS, Rohtak Pi. B. D. Sharma PGIMS, Rohtak (Co-Supervisor) (Supervisor)iit ETHICAL JUSTIFICATION The proposed study entitled is “To evaluate the effectiveness of scaleneand pectoralis minor muscle stretching exercises in patients with carpal tunnel syndrome.”. An Informed written consent will be taken from all the subjects. No invasive procedures will be done on the subjects, All the procedures to be used in the study do not carry any harmful effect on the subjects, Thus, the present study is well within the ethical norms & is ethically justified. yer Signature of candidate OK |) Suman Assistant Professor College of Physiotherapy Pt. B. D. Sharma PGIMS, Rohtak (Supervisor) Dr. Roop § Principal & Chairman, PG Board of Studies College of Physiotherapy Pt, B.D, Sharma PGIMS, Rohtak Dr. Surekha Dabla Senior Professor Head of Department of Neurology Pt. B. D, Sharma PGIMS, Rohtak (Co-Supervisor)ase wee oer usud au DECLARATION BY THE POST GRADUATE STUDENT Thereby declare that: AER Date: The study will be done as per Institutional protocol and guidelines. Study shall be initiated only after clearance from institutional ethics committee. Written, Informed consent of the subjects/eontrol (volunteers) will be obtained. “The probable risks involved in the study will be explained in full to the subjects in their own language. 1 will terminate the study at any stage, if I have probable cause to believe, in the exercise of the good faith, skill and careful judgment required for me that continuation of the ‘study/experiment is likely to result in injury/disability/death to the subject. Disclosure: i, Financial/funding (None) ii. Conflict of interest (None) Association (None) aim WO PG Student College of Physiotherapy Pt. B. D. Sharma PGIMS, RohtakINTRODUCTION common peripheral mononeuropathy of upper limb Carpal tunnel syndrome (CTS) is the mos iptoms due to the compression of median nerve characterized by local sensory and motor sym at wrist, This tunnel is located between the flexor retinaculum and carpal bone at wrist! The signs and symptoms associated with compression of the median nerve within the carpal tunnel usually include paresthesia, tingling, numbness, and pain within the cutaneous distribution of the median nerve to the thumb, index, middle, and radial half of the ring digits. Nocturnal this tingling in the hand interrupts sleep and seek medical be hand clumsiness, weakness of thumb and ‘of hand and interference with daily paresthesia is a frequent complaint; attention. In moderate to severe cases there wil atrophy of thenar muscle which decreases functional ability ies? This multitude of symptoms lead to impairment of manual functional capacity activit work disability, and considerable deterioration of overall health, activity limitation, discomfort! 1 tunnel syndrome is more mated to occur in 3-6% of the general population.* Carpal es of 30-602 male than men with a ratio of 3:1.%and between the 2g: It is esti common in fer Risk factors include family history, obesity, pregnancy, hypothyroidism diabcies mellitus and rheumatoid arthritis.” syndrome was first described by Paget in 1854. Pathophysiologically, the ¢ through an anatomical dian nerve entrapment wailable literature Carpal tunnel entrapment of a compartment that peripheral nerve occurs as a result of its passag has become too tight, resulting in altered function. Me in the carpal tunnel at the wrist is the most common ‘example of this. The a has indicated a combination of several pathophysiologic mechanisms in CTS. These ‘and include the increased pressure in the tunnel, median nerve mechanisms are interacting compression, and synovial tissue microcirculation injury, median nerve connective tissue hypertrophy.* he median nerve, several treatment options, both surgical and To relieve the pressure on 1 conservative, are available. Propo. safety, beneficial effects and low cost nents of conservative treatment emphasize the high level of {s associated with these approaches. Some authors have J be used as the first type of therapy. At the same time stated that conservative treatment should ‘al treatment and seek other therapies. ¢ proportion of CTS patient try 10 4 research is needed to determine approaches includes oral pharmacotherapy, wy avoid surgi the best therapeutic agents for non-surgical and local a larg Therefore, treatment of CTS.' Non- surgical medicalsteroid injections, Physical therapy for CTS usually involves clectrophysical modalities or carpal bone mobilization, fications or job t be the manual therapy, splinting, ultrasound, nerve gliding exercises, tendon gliding has better response in relieving symptoms.® Workplace modi changes are very important in the treatment of CTS. However, patient education mus ment protocols. Splinting of the wrist in the neutral position for nocturnal first step in all tre \woar js the effective non-aggressive treatment for CTS. It reduces the pressure and therefore lca greater potential of reducing symptoms.° pro} bilize the median nerve may en performed in a slow and yetween the excursion of the Ithas been suggested that gliding exercises that preferentially m: be a beneficial nonsurgical treatment for persons with CTS whi controlled manner. A study also demonstrated the relationship be gested that active finger inity median nerve and flexor tendon was consistently linear. They sui flexion would provide sufficient motion of the median nerve and flexor tendons in the vi of the wrist to prevent adhesion formation. It also suggested that these gliding exercises will reduce tenosynovial edema by the milking action of the exercises, improve venous return from the nerve bundles, and reduce pressure inside the carpal tunnel.” Surgical relieving of pressure is done by decompression surgeries but surgical treatment’s complications and failures have been shown to occur in 3-19% in large series, requiring re- exploration in up to 12%. One study also observed the failure rate of 15-20% Therefore other reason need to be considered like double crush syndrome in which compression of an axon at one location makes it more sensitive to effects of compression in another location, because of impaired axoplasmic flow. By definition, a first lesion must render axons more susceptible to effects of a second, leading to more than just the combined, independent effects of two esions.!° Upton and MeComas used the double crush hypothesis to explain why patients with carpal tunnel syndrome (CTS) sometimes feel pain in the forearm, elbow, upper arm, shoulder, chest, and upper back. They also used it to explain failed attempts at surgical repairs when neither surgery nor CTS diagnosis appeared faulty. They claimed that most patients with CTS not only have compressive lesions at the wrist, but also show evidence of damage to cervical nerve root. In one reported study the first area examined in CTS case was not the wrist, but the neck. It is here that a group of nerves known as the brachial plexus comes out of the mid to lower neck region, which passes from scalene triangle, costoclavicular space and pectoralis minor space, then branches out to the arms, hands and fingers.'® If there is pressure on any of these nerves, in these potential sites especially of the median nerve, the result may be CTS nerve compression in the neck can block the flow of nutrients to the nerves in the wrist, making sh wyit more susceptible to injury.!! Therefore this study aims to evaluate the effectiveness of scalene and pectoralis minor muscle stretching and cervical manual traction in patients with carpal tunnel syndrome, Operational Definations: Double crush syndrome (DCS): According to Upton and MeComas. Double crush syndrome is that in which neural function is impaired because single axon been compressed in one region and makes nerve susceptible to compression at another site.'" Scalene triangle: It is V shaped space between the anterior and medial scalene and their attachment at clavicle inferiorly.!* Costoclavicular space: this space is formed between clavicle and first rib.!? Scalene entrapment syndrome: it is defined as any tigthtening , shortening or spasm of the scalene muscle group can produce entrapment of brachial plexus.!? Pectoralis minor syndrome: it is defined as compression of brachial plexus under the pectoralis minor muscle." Boston carpal tunnel questionnaire (BCTQ): it is a questionnaire containing 11 questions regarding the severity of symptoms and concerning hand functional disability." Numeric pain rating scale(NPRS): it is a scale used to assess pain with a range from 0 to 10. It is reliable and valid scale.’ Scalene reflex: it is a term used to define a mechanism in which direct relationship between increased intrancural pressure over 40mmHg secondary to extrinsic and intrinsic mechanisms in both ulnar and median nerve, and ipsilateral scalenus muscle activity is clicited.'REVIEW OF LITERATURE ‘Adrian R. M. Upton etal in 1973 conducted a study and gave a hypothesis on The Double Crush In Nerve Entrapment Syndromes. In this study they electromyographically studied 115 patients with carpal tunnel syndrome. Out of 115 patients, 81 cases also had clectrophysiological evidence of associated cervical root lesions in the neck. The authors concluded that this concurrence of cervical radiculopathy and carpal tunnel syndrome was due to impairment of axoplasmic flow which makes a nerve susceptible to damage at another!? E. Wayne Massey et.al in 1981 studied on coexistent carpal tunnel syndrome and cervical radiculopathy. In this case study of 19 patients having carpal tunnel syndrome with cervical radiculopathy occurring at C-6 or C-7 were included. The authors also reported that 4 patients had associated brachial plexus lesion. The author gave explanation for the concurrence of the two lesion could be due to: an underlying susceptibility of peripheral nerve due to pressure, 2 proximal axon lesion rendering the distal nerve more vulnerable to pressure injury, interruption of lymphatic or venous drainage making it more vulnerable of entrapment at distal site and endoneural edema at either the proximal or distal site, rendering axon at other site more vulnerable.!" Jose J Monsivais et.al in 1995 conducted a study on scalene reflex and relationship between increased median or ulnar nerve pressure and scalene activity.in this study he tried to discover correlation between distal entrapment neuropathies, brachial plexus compression, and sealenus muscle. In this study pressure of 40mmHg was applied to median and ulnar nerve in the forelimbs of eight goats and this resulted into increased electro-physiologically activity in scalene muscle and when pressure ranging from 100 to 150mmHg, it resulted into increased lectro-physiologically activity in contralateral scalene muscle. This study concluded about 502 association of pain found in neck and muscle spasm of scalene in peripheral neuropathic Various studies have suggested that as by James O. Royder in 1998 that scalene triangle, costoclavicular space and pectoralis minor muscle tendon are possible compression site for brachial plexus, subclavian artery and subelavian vein as they pass from neck to upper limb. Jellad et.al in 2009 conducted a study on the value of intermittent cervical traction in recent cervical radiculopathy. Group A receives manual traction with conventional treatment, Group, B treated with intermittent mechanical traction with conventional treatment and Group C were treated with conventional treatment alone, Outcome measures Were cervical pain, radicularPain, disability and the use of analgesics which was measured at baseline, at the end and at 1, 3 and 6 months after treatment. The author concluded that manual or mechanical cervical traction appears to be a major contributory factor in cervical radiculopathy."* Richard j. Sanders et.al in 2017 published a reviewed on pectoralis minor syndrome: subclavicular brachial plexus compression. The authors concluded that neurovascular bundle containing brachial plexus, subclavian artery and subclavian vein is prone to compression as it Passes in scalene triangle, in costoclavicular space and under pectoralis minor muscle.!> Axpit Kamboj in 2018 studied on Effect of Two Passive Stretch Manoeuvres for 4 Weeks on Pectoralis Minor Length and Scapular Kinematics among Collegiate Swimmer. A sample of 30 swimmer were divided into two groups A and B, Scapular kinematic data for the Group B which is experimental group were measured immediately before and after an application of one of the two passive stretch treatments, Group A- Control shoulders received initial scapular kinematic measurements and post-intervention measurements after an approximate 1.Sminute rest period after performing 5 repetition of each movement of Active Range of Motion exercise ‘of Shoulder. This rest period was approximately the same amount of time necessary to apply the assigned stretch to the experimental shoulders : After measurement of the pectoralis minor length the mean at baseline for Group A (7.56)and Group B (8.8,) and in 4th week for Group ‘A (7.66)and Group B (9.65) and it was concluded that passive stretch manoeuvre are effective minor muscles and scapular kinematics among in maintenance of conditioning of pector collegiate swimmers.'®RATIONALE In many cases of carpal tunnel syndrome, despite decompression surgeries, symptoms are not getting relieved. Many authors have reported that ‘double crush syndrome” might be the reason for the failure of such decompressive surgeries in carpal tunnel syndrome. The most common site for proximal compression of median nerve or its roots, has been reported to be at intervertebral foramina, scalene triangle and retro-pectoralis minor tendon space. Therefore this study will aim to find out the effectiveness of scalene and pectoralis minor muscle stretching exercises and cervical manual traction in relieving the symptoms in patients with carpal tunnel syndromeRESEARCH QUESTION Is there any added effect of sealene, pectoralis minor muscle stretching exercises and cervical manual traction on pain, symptom severity, functional status and nerve conduction velocity in Patients with carpal tunnel syndrome?AIM AND OBJECTIVES OF THE STUDY Aim of the study To evaluate the effectiveness of scalene, pectoralis minor muscle st cervical manual traction on etching exercises and :ptoms severity, functional status and nerve conduction Velocity in patients with carpal tunnel syndrome. Objectives of the study lL To evaluate the effectiveness of scalene, pectoralis minor muscle stretching exercises and cervical manual traction on pain in patients with carpal tunnel syndrome. To evaluate the effectiveness of scalene, pectoralis minor muscle stretching exercises in patients with carpal tunnel and cervical manual traction on symptom severity syndrome. To find out the effectiveness of scalene, pectoralis minor muscle stretching exercises and cervical manual traction on functional status in patients with carpal tunnel syndrome. To find out the effectiveness of scalene, pectoralis minor muscle stretching exercises and cervical manual traction on nerve conduction velocity in patients with carpal tunnel syndrome. eae TM DAH CAA 97 hal DARAANRNIMNNDHYPOTHESIS Alternate Hypothesis * There will be a significant difference between the effectiveness of scalene, pectoralis minor muscle stretching exercises, cervical manual traction and conventional treatment on pain in patients with carpal tunnel syndrome. * There will be a significant difference between effectiveness of scalene, pectoralis minor muscle stretching exercises, cervical manual traction and conventional treatment on symptoms severity in patients with carpal tunnel syndrome. * There will be a significant difference between effectiveness of scalene, pectoralis minor muscle stretching exercises, cervical manual traction and conventional treatment functional status in patients with carpal tunnel syndrome. ‘+ There will be a significant difference between effectiveness of scalene, pectoralis minor muscle stretching exercises, cervical manual traction and conventional treatment on nerve conduction velocity in patients with carpal tunnel syndrome. Null Hypothesis There will be no significant difference between effectiveness of scalene, pectoralis minor muscle stretching exercises, cervical manual traction and conventional treatment on pain in patients with carpal tunnel syndrome. + There will be no significant difference between effectiveness of scalene, pectoralis minor muscle stretching exercises, cervical manual traction and conventional treatment ‘on symptoms severity in patients with carpal tunnel syndrome. * There will be no significant difference between effectiveness of scalene, pectoralis minor muscle stretching exercises, cervical manual traction and conventional treatment on functional status in patients with carpal tunnel syndrome. © There will be no significant difference between effectiveness of scalene, pectoralis minor muscle stretching exercis es, cervical manual traction and conventional treatment on nerve conduction velocity in patients with carpal tunnel syndrome. \ey10 FLOW DIAGRAM i ad Subject 1 be mm included ‘Subject to be exclided |p| “To evaluate te offectivencssofsalene and pectoralis minor muscle stretching exercise and cervical ‘manual traction in patients with carpal tunnel syndrome 2. Both male and female. ‘Age group between 30-60 year, Diagnosed cases of CTS J i recent history of trauma to neck and upper limb. ‘Subjects Subjects with history of injury to brachial plexus. ‘Subjects with Diabetes, neoplasms, hypothyroidism, kidney and cardiac ailments. Pregnant females. ‘Subjects with active infeetion in neck and upper extremity Subject who received steroid iniection at wrist within previous 3 month. | Samplesize |p Stocstion = | Totervention | gama | -Fnger exo Muscle Tendon ig Exercise -Pectoralis minor muscle stretching Exercise Data collection 40 subjects T < L —l ct v ‘Subjects will be divided into 2 groups - Control Group and Experimental Group with 20 patients in ‘each group. ‘Control group- Patient will receive Experineatal group” Patient will Conventional treatment including -Scalene muscle stretching Exercise “Median Nerve mobilization Exercise «= Night splinting - Cervical manual traction = Conventional treatment hike hk SD DANYO OD [a ees opp fe. ysis repent ?11 MATERIAL AND METHODS Study Design: Experimental study design Study Period: August 2022-August 2023 Study Subjects: Dingnosed cases of carpal tunnel syndrome Inclusion criteria: 1. Age between 30-60 year. 2. Both male and female. 3. Diagnosed cases of CTS Exclusion criteria: 1. Subjects with recent history of trauma to neck and upper limb. Subjects with history of injury to brachial plexus. Subjects with Diabetes, neoplasms, hypothyroidism, kidney and cardiac ailments. Pregnant females. Subjects with active infection in neck and upper extremity. yeep 6. Subject who received steroid injection at wrist within previous 3 month, Sample size: 40 Tomasz Wolny et.al 2018, conducted a study to evaluate the efficacy of manual therapy based on neurodynamic techniques on nerve conduction study, pain, symptom severity, functional status and hand grip strength in patients with carpal tunnel syndrome. The subjects were divided into experimental group A and control group B. Experimental group A received neuro-dynamics stretching exercises. In this study the reported mean and jandard deviation of motor conduction velocity preintervention was 51.10 (5.15) and post intervention reported mean and standard deviation of motor conduction velocity was 53.1 (3.44). Taking these values ‘as reference, the minimum sample size with 80% power of study and 5% level of significance is 18.8! wy12 Sample size formula: N> 2¢Standard devintion)?*(Za1Z) (mean difference?” and Zfi is value at power of 80% and Where 2a is value of Z at two side alpha error of 5% mean difference is difference in value of two groups.! Calculations: N > 2(5.15)?(1.9640.84)? ary N> __2%26.52x7.84 N218.8=19 Sample size of each group is 20. Therefore, sample size of 40 will be taken in the study. Sampling method: Random sampling Data collection: It will be done in Neurology OPD, PGIMS Rohtak and College of Physiotherapy, Pi. BDS, UHS, Rohtak PROCEDURE: ‘The ethical clearance will be taken from institutional Ethical committee of Pt. B, D. Sharma PGIMS Rohtak, A (otal of 40 subjects will be included in the study as per inclusion and exclusion criteria by using sereening proforma attached. A comprehensive description of study will be given to participants and the participants will be requested to sign an informed consent. The following demographic data of the subject will be taken- age, yender, height, weight, occupation, address.4 Hxerelne protocols LELOMD.A (N-20)- central groupe Vile proup wilh receive tendon yiding ezessis tor Dryer Hloxer proup of muscles, Median Herve meilizaticn izsvelos mod Hig Sind. endon gilding exercises for Winger flexor group of muscles,” Posttton of subjects sitting comfortably on w chile vith arm glace cn taba, Sherer and elbow will be flexed 90° and forearm WA) be in wuphiation Procedure «‘The patient vAll place his Singers in five different graitions seal, ed, Fist, table top, and straight fiet and will hold each position for 4 we, Dushmetry: Hepetition 10,2 Nes in day, 3 tines w werk, Sah wees 2, Median Nerve mobilization exercises? By the Therapist: «Position of subjeet- the patient bs peritioned in suph ying, © Position of theraplete The therapist faces the patient in stride standin, prition nd holding the patient's wifected bind on his hand vith pala ty pala wip. Procedures The following movement sequence: vill be: pesfornnen by the therapist- Shoulder depression, Shoulder abduction, Vorearm supination, Shoulder external ration, Wrist and fingers extension and Shaw extension, [All the movements are taken to the end of available range or to the paint where: syenptomns are produces, Doskmetry- Repetition 10, 2 times in a day, 3 times Inu week, for Aweek. 3, Hplinting? ‘Ve patient will be instructed to wear a splint wt night for 4 weeks Saperimental Group ~ (N-20) ft will receive conventional treatments along wth scalene, pectoralis minut muse fe stretching exercives and cervical manual traction, \ wy14 Stretching exercises of pectoralis minor muscle: Starting position: standing with shoulder abducted 90, elbow flexed 90 and palm placed on a flat planar surface, End position: the subject then rotated the trunk away from the elevated arm, increasing the horizontal abduction at the shoulder and maxi jing the stretch across the chest. The subject held this position for 30 seconds. + Dosimetry- 5 repetitions, twice in a day, 3 times a week, for 4wecks.!* Stretching exercise of scalene muscle."” For middle scalene Position of subject: sitting on a stool. Position of therapist: Therapist is standing behind the patient with one hand placed on lateral head and another hand at on shoulder. Procedure: the patient will be instructed to bend his/her neck laterally in opposite direction as far as possible. Then therapist will apply a stretch on lateral side of head with one hand and stabilizes shoulder with another hand. ‘The stretch will be held for 30 sec. The stretch will be followed by 30 sec rest in between the stretches. © Dosimetry-Repetition- 5, Duration —4 weeks, 3 times in a week. For anterior scalene Position of patient: sitting on a stool. Position of therapist: therapist is standing behind ‘the patient with one hand placed on lateral head and another hand at on shoulder. Procedure: the patient will be instructed to bend! the neck laterally in opposite direction and slightly bend the neck posteriorly, The therapist wil apply a stretch on lateral headin lateral and posterior direction and with the other hand will press the shoulder down. ‘The stretch will be held for 30 The stretch will be followed by 30 sec rest in between the wy stretches ooo gee yyy ds aaann no a7 DOO PNOPAG~wvvevueseeuseuvseusgebdd 15 # Dosimetry Repetition- 5, Duration ~4 weeks, 3 times in a week. Manual traction: Manual traction will be applied in supine position with neck approx 25-degrees flexed. The therapist will apply 10 second pull followed by 5 second rest." Dosimetry- 10 repetitions, 3 times in a week, for 4 weeks, Follow up It will be done on 4 weeks after completion of treatment protocol. Outcome Measures Variables Measures Pain ‘Namerie Pain Rating Seale.” ‘Sympioms Severity scale Boston Carpal Tunnel Questionnaire Seale." Functional Status scale Boston Carpal Tunnel Questionnaire Scale.” Conduction Velocity ‘Nerve Conduction Studies." 1. Numerie pain rating seale- Pain assessment will be done with Numerical Pain Rating Scale having 0-10 score. Score 0 means no pain and score 10 means severe pain. (ANNEXURE-1) 2, Boston carpal tunnel questionnaire (BCTQ): it isa questionnaire containing 11 questions regarding the severity of symptoms and concerning hand functional of Boston carpal tunnel questionnaire. wy16 Functional status seale- it will be evaluated by the Functional Status Scale, a part of Boston carpal tunnel questionnaire. . Median Nerve conduction study- it will be done by a nerve conduction study apparatus.STATISTICAL ANALYSIS Data will be analysed by using stntistical analysis sofiware like SPSS, (Statistica! Package of Social Sciences) statistical version suitable, Deseriptive statistics will be applied to present data in the form of median mode and standard deviation. x18 PARTICIPANT INFORMED CONSENT FORM Protocol / study number: Participant identification number of thesis: Title of study: To evaluate the effectiveness of scalene and pectoralis minor muscle } carpal tunnel syndrome Mobile no.: 7015714416 stretching exercises in patients Name of the investigator: Aasha Supervisor: Suman Co-Supervisor: Dr. Surekha Dabla By signing below, I confirmed the following: that was provided to me have ‘The contents of the information sheet date been read carefully by me/ explained in detail to me, and the nature and purpose of the study and its potential risk / benefits and expected duration of the study, and other relevant details of the study have been explained fo me in detail in my native language. I have fully understood the contents. I confirm that, I have opportunity to ask questions. I understand that my participation is voluntary and that I am free to withdraw at any time, without giving any reason, without my medical care or legal right being affected. T understand that the information collected about me during participation in this research and sections of any of my medical notes may be carefully looked by investigator and principal investigator (Suman) from College of Physiotherapy, PGIMS (Rohtak) where it is relevant to my taking part in research. I give permission for this individual to have access to my records, to present in meetings & conferences, publications if desired. agree to take part in the above study. Date: (Signature/Left thumb impression) Place: PFINPINMAN HMMA HEA AaKcarna s PP EDARHAODHAOD PPP P f19 ‘Name of the participant: Son! Daughter/ Wife: Complete postal address: This isto certify that the above consent has been obtained in my presence. Date: Place: Signature of investigator Witness - 2 Witness ~ 1 Signature20 fount afer wenta waa ieleia / rere te: OR a veut agar eT: uae aor ela: g BAITE w eRe on BAA Hes aes THRE FTA PAT RRS S Oiew fae ere ere Riga HATH BT AM; SHAM Trae AAT: 7015714416 wide: Gr Fe-raw: stake sara oa ener oe, 8 Praferfaa ot GB at feriftea year cae a aT... sens AR WAH FRAT TT A, FR ENT IS waar rears a Rea a VATAT TAT, she oT SA Hepa oh TeNT si Be WHAT SARI aH oA ares A area ara, gfe sree & ora urRifte PeeUH we ART ART ‘rere rere S eas or 81 A EA eRe a aA TAS Te 8. A OE Geer Efe, AR oT 3 ware EA or Aha A area g fee A after eafiaves 8 othe A Reet At ara a ‘frat orem a, A Patera Baur a orgh aif wt mente fare fT ae aA & fare ada #1 Ferrara & fas Sa Mey ane & Shera A a A epg wh ag GTN oh AR Reh ah Aen tee & aif a vive ar aauriigds Sew BEAT 81 otk wear oie Refrenereeh, Hichsngernee eee) MUM ara (AA) We Ue AR ha a MT aA ge fa ori 81 ga cafes a AR Reals oe UGG TA, Goat sik wT, Wee a safer ga a orga ear g afe alfa a A geefan arenes A 40 A & fee AeA wy2a (RRMA / ATE SHS BT FIRMA) er: afer aor ar: Ser aah ue: WRI Sle Wai: arg emer aa Be Fee & fas wear BEATA AN Sah eae A wre a TE V1 ‘Tag - 122 PARTICIPANT INFORMATION SHEET You are invited to participate in the study which is being done as a part of partial fulfillment of master program. Title: To evaluate the effectiveness of scalenc and pectoralis minor muscle stretching exercises in patients with carpal tunnel syndrome About the research study and intervention: The purpose of the study is to evaluate the effectiveness of scalene and pectoralis minor muscle stretching exercises in patients with carpal tunnel syndrome, Carpal tunnel syndrome (CTS) is the most common peripheral mononeuropathy of upper limb characterized by local sensory and motor symptoms due to the compression of median nerve at wrist. The signs and symptoms include paresthesia, tingling, numbness, and pain within the cutancous distribution of the median nerve to the thumb, index, middle, and radial half of the ring digits. Nocturnal paresthesia is a frequent complaint. In moderate to severe cases there will be hand clumsiness, weakness of thumb and atrophy of thenar muscle which deereases functional ability of hand and interference with daily activities. This multitude of symptoms lead to impairment of manual functional capacity, deterioration of overall health, activity limitation, work disability, and considerable discomfort. A group of nerves known as the brachial plexus comes out of the mid to lower neck region, which passes from scalene triangle, costoclavicular space and pectoralis minor space, then branches out to the arms, hands and fingers. If there is pressure on any of these nerves, in these potential sites especially of the median nerve, the result may be CTS nerve compression in the neck can block the flow of nutrients to the nerves in the wrist, making it more susceptible to injury. Therefore this study aims to evaluate the effectiveness of scalene and pectoralis minor muscle stretching and cervical manual traction in patients with carpal tunnel syndrome. Duration of the study: August 2022-August 2023, Benefit of the study: Though we expect some additional benefits in study outcome, but these cannot be assured. Moreover, your participation may not benefit you in monetary terms, Also, your participation may benefit current ley Fer nrn: annaan yh} 2979 ° ¢ c ¢ a9 f PPP opp Pf. f:vn v > » a 3 wSeVvUye UF CUNY Do, a oe 23 of the study: There will be no risk in any step of the study. Confidentiality: All the information about you will be kept confidential and limited to me and Principal investigator Suman and will not be shared with any person who is not a part of the study. We request you to allow us to use your data and photograph for publication where your identity and confidentiality of the data will be ensured. Financial implications: No extra charges will be taken or given to you for the study. Right to withdrawal: You have the right to withdraw from the research at any point of time whenever you desire without giving reason for the same. Whom to contact: In case of any doubt regarding the study, you can contact: Aasha, PG student, College of Physiotherapy, Pt. B. D. Sharma PGIMS, Rohtak (7015714416). Suman, Assistant Professor, College of Physiotherapy, Pt. B. D. Sharma PGIMS, Rohtak. Dr. Surekha Dabla, Head of Department of Neurology, Pt. B. D. Sharma PGIMS, Rohtak.wfeuntt yer wae a ore Ha By Fea Frere i ree aA rr fl eRe Sasa awe ite: eee & waft its aA te each MG A REPT CTE BF diea fae ore era Right SR sures oh weady & ay A: oorert ar aeea ental care Rigs are Cra A oer he Dae Rre AIH nia aA aA are onan a morercfteran or EAI wee! aoe err Rigs clteieey wens oe Tare aren & aids Gr Va dA ote ex cenit a Reaver ara Had sin ar aas ore ofeela AANA BI eT she wan 4 sig’, qecpie, Aer ohe eae ond Ged & viel & fee males dat & carte Pron y afhere eA re, BPS, Gare She ae ere Preareae AAT Te aR ar Rraraa 81 Te 8 we are A Gy a origins, os wt wait oh AT aafedfarat oft xe ef oh sre a wren erren oite SP mira & are EAs I an aed 21 cen HA ag wis Agora erafere ana a a, waa eared I frre, aaa ihn, ord Rercina he oral argiaur or oro ard G1 aes wie & eT Aor aA ae densi a Uw wag Ae a Pree Tea & aa a Aree oe 8, A eA Bain, aretaahager we ote dactefera rer ea A yore 8, fox are, ere ote ‘Safer cep rare rate SaaS Reve oh cicero cara Star @, oh SH Senfeta rgN A feria Sud mere aan a, oon ae Gi Gorm 8 fe 1da A Siciea ce Higa weg A aaa thaw aed ware HI ara Hx Teal @, fora Ue Te & fer afte daeavitar A rar yatta ga ora or sea are ore Rig are Atal A her ok Aas eet rena aA ee ote aren ft Pore arch A orate a Raker wT z arora a oral, area 2022-317 2023 TH “HA wT ETT: Ter ure & uu A py ofatted ened a Talia axa Y, aia ge nga al Rt rere 1 RAAT era, oA sae ore A ey we TT Fe yard i gare ore, ara ofan acters el rare 8: eer oT RRM oA ee Reg wy, leyRe aes OF Sve ies “a % 4 Fe ye 25 =a aA eet A atc, ee RAR oer Te Agora she ee ore aA rere 1 eT TTAB sme ar Nr opr Bs veh 9 ear ah oH TET TT itera: omy ak A ae rrr Hoe cA oT ote AR oe pH ra ST IAT Gh afr Boh oh rah fr ee 1 a aA re A ET BI EH AT ahr acl erg ora Se ewe er are A HAA Tt TIAL ugar ok Sarah erga gna at eA rete are rere Fr eet a ae eee fare ace a a ATRL ammo after: ama Fre errr aes BA oT fare @ area ore He ere worm fey fern aed BI ferad dad wr: aye Bs ae ah a dg AME A, on aT HL aA: ore, thsi a ora, wide fee fipfartree, ca. SH. sani tishtengearee, eae (7015714416) Sire saan, aleish erm, ddl A wa iano, Beare26 REFERENCES cchniques effective in the Clinical 1. Wolny’, Linck P, Is manual therapy based on neurodynamic I treatment of carpal tunnel syndrome? A randomized controlled trial. Rehabilitation, 2019 ;33(3):408-17. 2. Snkr F, Elsayed 6, Elbalawy Y, Noy and carpal bone mobilization in treating carpal tunnel rescar.2019;16(3):2690-2698, Vikronth GR, Vinod Kumar K.C, Lawrence Mathias, comparative effect of enrpal bone stis neural mobilization in improving pain, functional status and As with carpal tunnel syndrome. Int Jour of Physio. 2015; +-E1 A. Comparison between neural mobilization syndrome. Biosci '. Saulicz. F, Linck P, Shacklock M, Mysliwice A. Efficacy of manual therapy 2 neurodynamic techniques for the treatment of carpal tunnel syndrome: randomized controlled trial. Journal of manipulative and physiological therapeutics. 2017 1;40(4):263-72. 6. Duymaz T, Sindel D, Kesiktas N, Miskimanoglu L. Effiacy of some combined conservative micthods in the treatment of carpal tunnel syndrome: a randomized al and electrophysiological trial, Archives of Rheumatology. controlled cl 381(2):108-13. 8. Baysal O, Altay Z, Ozcan C, Ertem K, Yologlu S, Kayhan A. Comparison of three conservative treatment protocols in carpal tunnel syndrome. International journal of clinical practice. 2006,60(7):820-8. 9. Bukhari SR, Shakil-ur-Rehman S, Ahmad S, Naeem A, Comparison between effectiveness of mechanical and manual traction combined with mobilization and exercise therapy in patients with cervical radiculopathy. Pakistan journal of medical sciences. 2016;32(1):31. 10. Upton AM, Mccomas A. The double crush in nerve-entrapment syndromes. The Lancet. 1973 18;302(7825):359-62. 11. Masey E, Coexistent carpal tunnel syndrome and cervical radiculopathy (double crush. syndrome). Southern Med J. 1981;74:957-9. 12, Jose J. Monsivais, Sun Y, TP Rajashekhar. The scalene reflex relationship between increased median or ulnar nerve pressure and scalene muscle activity. Journ of recons microsur 1995; volume 11. 13, James O. Royder. Scalene entrapment syndrome. AAO Journal.1998; /25. 14,Jellad A, Salah ZB, Boudokhane S, Mignow H, Bahri 1, Rejeb N. The value of traction in recent cervical radiculopathy, Annals of physical and rehabilitation medicine, 2009 1;52(9):638-52. 15, Sanders RJ, Annest SJ. Pectoralis minor syndrome: subelavicular brachial plexus compression. Diagnostics. 2017 28;7(3):46 16, Arpit kamboj, , Saleem Akhtar Naqvi, Aashish Jain, Madhusadan Tiwari Effect of Two Passive Stretch Manoeuvres for 4 Weeks on Pectoralis Minor Length and Scapular Kinematics among ate Swimmer, J Yoga & Physio2018 — 5(5): JYP.MS.ID.555671 ° wy intermittent cervica7 R Effects of a stretching protocol for the 17. Rosa DP, Borstad JD, Pogetti LS, Camargo PI jematics in individuals with pectoralis minor on muscle length, function, and seapular nd without shoulder pain, J Hand Ther. 2017;30(1):20-29, 18. Lee J, Hwang 8, Han 8, Han D. Effeets of stretching the sealene museles on slow vital capacity, J Phys Ther Sci. 201 6;28(6):1825-8 19, Mody GN, Anderson GA, Thomas BP, Pallapati $C, Santoshi JA, Antonisamy B. Carpa) tunnel syndrome in Indian patients: use of modified questionnaires for assessment. J and Surg Eur.2015;34(5):671 20. Ferreira-Valente MA, Pais-Ribeiro JL, Jensen MP. scales, Pain. 2011;152(10):2399-2404. Validity of four pain intensity ratingPATIENT PERFORMA SECTION A: DEMOGRAPHIC DETAILS 28 ‘NAME: DATE: AGE: OCCUPATION: GENDER: Male/Female MOBILE NO. ADDRESS: Chief complaints: Past history: Personal history: Family history: Socioeconomic history: Symptoms history: 1. Pain © Intensity 0-10 NUMERIC PAIN RATING SCALE AwCe od Fe des 29 eile ; i) + Duration: acute / chronic i > © Severity: mild / moderate / severe mS + Pain pattern: localize / radiating : Je © Ons sudden / gradual Js © Type: t ‘ | o © Aggravating factors: - © Relieving fhetors che Relieving factors: 5 . © Diurnal variation: . | SECTION B: Sercening Questions Ss 7 ! 3 1. Do you have history or recent neck and upper limb injury or surgery? Yes/No - 9 2. Are you pregnant? Yes/No. n I. 3. Do you have diabetes? Yes/No ~ le 4, Are you taking any oral contraceptive medication? Yes/No all 2 5. Do you have hypothyroidism? Yes/No ~ | » 6. Do you have rheumatoid arthritis? Yes/No | 3 7. Do you have any other neurological problem? Yes/No ~ 5 8. Do you have any kidney related diseases? YesiNo ! z » 2 9. Do you have history of hypertension? ‘Yes/No S le A 10. Do the hand symptomps influences your sleep? Yes/No ~ | c 11, Do you take any steroid injection at wrist in past 3 months? Yes/No =o BS Section C: Behavioural factors ~ I<. 1, Do you smoke? YesiNO- ‘ \* Ly 2. Do you take alcohol? Yes/No | ar , . fi Section C; clinical test ae Phalen’s test: It is performed by full flexion of paticnts’s wrist for full 60sec. n at least one of the three radial ‘The test is recorded positive if patient experiences we‘The measurement of NPRS score aqvestionnaire: sSymptoms severity scale b,. Funetional scale Variable Dayo Wek (Pre-tnerventon) _| (Post nerventon) 1 Pain z Boston carpal tunnel 3 ‘Nerve conduction studies Sensory conduction velocity © Motor Conduction Velocity © Distal Motor Latency 30of A & { | 1 | 1 1 | | 1 | | | 1 | | 1 1 1 | | + .ao te 31 ANNEXURE- 1 The Numeric Pain Rating Scale Instruction General information: ‘The patient is asked to fill three pain ratings, corresponding to current, best and worst pain experienced over the past 24 hours. * The average of the three ratings was used to represent the patient's level of pain over the previous 24hours. 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