Journal of Bodywork & Movement Therapies 27 (2021) 522e528

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Journal of Bodywork & Movement Therapies

journal homepage: www.elsevier.com/jbmt

Myofascial Pain and Treatment

The treatment effect of intramuscular stimulation on carpal tunnel

syndrome: A blinded randomized trial on 75 patients
Knut Birger Kvist a, Ronnie Hilland a, Rune Enehaug b, Jon Schjelderup c, Stein Atle Lie d, *,
Anne-Kristine Halse e, f
a
IMS Pain Clinic, Hilland Physical Institute, Bergen, Norway
b
Stadium Physiotherapy, Brann Footballstadium, Bergen, Norway
c
Idrettsveien General Practice, Brann Footballstadium, Bergen, Norway
d
Department of Clinical Dentistry, University of Bergen, Norway
e
Department of Clinical Science, University of Bergen, Norway
f
Department of Rheumatology, Haukeland University Hospital, Bergen, Norway

a r t i c l e i n f o a b s t r a c t

Article history: Background: Carpal tunnel syndrome (CTS) is a disorder with a prevalence of about 5.8% for females and
Received 24 July 2020 0.6% for males. This study aims to determine whether intramuscular stimulation (IMS) to the pronator
Received in revised form teres muscle subsequently reduces the severity of clinical parameters and the diameter of the median
10 March 2021
nerve.
Accepted 28 March 2021
Methods: Seventy-five individuals with a cross-sectional diameter of the median nerve of more than
2 mm were included in this randomized clinical trial. Thirty-seven individuals received IMS to the
Keywords:
pronator teres muscle with a depth of up to 45e50 mm. The 38 individuals in the control group received
dry needle
Intramuscular stimulation (IMS ad Modum
an acupuncture needle at Li11 with a depth of 4e5 mm. Both groups had 7 treatments within 7 weeks.
Gunn) The primary outcome was the cross-section of the median nerve in the carpal tunnel. Additionally,
Carpal tunnel syndrome Phalen's test, Tinel's sign, VAS for pain intensity, and pincer grip strength were measured.
Results: Both IMS subjects and controls showed significant reductions in the cross-section of the median
nerve from baseline to follow-up (p < 0.001 and p ¼ 0.002 respectively). The IMS group had the largest
change, but the difference in change between the groups was not significant (p ¼ 0.39). On all clinical
tests, IMS subjects showed significant improvement from baseline compared with the control group
(largest p ¼ 0.002).
Conclusion: In this study we found that IMS to the pronator teres muscle significantly improved all
clinical variables measured, compared with the group receiving acupuncture. Furthermore, the cross-
section of the median nerve reduced over time for both groups. IMS may be a low-risk alternative
while patients are waiting for surgery.
Trial registration: Clinicaltrials. gov Identifier: NCT01102868. Retrospectively registered: March 29th,
2010.
© 2021 Elsevier Ltd. All rights reserved.

1. What this paper adds 2. Background

A simple non-surgical treatment using intramuscular stimula-
tion with dry needles may have a positive effect on carpal tunnel
syndrome.
* Corresponding author.
E-mail address: stein.lie@uib.no (S.A. Lie).
Carpal tunnel syndrome (CTS) is a neuropathic condition where
the median nerve is entrapped within the carpal tunnel (Gunn
1990, 1996; Todnem and Lundemo 2001; Haase 2007), affecting
daily life and work for many people (Tsai et al., 2019). In this study,
CTS is defined as compression of the median nerve as demonstrated
by MRI (Horch et al., 1997) or ultrasound (Kimura 1979; Chen et al.,
1997; Sternbach 1999; Sarria et al., 2000; Keles et al., 2005). In CTS
the median nerve may be impaired in the narrowed space in the

https://doi.org/10.1016/j.jbmt.2021.03.020
1360-8592/© 2021 Elsevier Ltd. All rights reserved.
K.B. Kvist, R. Hilland, R. Enehaug et al.
carpal channel, bordered by the retinaculum, the carpal bones,
radiale tuberculum ossis trapezii, ulnare os pisiforme, and hamulus
ossis hamati. A static compressed and impaired median nerve may
be demyelinized and its axoplasmatic flow altered (Haase 2007). In
CTS, the median nerve might become over-sensitized, particularly
in the proximal and upper part (Sternbach 1999). An impaired
function might be related to increased pressure on the nerve in the
carpal tunnel (Haase 2007), which may result in sensory impair-
ment, leading to pain, paraesthesia, numbness in the innervated
fingers, and motor impairment (Gunn 1990). These are clinical
features of the neuropathy, which may cause motor impairment
and a weaker pincer grip (digits I and II).
A number of systemic conditions including rheumatoid arthritis,
hypothyroidism, diabetes mellitus and pregnancy are associated
with CTS (Haase 2007). CTS can also be a result of local trauma,
excessive use of the hand, or prolonged improper positioning.
However, for many cases of CTS, no direct cause can be identified,
and hence a combination of different conditions may cause the
symptoms. CTS is fairly common in adults with a prevalence of
about 5.8% for females and 0.6% for males (De Krom et al., 1992).
One feature of neuropathy of myofascial pain is muscle short-
ening (Gunn 2004). Muscle shortening may lead to tendinitis/ten-
dinosis due to spasm or contracture of the muscle (Gunn 2004;
Gunn 2004) and local oedema/inflammation (Gunn, 1997). When
the pronator teres muscle is shortened, the median nerve can be
entrapped, compressed and impaired as it emerges through the
muscle. The impairment of the median nerve can be further
increased if the common carpal sheath is swollen by oedema/
inflammation (Gunn 2011).
Impaired nerve function is related to the development of the
muscle shortening and the increased tension on the ligaments/
tendons (Gunn 1996, 2011). A study pointing out the association
between neuromuscular transmission disorders and the trigger
point muscles of myofascial pain syndrome indicates that such
mechanisms are involved (Chang et al., 2008).
Treatment of CTS can be surgical or non-surgical. Patients with
constant sensory disturbances and/or muscular weakness are
generally offered surgical treatment where the flexor retinaculum
is divided, providing more space for the median nerve in the carpal
tunnel. Non-surgical treatment is offered for patients with mild and
moderate symptoms or as a temporary treatment for patients
waiting for surgery. Splinting, exercises, activity and ergonomic
modifications, therapeutic ultrasound, lasers and steroids have
been shown to provide only short-term or no benefit, while a local
steroid injection can give symptom relief, removing the need for
surgery (Peters et al., 2013). Some studies have shown positive ef-
fects of acupuncture as treatment of CTS (Ho et al., 2014; Cox et al.,
2016; Wells et al., 2017).
Intramuscular stimulation (IMS ad modum Gunn), a dry
needling technique, has been shown to be an effective treatment
for several muscular conditions/myofascial pain syndromes, such
as chronic low back pain and whiplash-associated disorders (Gunn
et al. 1980, 2001). Muscle shortening, palpated as ropey bands
within the muscle, is a fundamental feature of myofascial pain.
These bands are often pain-free but can become tender and painful.
To our knowledge, IMS has not been systematically tested for
treatment of CTS. However, a study by Gascon-Garcia et al. dem-
onstrates via ultrasound that dry needling directly to the carpal
tunnel may be effective (Gascon-Garcia et al., 2018). Furthermore,
Gascon-Garcia et al. demonstrate the mechanisms related to
“needle grasp”.
We hypothesize that CTS may partly be a result of pressure on
the median nerve in the carpal tunnel due to local oedema/
inflammation appearing secondary to myofascial trigger points in
the pronator teres muscle. By treating the myofascial trigger points
523
Journal of Bodywork & Movement Therapies 27 (2021) 522e528
with IMS, the median nerve may be decompressed and the nerve
function may partially be restored. This can improve the innerva-
tion of shortened flexor muscles of the forearm and result in
relaxation of the muscles, reducing the pulling of the muscle ten-
dons in the carpal tunnel, giving more space to the median nerve.
Reducing the pressure on the median nerve in the carpal tunnel
may result in less inflammation and oedema, thereby improving
the function of the median nerve and reducing the CTS symptoms.
In this study, we therefor targeted the pronator teres muscle for the
IMS treatment of CTS. The aim of this study was to perform a
randomized controlled trial to evaluate the effect on clinical vari-
ables and the diameter of the affected nerve. Our study adheres to
the CONSORT guidelines.
3. Methods
3.1. Randomization
Participants, not arms, were randomized using a computer-
generated randomization list stratified by a clinician, with a block
size of 6. The trial statistician (SAL) made the randomization list.
When the arm of a patient met the inclusion criteria of the study,
the clinician contacted the trial secretary, either via SMS or email, to
inquire which treatment the patient was randomized to. The allo-
cation code, including details of block size, was not revealed to the
clinicians. There were 41 patients randomized to the IMS group and
42 to the control group. After the randomization, before any data
were collected, 8 patients withdrew (4 in each group) from the
study, resulting in 75 patients (37 (63 arms) in the IMS group and
38 (67 arms) in the control group) (Fig. 1).
3.2. Sample size
Sample size calculations were based on the mean numbers and
standard deviations in Table 1 in Sarria et al., (2000), for bowing of
retinaculum (mm), proximal area (mm2), middle area (mm2), and
distal area (mm2). The sample size, based on simple independent
samples t-tests, needed to detect a difference varied between 9 and
38 in each group. The maximum sample size (n ¼ 38, in each group)
was found for the proximal area of the median nerve. All sample
size calculations were performed using a 5% level of significance
and a power of 80%.
3.3. Loss to follow-up
One patient, with bilateral CTS in the control group, did not
attend the clinical ultrasound at follow-up. The patient was still
included in the analysis of the cross-sectional diameter of the
median nerve according to the intention to treat principle.
3.4. Inclusion and exclusion criteria
Via newspaper advertisements, individuals of working age
(18e67 years) with symptoms consistent with CTS were invited to
participate in the study. The main inclusion criterion was an ul-
trasound verifying a cross-sectional diameter of the median nerve
of 2 mm or more. The first assessment of eligibility, based on
clinical symptoms, was performed by a clinician. Based on this
assessment, 144 individuals were referred for ultrasound verifica-
tion. Recruitment of patients started in April 2009 and the last
patient was enrolled in April 2010. Based on the inclusion criteria,
83 patients were enrolled for the study. The exclusion criteria were
a negative neurophysiology result, epilepsy, heart disease, rheu-
matism, unstable angina pectoris, metal allergy, needle phobia,
infection, coagulation disorders, or cognitive problems. Four
K.B. Kvist, R. Hilland, R. Enehaug et al. Journal of Bodywork & Movement Therapies 27 (2021) 522e528

Fig. 1. CONSORT flow diagram.

Table 1
Mean values and changes, with 95% confidence intervals, for the continuous measures based on fixed effects from mixed effects models, for the 75 patients (130 arms).

Baseline (95% CI) Follow-up (95% CI) Change (95% CI) p-value p-value for differences
for change

Cross-sectional diameter in mma

IMS 2.20 (2.11; 2.30) 2.03 (1.94; 2.13) 0.17 (0.25;-0.09) <0.001 0.39
Control 2.19 (2.10; 2.28) 2.07 (1.98; 2.16) 0.12 (0.20;-0.05) 0.002
Pain (VAS)b
IMS 4.98 (4.33; 5.62) 2.92 (2.27; 3.57) 2.28 (2.92;-1.65) <0.001 <0.001
Control 4.94 (4.31; 5.57) 4.39 (3.76; 5.02) 0.66 (1.27;-0.04) 0.036
Force in pincer grip in kgc
IMS 6.30 (5.46; 7.15) 7.75 (6.91; 8.60) 1.45 (0.99; 1.91) <0.001 <0.001
Control 7.04 (6.20; 7.87) 7.29 (6.45; 8.12) 0.25 (0.20; 0.70) 0.27
a
Missing information on 2 arms (1 patient), both arms at follow-up.
b
Missing information on 16 arms (8 patients), 8 arms at follow-up.
c
Missing information on 1 arm (1 patient) at follow-up.

trained IMS clinicians, two MDs (KBK and JS) and two physiother-
apists (RH and RE), performed the IMS or control treatment ac-
cording to the randomization scheme. The two physiotherapists
(RH and RE) also have education and training in classical
acupuncture.
3.5. Outcomes
At the start of the study the cross-sectional diameter of the
median nerve was measured by ultrasound (GE Healthcare Logic
P6) (Torres-Costoso et al., 2018). The benefit of ultrasound in
musculoskeletal systems has been advocated in several studies
(Chang et al. 2017, 2018; Wu et al., 2018). The measurements were
524
read to the nearest 0.1 mm. The primary outcome was change in the
cross-sectional diameter of the median nerve. The primary
outcome in the trial was altered from the cross-sectional area to the
cross-sectional diameter of the median nerve. This was done since
the cross-sectional diameter was achievable and since this is more
precise and less dependent on the angle of the section of the nerve.
The clinician (AKH) performing the ultrasound measurements was
blinded to the group allocation of the participants.
The sensory function of the median nerve was tested by stan-
dard methodology. Tinel's sign and Phalen's test were also per-
formed on all patients. Tinel's sign consists of repeated tapping for
about 5 s or applying pressure over the median nerve at the wrist.
Numbness or paraesthesia of fingers is a sign of sensory
K.B. Kvist, R. Hilland, R. Enehaug et al. Journal of Bodywork & Movement Therapies 27 (2021) 522e528

malfunction of the median nerve. Phalen's test consists of pressing

the wrist gently in full flexion for about 1 min, and then noting any
numbness or paraesthesia in the fingers. Pincer grip strength
(force) in kilograms was measured by a manometer. Pain intensity
in hand and fingers was subjectively recorded using a VAS scale
from 0 to 10.
All variables were recorded at baseline and at follow-up, 6
weeks after start of the intervention. The ultrasound measurements
were taken within one week of follow-up, while the other mea-
surements were performed at follow-up.
One patient (two arms) had missing data for the follow-up ul-
trasound. As for the other outcomes, the amount of missing data
varied. The highest amount of missing data was for Phalen's test,
where a total of 17 arms (7 patients) had missing data, 8 arms at
baseline and 9 arms at follow-up. The lowest amount was for
strength with missing data only for one arm at follow-up.

3.6. Interventions

The IMS group received deep intramuscular stimulation in the

pronator teres muscle at the motor point at a depth of up to 50 mm
(Fig. 2). Patients allocated to the control group received an
acupuncture needle at the acupuncture point Li11 with a depth of
4e5 mm (Fig. 3). Both treatments lasted for about half an hour, of
which the needle was in place for 20 min. Both groups received 7
treatments at one-week intervals over 6 weeks. Sterile disposable
IMS acupuncture needles were used for the both the IMS and the
acupuncture treatment.
The IMS approach is used for both examination and treatment.
Based on the feedback from the deep needle, the IMS therapist can
Fig. 3. Control needle at the acupuncture point Li11.
identify the condition of the muscle and modify the depth and
duration of the needle in the muscle. IMS is therefore not only dry
needling treatment of trigger points. The rationale for using
acupuncture point Li11 as the control treatment is its proximity to
the IMS treatment point. Furthermore, a shallow needle at Li11 was
anticipated to have a minor effect on the carpal tunnel, compared
with the IMS needle.

3.7. Statistical methods

The 75 patients in this study had repeated measures over time

and some had bilateral CTS, and we therefore used generalized
linear mixed effects models to study the outcome measures be-
tween the IMS and the control group. For the continuous outcomes,
we applied an identity link function and a normal distribution for
the data, reporting change in mean values and mean differences.
For the binary outcomes, we used a logit link and a binomial dis-
tribution, reporting odds ratios (ORs). Treatment category (IMS or
not) and time (baseline and follow-up) were entered as fixed ef-
fects, while patient was entered as a random effect. The random
effect model (corresponding to a random intercept model) would
thus account for correlations between observations from the same
individual. For the continuous measures, the model will equal a
variance component model. To account for differences in variance
(heteroscedasticity), a random effect for differences between
treatment groups and between the two time points was added. For
the continuous variables, normal assumption was tested on the
residuals of the model using histograms of the residuals, normal
probability plots and the Shapiro-Wilk test. The statistical analysis
was performed using the lme4 library in the statistical package R
(www.r-project.org). P-values less than 0.05 were considered sta-
Fig. 2. IMS needle in pronator teres muscle. tistically significant.
525
K.B. Kvist, R. Hilland, R. Enehaug et al.
4. Results
Bilateral CTS, based on the clinical assessment and the cross-
sectional diameter of the median nerve, was present in 55 pa-
tients, while 13 patients had CTS only in the right arm and for 7
patients only the left arm was affected. Hence 130 arms for the 75
patients were included in the analysis (Fig. 1). For 22 of the patients
diagnosed with bilateral CTS, the cross-sectional diameter of the
median nerve was 2 mm or more only in one of the arms. The mean
age in the IMS group was 52 years (SD ¼ 11), while it was 55 years
(SD ¼ 9) in the control group. There were 8 males (22%) in the IMS
group and 10 males (26%) in the control group.
There was a statistically significant change in the diameter from
baseline to follow-up for both the IMS and control groups
(p < 0.001 and p ¼ 0.002 respectively). The change was larger for
the IMS group, but there was no significant difference in the change
over time between the groups (p ¼ 0.39) (Table 1).
In the per protocol analysis, including only the 108 arms (75
patients) which at baseline fulfilled the inclusion criterion of more
than 2 mm for the cross-sectional diameter, there was a reduction
in the IMS group of 0.17 mm (p < 0.001) and a reduction in the
control group of 0.12 mm (p ¼ 0.002). The difference in change was
not statistically significant (p ¼ 0.78).
As for clinical variables, patients reported a significantly larger
change on the VAS scale for pain (p < 0.001), while significantly
higher force in the pincer grip was recorded (p < 0.001) (Table 1).
The clinical measures for Tinel's sign and Phalen's test both showed
a statistically significant improvement in favour of the IMS group
(p < 0.001 and p ¼ 0.002 respectively, Table 2). The measure for the
standard test of sensory function of the median nerve also gave
results in favour of IMS (p < 0.001). No patients reported any
adverse effects.
5. Discussion
Based on the findings in the present study, we argue that IMS
may be a convenient and safe treatment for CTS, even though no
proof of efficacy could be derived from the primary outcome.
However, for all clinical symptoms IMS showed a statistically sig-
nificant reduction in severity, compared with the baseline mea-
sures. Furthermore, the reduction in the IMS group was statistically
superior to that of the control group. We found no other studies on
IMS treatment on the pronator teres muscle for CTS patients. The
VAS measure of pain and force in pincer grip were performed by
patients blinded to the treatment, and are hence reliable outcomes
for the effect of IMS. Symptoms of CTS may vary over time and
during the day. VAS measured as average pain during the last 24 h,
Table 2
Crude percentages per arm of negative (Tinel's and Phalen's) or normal (standard sensory function) test. Changes from baseline to follow-up given as odds ratios (OR) with 95%
confidence intervals, for the categorical measures for the 75 patients (130 arms), were based on fixed factors from a mixed effects model.
Baseline (95% CI) Follow-up (95% CI) OR for change (95% CI)
Tinel's sign for sensory functiona
IMS 58.1% 83.9% 9.9 (2.57; 38.1)
Control 31.8% 40.6% 2.2 (0.8; 6.0)
Phalen's test for sensory functionb
IMS 62.1% 86.2% 15.3 (3.2; 74.5)
Control 43.8% 50.8% 2.1 (0.7; 5.7)
Standard sensory function testc
IMS 19.4% 50.0% 21.1 (3.8; 117.1)
Control 11.3% 16.1% 31.4 (0.4; 2334.9)
a
Missing information on 6 arms (3 patients), 4 arms at follow-up.
b
Missing information on 17 arms (7 patients), 9 arms at follow-up.
c
Missing information on 12 arms (4 patients), 6 arms at follow-up.
526
Journal of Bodywork & Movement Therapies 27 (2021) 522e528
at baseline and follow up, will therefore not express the possible
variation in severity for patients during the day. Tinel's sign, Pha-
len's test and the standard test for sensory function were per-
formed by a non-blinded clinician.
For the diameter of the median nerve in the carpal tunnel as
measured by ultrasound, we found a statistically significant
reduction both for the IMS treated group and the control group.
Ultrasound has become a standard method of diagnosing CTS and
also for determining changes after treatment (Kotevoglu and
Gulbahce-Saglam 2005; Yoshii et al., 2015). In this study, we used
ultrasound measures as the primary outcome after treatment with
IMS needling. The ultrasound measures were performed by a
clinician blinded to the group allocation and were hence unbiased.
We would argue that the most reliable measure is the blinded
measure of the nerve diameter. Hence, showing a reduction in this
measure is of particular interest. Furthermore, patients blinded to
treatment reported significant changes in pain and pincer grip force
in favour of IMS. The clinical measures (Tinel's sign and Phalen's
test) performed by the IMS clinician support the findings from the
blinded and patient-reported measures.
The reduction in diameter in the IMS group was larger, but not
significantly different from the change observed for the control
group. There are some possible explanations for the change in
cross-section also found in the control group. In both groups, pa-
tients may have reduced their level of activity during treatment. A
contributing factor to the change in cross-section of the median
nerve found in both the IMS group and the control group, could
thus be that some patients, on their own initiative, reduced their
activity levels during the treatment period, leading to reduced
inflammation and swelling. Furthermore, for the control group
there might have been an effect of the acupuncture needle, even
though the acupuncture needle was positioned with the intention
to have no effect. Studies have shown that acupuncture is effective
in the treatment of CTS (Maeda et al. 2013, 2017). Studies have also
demonstrated that acupuncture can be superior to steroids for the
treatment of CTS (Yang et al., 2009).
Differences between the effects of dry needling and acupunc-
ture have been debated (Zhou et al., 2015). The sample size calcu-
lation preceding this study did not take into account that the
control group would show any effect and consequently the sample
size calculated to show a difference may have been under-
estimated. Using a well-known acupuncture point as the control
condition in this study may therefore be a weakness of the study.
Surgery, which releases the pressure on the median nerve
directly in the carpal tunnel, is the standard treatment for CTS.
Surgery may unfortunately have adverse effects and rehabilitation
may be needed. However, a Cochrane review found little evidence
p-value OR for difference (95% CI) p-value for differences
for change
<0.001 9.92 (2.04; 48.3) 0.004
0.12
<0.001 13.5 (2.4; 75.4) 0.003
0.17
<0.001 13.7 (1.3; 144.1) 0.029
0.12
K.B. Kvist, R. Hilland, R. Enehaug et al.
of effects of rehabilitation after surgery for CTS (Peters 2013).
In randomized studies, dry needling has proven effective for
myofascial pain (Diracoglu et al., 2012) and a systematic review has
found IMS to be effective and safe (Lim et al., 2011). It has also been
demonstrated that dry needling directly to the carpal tunnel is an
alternative (Gascon-Garcia 2018). In two Cochrane systematic re-
views, O'Connor et al. and Verdugo et al. conclude that there are no
non-surgical methods with an effect on CTS (O'Connor et al., 2003;
Verdugo et al., 2008). However, a systematic review of alternative
treatments for CTS, not including dry needling, argues that some
alternative treatments could be tried preceding surgery (Goodyear-
Smith and Arroll 2004).
5.1. Strengths and limitations
The systematic selection criteria of a representative sample of
patients and few dropouts are major strengths in this study. Double
blinding of IMS treatment is impossible since the performing
clinician knows which treatment he is giving. However, the cross-
section of the median nerve was unbiased since this measure was
performed by a clinician blinded to the treatment.
6. Conclusion
We argue that IMS ad modum Gunn could be a promising
treatment, e.g. preceding surgery, for CTS. However, studies
comparing surgery, acupuncture and IMS should be performed to
compare the difference between these methods.
Ethics approval and consent to participate
The Western Norway Regional Ethics Committee approved the
study (reference number: 2008/118). The research was carried out
in compliance with all principles in the Helsinki Declaration. Per-
sonal confidentiality was guaranteed, and informed consent was
signed by each participant with emphasis on the right to withdraw
from the study at any time without any explanation.
Availability of data
The data and script/command files (for the statistical analysis in
R) are available from the corresponding author on reasonable
request.
Funding
Eckbo Legacies (https://www.eckbos-legat.no/) and the Nor-
wegian Acupuncture Association (http://www.akupunktur.no/)
provided funding of the trial secretary for the recording of data. The
funding organizations had no role in the study design, data
collection, analysis, decision to publish, or preparation of the
manuscript. None of the authors received financial support for this
study.
Consent to publish
Not applicable.
Conflicts of interest
The authors KBK, RH, RE, and JS are clinicians who perform IMS
and organize courses in IMS. None of the authors have commercial
association that might pose a conflict of interest.
527
Journal of Bodywork & Movement Therapies 27 (2021) 522e528
Implications for research and practice
IMS is a simple, low-risk and inexpensive treatment for a
common disorder. It could therefore be an adequate, safe and
convenient alternative for patients reluctant to have surgery, or an
option for patients waiting for surgery.
Trial registration
The trial was registered in ClinicalTrials.gov, registration num-
ber: NCT01102868, retrospectively registered on March 29th, 2010.
Since patient enrolment started in April 2009 (and ended in April
2010) the trial is considered to be retrospectively registered. No
analyses were performed until all follow-up data were collected
(June 2010).
CRediT authorship contribution statement
Knut Birger Kvist: Conceptualization, Methodology, Investiga-
tion, Resources, Writing e original draft, Writing e review & edit-
ing, Project administration, Funding acquisition. Ronnie Hilland:
Conceptualization, Methodology, Investigation, Resources, Writing
e original draft, Writing e review & editing, Writing e original
draft, Writing e review & editing, Funding acquisition. Rune Ene-
haug: Conceptualization, Methodology, Investigation, Resources,
Writing e original draft. Jon Schjelderup: Conceptualization,
Methodology, Investigation, Resources, Writing e original draft.
Stein Atle Lie: Conceptualization, Software, Formal analysis, Re-
sources, Data curation, Writing e original draft, Writing e review &
editing, Supervision, Project administration. Anne-Kristine Halse:
Conceptualization, Methodology, Investigation, Resources, Writing
e original draft, Writing e review & editing, Supervision, Project
administration.
Declaration of competing interest
The authors Knut Birger Kvist, Ronnie Hilland, Rune Enehaug,
and Jon Schjelderup are clinicians performing IMS and arrange
courses in IMS. Neither of the authors have commercial affiliation
that alter the adherence of the study.
Acknowledgement
Eckbo Legacies (https://www.eckbos-legat.no/) and the Nor-
wegian Acupuncture Association (http://www.akupunktur.no/) are
acknowledged for their funding of the trial secretary.
Abbreviations
IMS Intramuscular stimulation (ad modum Gunn)
CTS Carpal tunnel syndrome
VAS Visual analogue scale
OR odds ratio
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.jbmt.2021.03.020.
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