1006857

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HANXXX10.1177/15589447211006857HandAbdolrazaghi et al

Surgery Article
HAND

Effectiveness of Tendon and Nerve

1­–8
© The Author(s) 2021
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DOI: 10.1177/15589447211006857
https://doi.org/10.1177/15589447211006857

of Patients With Mild Idiopathic journals.sagepub.com/home/HAN

Carpal Tunnel Syndrome:

A Randomized Controlled Trial

Hossein Ali Abdolrazaghi1, Mahmoud Khansari1, Maryam Mirshahi1 ,

and Mahin Ahmadi Pishkuhi2

Abstract
Background: There is limited evidence regarding the efficacy of different treatment options in patients with carpal tunnel
syndrome (CTS). This study aimed at assessing the effectiveness of nerve and tendon gliding exercises in the treatment of
patients with mild CTS. Methods: The current prospective, randomized trial with pretest-posttest design was conducted
on 80 patients with mild CTS randomly assigned to 2 groups. The treatment group was instructed to perform gliding
exercises in addition to the wrist splint use. The control group only used the wrist splint. All the patients were instructed
to use the splint at night and during the day if required. Patients were evaluated in terms of clinical parameters (ie, grip
and pinch strength). The severity of symptoms and functional status was also determined using the Boston Carpal Tunnel
Syndrome Questionnaire. The subjects were followed up for 6 weeks. Results: There were no significant differences in all
parameters between groups. The pretest-posttest analysis showed a statistically significant improvement in subjective and
objective parameters in the treatment group. However, in the control group, only a significant improvement was observed
in grip strength. Wrist splint use led to a significant change in the severity of symptoms only over the second week.
Conclusions: Both gliding exercise and wrist splint groups showed some improvement in the severity of symptoms and
functional status scores. However, the gliding exercises did not offer additional benefit compared with wrist splint alone.

Keywords: carpal tunnel syndrome, nerve gliding exercises, tendon gliding exercises, wrist splint, conservative treatment

Introduction treatment, in comparison with surgical therapies, is that

Carpal tunnel syndrome (CTS) is the most common neu-
ropathy caused by compression and tension of the median
nerve at the carpal tunnel of the wrist.1 The prevalence of
CTS varies in different populations.2,3 Studies show that it
has different etiologies and is more common in women than
in men.1,4 Every condition that decreases the size of the tun-
nel or causes swelling in the inside structures may lead to
the compression of the median nerve. Carpal tunnel syn-
drome is diagnosed based on clinical signs and symptoms,
and ultimately electrodiagnostic testing.5 The most com-
mon symptoms of CTS are pain and paresthesia (pins and
needles) with or without numbness in the median nerve area
of the wrist.3 Treatment of CTS is based on eliminating the
pressure on the median nerve.
Although different surgical and nonoperative procedures
are used in treating CTS, evidence for the efficacy of treat-
ment options is limited.6-8 The advantage of nonoperative
there are no consequences such as painful scars, postopera-
tive complications, and delay in rehabilitation.9 Several
nonoperative therapies are used to reduce the symptoms of
idiopathic CTS. Wrist splinting is a method widely used in
treating patients. These splints hold the wrist in a neutral
and nonbending position, and thus the lowest amount of
pressure is applied to the median nerve. Although the best
time to use the wrist splint is not specified, it is often recom-
mended to use it during the night or in daytime in case of
1
Department of Hand and Reconstructive Surgery, Sina Hospital, Tehran
University of Medical Sciences, Tehran, Iran
2
Pars Advanced and Minimally Invasive Medical Manners Research
Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran
Corresponding Author:
Maryam Mirshahi, Sina Hospital, Tehran University of Medical Sciences,
Imam Khomeini Avenue, Hassan Abad Square, Tehran 1136746911, Iran.
Emails: m.mirshahi2000@yahoo.com; m-mirshahi@sina.tums.ac.ir
2 HAND 00(0)
repetitive wrist movements.10 Exercise therapy is one of the
newest methods to control CTS symptoms. Reduced nerve
gliding was observed in the respective channel in patients
with CTS,11 and exercise provides conditions for flexibility
and the enhancement of the nerve gliding. Flicking fingers,
even when hands are motionless, creates the proper move-
ment of the median nerve and the flexing tendon along the
wrist, which prevents adhesion.12 The alternating flexion-
extension exercises of the wrist and fingers actually cause
stretching of the carpal tunnel connections, widening the
longitudinal area of the connection between the nerve and
transverse carpal ligament, reducing the tenosynovial swell-
ing, improving the venous return from the nerve nodes, and
reducing the pressure within the carpal tunnel.6,13 Although
many studies are conducted on the effects of conservative
treatments on patients with CTS, their results are controver-
sial, and further studies in this area seem necessary. Based
on a recent systematic review, tendon and nerve gliding
exercises, when combined with conventional treatments,
may have a favorable effect on patients with CTS.6
Therefore, the current clinical trial aimed at assessing
the effectiveness of nerve and tendon gliding exercises in
the treatment of patients with mild idiopathic CTS.
Materials and Method
Study Population
In this clinical trial, all patients with clinically suspected CTS
referred to the surgery and sports medicine clinic were
assessed for eligibility. The study was performed from Janu-
ary 2017 to February 2019 at Sina Hospital, Tehran, Iran.
Inclusion criteria were: age >18 years, reporting of symp-
toms of CTS (pain, paresthesia in the area of hand innervated
by the median nerve), and electrophysiological findings of
nerve compression (mild CTS). Exclusion criteria were: pre-
vious treatment with splint or surgery; history of any trauma
on the hands, neck, and shoulders within 3 months of the
study onset; history of wrist surgery; history of pregnancy;
diabetes; thyroid disorders; and any findings suggesting con-
ditions that interfere with CTS (eg, cervical radiculopathy).
Informed consent was obtained from all patients for being
included in the study. All procedures followed were in accor-
dance with the ethical standards of the responsible committee
on human experimentation of Tehran University of Medical
Sciences, Tehran, Iran, and with the Helsinki Declaration.
Protocol
Patients were selected based on medical history, physical
examination results, and electrophysiological findings. In
this study, a hand surgeon confirmed inclusion/exclusion
criteria and completed neurologic examinations. A surgeon
assistant obtained informed consents, collected self-report
questionnaires, and conducted treatment allocations. A
sports medicine specialist also visited the patients to com-
plete special CTS examination, train the exercise proto-
col, and follow up their compliance with the intervention.
In the first visit, all the patients completed the Boston
Carpal Tunnel Syndrome Questionnaire (BCTQ). A log
book containing detailed explanation of prescribed exer-
cises and a self-report daily exercise checklist were given
to participants. Subjects were free to withdraw from the
study at any time during the follow-up period. Follow-up
examinations were scheduled at 2- and 6-week intervals
after the intervention.
Blinding
Except sports medicine specialist who educated patients for
correct exercising, other researchers were blind to the allo-
cated treatments.
Treatment Allocation
Patients were randomly allocated to receive either splinting
or splinting with exercise (Figure 1). A researcher (M.KH)
not involved in the selection and treatment of patients pre-
pared and sealed opaque envelopes containing the treatment
options. Every patient randomly chose 1 sealed opaque
envelope to determine the type of intervention. If bilateral
symptoms were present, the hand with the more severe
symptoms (according to the patient) was treated.
Treatment
After assigning patients to specific groups, prefabricated
splints (wrist and forearm splint; Tynor, India) were given
to both groups, and the subjects were asked to use it for 6
weeks. In these splints, the wrist was held in a neutral posi-
tion, and the fingers were free. The subjects were urged to
wear the splint during the night or in daytime in case of
repetitive wrist movements. The patients in the treatment
group were prescribed a tendon and nerve gliding exercise
program developed by Totten and Hunter.14 In tendon glide
exercises, fingers are held in 5 positions of straight, hook,
fist, tabletop, and long fist, respectively (Figure 2). The
fingers are in full extension between these positions. At all
stages of this exercise, the wrist is in a neutral position. By
doing the nerve glide exercises, the median nerve moves
through the wrist and the fingers in 6 different positions. To
do this exercise, the elbows are kept supinated with 90° of
flexion, and the shoulder and neck are in the neutral posi-
tion. In the first state, the wrist is in a neutral position, and
the fingers and thumb are in flexion. In the second state,
the wrist is in a neutral position, and the fingers and thumb
are in extension. In the third state, the wrist and fingers are
in extension, and the thumb is in a neutral position. Then,
Abdolrazaghi et al 3

Figure 1.  The study flowchart.

the wrist, fingers, and thumb are held in the extension
position. In the next step, maintaining the previous posi-
tion, the forearm is kept supinated. In the final step, a mild
extension is applied to the exercising thumb by the oppo-
site hand (Figure 3). Patients were asked to perform all the
exercises 3 times a day, 10 repeats each time, and hold
each position for 5 seconds. The exercise therapy lasted
for 6 weeks. During the treatment, patients were asked to
confirm daily exercise in the checklist tailored for this pur-
pose. After the treatment, the patients were revisited, and
the tests performed at baseline were repeated for them.
Outcome Measures
Demographic information and medical history of the sub-
jects were collected using a structured questionnaire.
4 HAND 00(0)
Figure 2.  Tendon gliding exercises. In tendon gliding exercises,
fingers are held in 5 positions of (a) straight, (b) hook, (c) fist,
(d) tabletop, and (e) long fist.
Severity of the symptoms was assessed by BCTQ. The sec-
ondary outcome measures were the grip and pinch strength
assessed by dynamometer and pinch meter, respectively.
Results of nerve conduction studies were used to confirm
the severity of CTS.
The BCTQ is an instrument specifically developed for
patients with CTS.15 The symptom severity scale includes
11 items on pain, nighttime symptoms, numbness, paresthe-
sia, and weakness, and the functional status scale evaluates
8 activities (ie, difficulty in writing, buttoning up the shirt,
opening the can, holding a book, holding the phone, house-
work, carrying the vegetable bag, and bathing and dress-
ing). The items are scored based on a 6-point Likert scale
from 1 (no difficulty with activity) to 5 (cannot perform the
activity at all).
Special Tests
After receiving the medical history, physical examination
was performed using the Tinel sign and the Phalen maneu-
ver, carpal compression, and 2-point discrimination tests.
Sensitivity ranges from 42% to 85% for the Phalen test and
from 38% to 100% for the Tinel test; specificity ranges
from 54% to 98% and from 55% to 100%, respectively.2 To
examine the Phalen sign, the patient flexes his wrist for 60
seconds; a positive Phalen sign is defined as paresthesia or
numbness in the median nerve area during testing. To per-
form the Tinel test, the median nerve in the wrist is lightly
tapped over, and if the patient experiences paresthesia in the
median nerve pathway, the result is considered as positive.16
The carpal compression test is to apply a direct pressure
over the carpal tunnel and its contents, including the median
nerve, for 30 seconds; if pins and needles are felt at the end
of the fingers, the test result is considered as positive.3,17
This test is more sensitive and more specific than the Tinel
and the Phalen tests.17 The 2-point discrimination was mea-
sured by the Jamar discriminator on the pulp of the 3 radial
fingers, and the mean of the numbers was recorded.18 The
grip strength was measured by the Jamar handheld dyna-
mometer. For this purpose, the patient sits comfortably, and
while the shoulders are abducting, the elbow is bent by 90°
and the forearm is placed in a neutral position. The patient’s
wrist has an extension of 0° to 30° during grip measure-
ment. In each handgrip, the strength was measured 3 times
with 1-minute rest between, and then the mean values were
recorded.19 The pinch strength of the patients was measured
by a pinch meter (Jamar) between the tip of the thumb and
the second finger. The patient’s pinch was also measured 3
times in the same grip measurement state, and the mean of
it was recorded.20 All measurements were performed by a
sports medicine specialist.
Statistical Analysis
Statistical analysis was performed using SPSS software
(V.22.0). Results of normally distributed continuous vari-
ables are expressed as mean ± SD; categorical data are
expressed as percentages. The Shapiro-Wilk test was used
to examine whether the variables were normally distrib-
uted. Groups data were compared using the Mann-Whitney
U test. The Wilcoxon and McNemar tests were used to com-
pare the parameters of the 2 groups before and after treat-
ment. A value of P ≤ .05 was considered as the level of
significance.
Results
In this study, 2 subjects withdrew: one of them had an
injection and the other one was lost to follow-up (Figure
3). Thus, 80 subjects (13 men and 67 women) completed
the study. The participants were divided into 2 groups. The
treatment group included 42 (52.5%) participants per-
forming exercises in addition to using splint, and the con-
trol group included 38 (47.5%) participants using only
wrist splint. Among the participants, 49 (61.3%) and 31
(38.7%) were housewife and employee, respectively.
Forty-five subjects reported bilateral CTS. Demographic
characteristics and clinical features of both groups before
the treatment are illustrated in Table 1. There was no sig-
nificant difference between the groups in any of the
parameters. Based on the given checklist, adherence to
exercise protocol was 85%.
Examining the data obtained from questionnaires
showed that the data were not normally distributed based on
the results of the Kolmogorov-Smirnov and Shapiro-Wilk
tests; therefore, nonparametric tests were used for analysis.
The results of comparison of the mean of all scores
related to BCTQ showed no significant difference between
the 2 groups in severity of the symptoms and the functional
status in any of the intervals (Table 2). Comparison of the
results of each group before and after the intervention
showed a significant difference after 2 weeks in the severity
of symptoms and function of patients in the treatment group
(P < .001). This improvement was also observed on the
sixth week (P < .001), whereas the control group showed
Abdolrazaghi et al 5

Figure 3.  Nerve gliding exercises.

Note. (a) Wrist in a neutral position, and the fingers and thumb in flexion. (b) Wrist in a neutral position, and the fingers and thumb in extension.
(c) Wrist and fingers in extension and the thumb in a neutral position. (d) Wrist, fingers, and thumb in extension. (e) Wrist, fingers, and thumb in
extension and the forearm in supination. (f) Mild extension to the exercising thumb by the opposite hand.

Table 1.  Demographics and Clinical Features of the Participants.

Treatment group Control group

Variable n = 42 n = 38 P value
Age, y 49.9 ± 8.92 49.5 ± 10.19 .85
Weight, kg 75.79 ± 14.37 73.63 ± 10.9 .45
BMI 28.26 ± 4.78 27.83 ± 3.69 .66
Working times per week, h 34.17 ± 12.66 39 ± 10.87 .07
Tinel sign, positive, No. (%) 6 (14) 3 (8) .41
Phalen sign, positive, No. (%) 11 (26) 12 (31) .62
Compression sign, positive, No. (%) 13 (31) 7 (18) .30
Hand grip strength, kg 19.14 ± 7.96 19.33 ± 6.99 .91
Pinch strength, kg 13.01 ± 4.09 13.26 ± 4.14 .78
Two-point discrimination, mm 5.79 ± 0.87 5.66 ± 0.7 .47
Functional status scorea 15.47 ± 7.29 13.84 ± 5.42 .41
Symptom severity scorea 25.69 ± 10.92 22.57 ± 9.06 .20

Note. Data are expressed as mean ± SD or No. (%). BMI = body mass index.
a
Higher scores indicate greater impairment.

Table 2.  Comparison of the Total Score of Boston Questionnaire at Different Time Intervals Between 2 Groups.

Severity of symptoms Functional status

Time, wk Treatment group Control group P value Treatment group Control group P value
0 25.6 ± 10.9 22.5 ± 9.0 .2 15.4 ± 7.2 13.8 ± 5.4 .4
2 21.8 ± 10.4 21.8 ± 9.6 .8 13.8 ± 7.2 13.7 ± 5.8 .4
6 16.9 ± 7.6 18.6 ± 6.9 .1 11.7 ± 5.1 12.2 ± 4.6 .1

Note. Data are expressed as mean ± SD.

only a significant improvement in the severity of the symp-
toms during the second to sixth week (P = .003) (Table 3).
There was no significant difference between the 2 groups
regarding the severity of symptoms and functional status at
baseline, as well as the second and sixth week. Except for
the amount of weakness in the hand (P = .04) and one of
the hand functions (buttoning up shirts) (P = .03), which
were significantly higher in the treatment group than the
control group, none of the variables related to the symptoms
and function had a significant difference between the 2
groups.
At the examination performed 6 weeks after the treat-
ment, there was no statistically significant improvement in
all parameters in both groups, except for pinch and grip
6 HAND 00(0)

Table 3.  Comparison of the Total Score of Boston Questionnaire at Different Time Intervals in Each Group.

Severity of symptoms Functional status

Time, wk Treatment group Control group Treatment group Control group

0 25.6 ± 10.9 22.5 ± 9.0 15.4 ± 7.2 13.8 ± 5.4
2 21.8 ± 10.4* 21.8 ± 9.6 13.8 ± 7.2* 13.7 ± 5.8*
6 16.9 ± 7.6# 18.6 ± 6.9# 11.7 ± 5.1# 12.2 ± 4.6

Note. Data are expressed as mean ± SD.

*P <.05 comparison of before treatment and second week.
#
P <.05 comparison of second week and sixth week.

Table 4.  Comparison of Pinch and Grip Strength at Different Time Intervals in Each Group.

Pinch strength, kg Grip strength, kg

Time, wk Treatment group P value Control group P value Treatment group P value Control group P value
0 13.0 ± 4.0 <.001* 13.2 ± 4.1 .1 19.1 ± 7.9 <.001* 19.3 ± 6.9 .1
2 14.0 ± 4.4 13.7 ± 3.9 20.3 ± 7.8 19.7 ± 6.6
6 14.8 ± 4.4 <.001* 13.6 ± 3.9 .1 22.4 ± 7.8 .001* 21.3 ± 7.8 .005*

Note. Data are expressed as mean ± SD.

*Statistical significance (P value) set at <.05.

strength (Table 4). There was a statistically significant
improvement in pinch and grip strength at all times of assess-
ment in the treatment group. Grip strength in the treatment
group improved from 19.14 to 22.47 kg (P < .001). Grip
strength in the control group showed only improvement after
6 weeks from intervention onset (P = .005), but difference
in pinch strength was not significant.
Discussion
The main finding of the present randomized controlled
trial was that both the treatment and control groups
improved over time. However, there were no significant
differences between the groups. Pinch and grip strength
significantly improved in the treatment group from base-
line to the 6-week follow-up. In the control group, pinch
strength was greater over 2 weeks; however, the improve-
ment was not sustained for the additional 4 weeks. Grip
strength in the control group significantly improved at the
end of follow-up. There was no difference in the results of
the Tinel, Phalen, and compression tests after the treat-
ment in the 2 groups.
Currently, several nonoperative interventions are used to
treat CTS. However, there are doubts about which treatment
is the most appropriate one. Despite the low level of evi-
dence, the effectiveness of immobilization is somewhat
ascertained,12 although there still exists scarcity of evidence
about the effectiveness of exercise in CTS treatment. Some
studies indicate limited evidence for the effectiveness of
exercise therapy.3,12,21
In a study similar to the current one, Akalin et al22
assessed the effect of nerve and tendon gliding exercises
on CTS. They reported that both groups had improvement
in all parameters. Although the results were more satisfac-
tory in the group that received exercise than the group that
used only splint, the difference was not statistically sig-
nificant except for the lateral pinch strength. In a similar
study by Pinar et al,13 a before and after intervention anal-
ysis showed improvement in all of the outcome measures
in both groups. However, they found that the group in
which nerve gliding exercises were added to conservative
therapy approaches demonstrated more rapid pain reduc-
tion and greater functional improvement, especially in
grip strength. Another investigation assessed the effective-
ness of tendon and nerve gliding exercises as a part of
combined treatment, separately.23 The authors reported
that the combination of tendon gliding exercises with con-
ventional treatments may be more effective than nerve
gliding exercises. The result of another study24 showed
that the combination of orthosis, nerve/tendon gliding
exercises, and ultrasound therapy did not offer additional
benefit compared with orthosis alone.
In the control group, the wrist splint significantly
reduced symptoms over 2 weeks, and that improvement
was sustained for an additional 4 weeks. Although this
finding was consistent with those of other studies, in this
study, wrist splint did not have any effect on functional
status. A possible reason for the effectiveness of wrist
splint is decreasing pressure in the carpal tunnel by hold-
ing the wrist firm in a neutral position.12 But in other
groups receiving exercise in addition to wrist splint,
either severity symptoms or functional status improved in
2 and 6 weeks. In the control group, grip strength showed
improvement at the end of the sixth week. It was the time
Abdolrazaghi et al 7
that severity of symptoms decreased. It can be concluded
that decreased symptoms led to grip strength improve-
ment. But in the treatment group, grip and pinch strength
as well as symptoms and functional status improved in
parallel and during the follow-up. Tendon gliding exer-
cises involve a sequence of finger movements, and nerve
gliding exercises include wrist and finger movements.
Gliding exercises reduce pressure inside the carpal tunnel
through decreasing adhesions around the tendons and
median nerve, tenosynovial edema, direct mobilization of
the nerve, improving the excursion of the nerve and ten-
dons, and facilitating venous return; thus, these dynamic
exercises would improve symptoms.12,22,25 The pressure
in the carpal tunnel is lowest in the neutral position; how-
ever, the pressure rises significantly as the wrist is moved
into flexion or extension,25 but nerve and tendon gliding
exercises with controlled active wrist and finger motions
can reduce pressure in the canal.
The limitation of this study was the short-term follow-
up. Outcome measures were assessed at 2 and 6 weeks.
Thus, long-term results are unknown. However, this study
had methodological strengths, including the randomized
design, the use of valid and standard measures, and the
evaluation of the functional status of patients.
In this study, exercise therapy was prescribed in asso-
ciation with splint use. Future research needs to be con-
ducted to determine the effectiveness of these exercises
as a single treatment with a longer follow-up to deter-
mine long-term effects of the intervention. It is also sug-
gested that further studies be designed with a larger
sample size and a more strenuous adherence to the exer-
cise protocol.
Conclusion
According to the results of this study, both gliding exercise
and wrist splint groups showed some improvement in
symptom severity and functional status scores. However,
the gliding exercises did not offer additional benefit com-
pared with wrist splint alone.
Acknowledgments
The present research has been supported by Tehran University of
Medical Sciences & Health Services as a thesis. The authors
would like to thank the Epidemiology and Biostatistics Unit of
Research Development Center of Sina Hospital for their technical
assistance.
Ethical Approval
This study was approved by our institutional review board.
Statement of Human and Animal Rights
All procedures followed were in accordance with the ethical stan-
dards of the responsible committee on human experimentation of
Tehran University of Medical Sciences, Tehran, Iran, and with the
Helsinki Declaration.
Statement of Informed Consent
Informed consent was obtained from all patients for being included
in the study.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: This
research has been supported by Tehran University of Medical Sci-
ences & Health Services as a thesis.
Trial Registration
This trial has been registered at Iranian Registry of Clinical Trials
(http://www.IRCT.ir) with ID IRCT20191222045849N2
ORCID iD
Maryam Mirshahi https://orcid.org/0000-0002-8754-4937
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