Journal of Hand Therapy xxx (2020) 1e9

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Journal of Hand Therapy

journal homepage: www.jhandtherapy.org

The long-term effect of neurodynamics vs exercise therapy

on pain and function in people with carpal tunnel syndrome:
A randomized parallel-group clinical trial
Hayat Hamzeh PT, MSc a, *, Mohammad Madi PT, PhD b, Alia A. Alghwiri PT, PhD a,
Ziad Hawamdeh MD, PhD c
a
Department of Physiotherapy, School of Rehabilitation Sciences, The University of Jordan, Amman, Jordan
b
Department of Physiotherapy and Occupational Therapy, The Hashemite University, Zarqa, Jordan
c
Department of Special Surgery, Orthopaedic and Rehabilitation Medicine Section, School of Medicine, The University of Jordan, Amman, Jordan

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

Article history: Introduction: Carpal tunnel syndrome (CTS) is a common disorder that limits function and quality of life.
Received 5 December 2019 Little evidence is available on the long-term effect of neurodynamics and exercise therapy.
Received in revised form Purpose of the Study: This study aimed to examine the long-term effect of neurodynamic techniques vs
3 May 2020
exercise therapy in managing patients with CTS.
Accepted 22 July 2020
Available online xxx
Study Design: Parallel group randomized clinical trial.
Methods: Of 57 patients screened, 51 were randomly assigned to either receiving four sessions of neu-
rodynamics and exercise or home exercise therapy alone as a control. Blinded assessment was performed
Keywords:
Carpal tunnel syndrome
before treatment allocation, at treatment completion, and 6 months posttreatment. Outcome measures
Neurodynamics included Symptom Severity Scale (SSS), Functional Status Scale (FSS), Shortened version of the Disabil-
Exercise therapy ities of the Arm, Shoulder, and Hand (DASH), Numerical Pain Rating Scale, grip strength and range of
Manual therapy motion.
Randomized clinical trial Results: Data from 41 individuals (52 hands) were analyzed. The neurodynamics group demonstrated
significant improvement in all outcome measures at 1 and 6 months (P < .05). Mean difference in SSS
was 1.4 (95% CI¼ 0.9-1.4) at 1 month and 1.6 (95% CI ¼ 0.9-2.2) at 6 months. Mean difference in FSS was
0.9 (95% CI ¼ 0.4-1.4) at 1 month and 1.4 (95% CI ¼ 0.7-2.0) at 6 months. Significant between-group
differences were found in pain score at 1 month (1.93) and in FSS (0.5) and Shortened version of
DASH (12.6) at 6 months (P < .05). No patient needed surgery 1 year after treatment.
Conclusions: Although both treatments led to positive outcomes, neurodynamics therapy was superior in
improving function and strength and in decreasing pain.
Ó 2020 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved.

Introduction demonstrating superior short-term effectiveness over surgery as

Carpal tunnel syndrome (CTS) is one of the most commonly
diagnosed peripheral neuropathies.1,2 It results from a compressed
median nerve at the level of carpal tunnel, leading to marked pain,
impaired mobility, and poor quality of life.3 With an increasing
prevalence and incidence, CTS places an economic burden on
management.4 Thus, identifying efficient and effective in-
terventions is paramount.
There is now an emerging evidence supporting conservative
management options over surgical ones,5 with physiotherapy
* Corresponding author. Department of Physiotherapy, School of Rehabilitation
Sciences, The University of Jordan, Amman 11942, Jordan.
E-mail address: h.hamzeh@ju.edu.jo (Hayat Hamzeh).
well as an equivalent long-term effectiveness.6,7 This lends more
support to trying physiotherapy management before deciding on
surgery. Albeit, there is a limited evidence on what conservative
approaches are more effective in mild to moderate CTS cases,8 as
well as their long-term effectiveness.9,10
Two main physiotherapy approaches are frequently used to
manage CTS: neurodynamics and exercise physiotherapy.11 Neu-
rodynamics therapy is characterized by using specific manual
techniques to change the mechanical characteristics around pe-
ripheral nerves. The effect of neurodynamics manual therapy has
been found to be inconclusive in multiple systematic reviews.11-13
However, recent randomized controlled trials confirmed its short-
term effectiveness compared with surgery,7 sham treatment,14
and control groups,15,16 with only 2 studies exploring the long-

0894-1130/$ e see front matter Ó 2020 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jht.2020.07.005
2 H. Hamzeh et al. / Journal of Hand Therapy xxx (2020) 1e9
term effectiveness.7,17 On the other hand, the evidence behind the
effectiveness of exercise-based physiotherapy regimes, which
include carpal bone mobilization, soft tissue mobilization, and
tendon gliding, is similarly incomplete based on findings of a
Cochrane review.13
In light of this available evidence, a robust investigation that
examines both neurodynamics and exercise physiotherapy ap-
proaches is required. Therefore, the aim of this study was to
examine the long-term effect of neurodynamics therapy compared
with regular physiotherapy exercise on pain and function of pa-
tients with CTS.
Methods
Design
This study is a randomized parallel-group clinical trial.
Ethics
The study was approved by the International Review Board
committee of Jordan University Hospital (47/2016/2256). It was
registered in Clinicaltrials.gov under the registration number:
NCT03243227. All participants signed an informed written consent
before participation in the study.
Setting
All assessment and treatment procedures were performed in
the Department of Physiotherapy, the University of Jordan. Data
collection took place between August 2017 and May 2019.
Participants
Potential participants were recruited through advertisement in
physical medicine and rehabilitation unit of one of the main hos-
pitals in Amman, Jordan, and through social media. Participants
who met the inclusion criteria (age >18 years and a confirmed CTS
diagnosis both clinically by a physician and using nerve conduction
test) were recruited. Clinical diagnosis was based on confirming the
presence of pain and paresthesia in median nerve distribution area,
positive Phalen's maneuver and median nerve compression tests,
and presence of the flick sign. Nerve conduction velocity values
<50 m/s and/or increased motor latency >4 m/s was considered as
confirmation of diagnosis. Exclusion criteria included previous
trauma or surgery involving the upper extremities, known neuro-
logic condition, pregnancy, and history of radiating neck or back
pain in the previous 3 months.
Table 1
Group 1 (neurodynamics) management protocol
a
Week Neurodynamics manual therapy
1 Glenohumeral accessory mobilization, wrist accessory mobilization.
Simultaneous shoulder adduction þ elbow extension, followed by
shoulder abduction þ elbow flexion
2 Simultaneous shoulder depression and wrist flexion, simultaneous
shoulder elevation and wrist extension
3 Simultaneous elbow extension and wrist flex, simultaneous elbow
flexion, and wrist extension
4 Simultaneous shoulder elevation and wrist flexion, simultaneous
shoulder depression and wrist extension simultaneous elbow flexion
and wrist flexion, and simultaneous elbow extension and wrist extension
a
Consisted of one 60-min session per week. Each session included 3 sets of 10 repetitions. Starting position in Upper Limb Tension Test 1 (ULTT1) position.19
b
All exercises were practiced under supervision before asking the participant to do it at home (2 daily sessions as tolerated).
A sample size of 42 participants was considered sufficient for
this study based on a priori analysis. It was calculated using G Po-
wer software with alpha significance level set at 0.05, statistical
power of 0.80, a 2-tailed null hypothesis, and a minimal clinically
important difference of 1.04 in the primary outcome measure
Boston carpal tunnel questionnaire.18 A 20% dropout was expected;
therefore, the study aimed to recruit a minimum of 50 patients.
Procedures
A blinded assessor conducted a baseline assessment of included
participants before randomization. Randomization into either
treatment or control group was done by an administrator who is
not otherwise involved, through random permuted blocks, using
sealed envelope (https://www.sealedenvelope.com)19 just before
treatment allocation. Afterward, an experienced physiotherapist
applied treatment protocol to both groups without knowing their
assessment outcomes. The treatment group (NDT) received
specialized neurodynamics treatment. The management protocol
consisted of one 60-minute weekly sessions over a period of 4
weeks. The details of each treatment session are included in Table 1.
Each session followed published neurodynamics concepts for me-
dian nerve.20 It included neurodynamics manual therapy and
neurodynamic-based home exercises. All manual therapy tech-
niques were performed in the median neurodynamic test position
(Upper Limb Tension Test 1). Participants practiced home exercise
in the session under supervision to ensure optimal performance.
Treatment was progressed when the participant was able to go
through previous week activities without provoking symptoms.
Control group (EXT) received 4 sessions of supervised exercise that
are based on the Arthritis United Kingdom and the Chartered So-
ciety of Physiotherapy recommendations.21 It included 10  3
repetitions of tendon gliding, wrist and hand strengthening,
stretching, and active range of motion (AROM) exercise. A pamphlet
that explains the same exercises was given to participants to follow
over a period of 4 weeks. Participants in both groups were asked to
perform exercises twice daily at home during and after the
completion of sessions. They were not prevented from seeking
further treatment between follow-ups because of ethical consid-
erations. At the 2 follow-up phases, participants were asked
whether they received other therapeutic interventions.
Outcome measures
All primary and secondary outcome measures were adminis-
tered by a blinded assessor at baseline assessment (pretreatment),
directly at treatment completion (1 month), and 6 months
Home neurodynamics exerciseb
Median nerve gliding exercise
Wrist flexion þ elbow extension þ neck side flexion
Shoulder depression þ wrist flexion, shoulder elevation þ wrist extension
Median nerve tension extension
Wrist flexion þ elbow extension þ neck side flexion
Shoulder depression þ wrist flexion, shoulder elevation þ wrist extension
Busy bee flexion
Shape of (Z) exercise
Free the bird exercise
Wall stretch exercise
 H. Hamzeh et al. / Journal of Hand Therapy xxx (2020) 1e9
Fig. 1. CONSORT flow diagram.
posttreatment completion (long term). Tertiary outcome measure
was administered 1 year after treatment completion.
Primary outcome measures
Boston Carpal Tunnel Syndrome Questionnaire
A self-reported questionnaire includes 2 distinct scales: (1) the
Symptom Severity Scale (SSS), which has 11 questions and uses a 5-
point Likert scale; and (2) the Functional Status Scale (FSS) con-
taining 8 items, which have to be rated for degree of difficulty on a
5-point Likert scale.22 Each scale generates a final score (sum of
individual scores divided by number of items), which ranges from 1
to 5, with a higher score indicating greater disability. A validated
and reliable Arabic version of Boston Carpal Tunnel Syndrome
Questionnaire (BCTSQ) was used in this study.23
Secondary outcome measures
Shortened version of the Disabilities of the Arm, Shoulder, and Hand
A patient-based outcome measure was used to assess function
in patients with arm or hand pain. The scores for all items are then
used to calculate a scale score ranging from 0 (no disability) to 100
3
(most severe disability). Both Shortened version of the Disabilities
of the Arm, Shoulder, and Hand (QuickDASHa; general disabilities)
and the optional QuickDASHb (work-related disabilities) data were
collected. A valid and reliable Arabic version of QuickDASH was
used in this study.24
Numerical Pain Rating Scale
A subjective rating of pain severity is specified by asking par-
ticipants to rate their pain severity as a number from 0 to 10. The
higher the number, the greater level of pain.
Wrist range of motion
All wrist joint movements (flexion, extension, abduction, and
adduction) were measured actively and passively using universal
plastic goniometer. Measurements followed the test procedures
described in Clarkson's musculoskeletal assessment textbook25
and were performed by the same blinded examiner throughout
the study. The participants were seated with elbow flexion and
forearm pronation. For ulnar and radial deviations, the palmar
surface of the hand rested lightly on a table; and for wrist flexion
and extension, the palmar surface of the hand rested over the
end of the table.
4 H. Hamzeh et al. / Journal of Hand Therapy xxx (2020) 1e9

Table 2
Sample characteristics

Characteristic Treatment group NDT (n ¼ 20, hands ¼ 23) Control group EXT (n ¼ 21, hands ¼ 29) All
Age, mean (SD) 50.85 (9.14) 45.71 (12.26) 48.22 (11)
BMI, mean (SD) 25.20 (3.68) 24.32 (4.80) 24.75 (4.26)
Nerve conduction latency, mean (SD) 5.14 (1.85) 4.25 (1.04) 4.64 (1.5), range 2.2-11
Nerve conduction velocity, mean (SD) 46.46 (7.60) 48.69 (11.56) 47.7 (10), range 23.8-69.9
Severity, n (%)a
Mild (Grade 2) 8 (34.78) 16 (55.17) 24 (46.15)
Moderate to severe (Grades 3 and 4) 12 (52.17) 13 (44.83) 25 (48.08)
Severe (Grades 5 and 6) 3 (13.04) 0 (0.00) 3 (5.77)
Sex, n (%)
Female 18 (90) 19 (90.5) 37 (90)
Male 2 (10) 2 (9.5) 4 (10)
Affected side, n (%)
Right 5 (25) 9 (43) 14 (34)
Left 11 (55) 4 (19) 15 (37)
Bilateral 4 (20) 8 (38) 12 (29)
Onset, n (%)
0-6 mo 3 (15) 6 (28) 9 (22)
6-12 mo 5 (25) 1 (5) 6 (15)
12-24 mo 2 (10) 1(5) 3 (7)
>24 mo 10 (50) 13 (62) 23 (56)

BMI ¼ body mass index; SD ¼ standard deviation.

Nerve conduction latency in milliliter per second, and nerve conduction velocity in meter per second.
a
Based on Bland's26 system of classifying CTS severity.

Hand grip strength
Hand grip strength was measured using a hand held dyna-
mometer device (Jamar Hydraulic Hand Dynamometer). Readings
were taken in pounds lb. (1 lb ¼ 0.454 kg). The average value of 3
trials was scored.
repeated measures analysis of variance was used to calculate the
differences within each group in primary and secondary outcome
measures between baseline and 1 month as well as between
baseline and 6 months. Mean and 95% confidence interval (CI) were
calculated for all differences.

Tertiary outcome measure Results

Surgery Fifty-seven patients diagnosed with CTS participated in this

After one year of intervention, participants were asked whether
or not they received median nerve decompression surgery.
Data analysis
Data analysis was conducted using IBM SPSS Statistics for
Windows, version 23 (IBM Corp, Armonk, NY). All obtained data
were tabulated, and means, standard deviations, and differences
were calculated.
Independent Student’s t-test was used to estimate between-
group differences in primary and secondary outcome measures. A
study. Data from 41 subjects (52 hands) were included in the
analysis. Consolidated Standards of Reporting Trials flow diagram is
shown in Figure 1. Baseline characteristics of participants are
included in Table 2. There were no significant differences in all
variables between both groups at baseline.
Significant between-group differences were found in measures of
function (FSS and QuickDASHa) at 6 months but not in SSS measure
of symptoms. Analysis revealed improvement in SSS by 1.36. Sig-
nificant effect of therapy was found in all BCTSQ and QuickDASH
scores for both groups at 1 and 6 months (Table 3 and Fig. 2).

Table 3
Between- and within-group differences, effect of therapy in BCTQ and DASH scores

Outcome measure Group Baseline 1 mo 6 mo Difference at 1 mo Difference at 6 mo

(mean difference, 95% CI) (mean difference, 95% CI)
SSS NDT 3.17 (0.86) 2.04 (0.68) 1.64 (0.66) 1.36a (0.9 to 1.8) 1.55a (0.9 to 2.2)
EXT 2.71 (0.76) 2.16 (0.74) 1.88 (0.60) 0.65a (0.4 to 1.0) 0.79a (0.5 to 1.1)
FSS NDT 2.80 (0.87) 2.08 (0.82) 1.35 (0.48) 0.86a (0.4 to 1.4) 1.36a (0.7 to 2.0)
EXT 2.63 (0.84) 2.17 (0.97) 1.84 (0.87) 0.48a (0.2 to 0.8) 0.73a (0.34 to 1.1)
QuickDASHa NDT 53.04 (23.71) 25.59 (21.37) 9.20 (12.92) 33.96a (19.5 to 48.4) 44.41a (27.0 to 61.8)
EXT 52.05 (23.43) 28.46 (24.41) 21.80 (21.43) 26.14a (16.0 to 36.2) 30.06a (19.0 to 41.1)
QuickDASHb NDT 51.09 (25.40) 23.64 (20.90) 12.87 (18.02) 31.99a (14.7 to 49.2) 38.60a (18.1 to 59.1)
EXT 50.00 (28.79) 30.17 (27.60) 22.73 (24.06) 21.59a (8.2 to 35.0) 29.26a (11.2 to 47.3)

Between-group difference

Baseline 1 mo 6 mo
SSS P ¼ .05; 0.46 (0.01 to 0.9) P ¼ .53; 0.13 (.5 to 0.3) P ¼ .24; 0.24 (0.7 to 0.2)
FSS P ¼ .48; 0.17 (0.3 to 0.7) P ¼ .73;0.09 (0.6 to 0.4) P ¼ .04a; 0.49 (1.0 to 0.01)
Quick DASHa P ¼ .88; 0.99 (12.2 to 14.2) P ¼ .66; 2.87 (15.8 to 10.1) P ¼ .04a; 12.60 (24.5 to 0.7)
Quick DASHb P ¼ .89; 1.09 (14.3 to 16.4) P ¼ .35; 6.53 (20.5 to 7.4) P ¼ .17; 9.86 (24.0 to 4.3)

EXT ¼ control group; FSS ¼ Functional Status Scale; NDT ¼ the treatment group; QuickDASHa ¼ Shortened version of the Disabilities of the Arm, Shoulder and Hand (general
disabilities); Quick DASHb ¼ Shortened version of the Disabilities of the Arm, Shoulder and Hand (work-related disabilities); SSS ¼ Symptom Severity Scale.
a
Statistically significant (P < .05).
 H. Hamzeh et al. / Journal of Hand Therapy xxx (2020) 1e9 5

Fig. 2. Neurdynamics group mean change of outcome measures at 1 ¼ baseline measurement; 2 ¼ 1-mo follow up; 3 ¼ 6-mo follow up.

Significant difference in worst pain rating was found in both
groups (p < .05) at 1 and 6 months. NDT group had also significant
difference in mean pain rating at 1 and 6 months. There was a
significant between-group difference at 1 month. Full pain rating
results are presented in Table 4 and Figure 2.
Significant changes in range of motion (ROM) were found in
both groups at 1 and 6 months, especially in AROM measurements.
No significant between-group change was found in ROM mea-
surements, except for Flexion at 1 month (Table 5).
Significant improvement in grip strength was found in the
NDT group at 1 and 6 months. However, no significant between-
group difference was noticed at any time of measurement
(Table 6).
At the point of 6-month follow-up, the patients did not report
receiving any treatments other than mild analgesics such as
paracetamol or nonsteroidal anti-inflammatory drugs when
needed. When contacted, 1 year after receiving treatment, none of
the participants in this study reported that he/she received median
nerve decompression surgery.
Discussion
This randomized clinical trial found that both neurodynamics
and exercise therapy are effective in decreasing pain and improving
function in patients with CTS at both 1 and 6 months. However, the
effectiveness of neurodynamics was higher in all outcome mea-
sures. Between-group differences were higher in pain, BCTSQ, and
QuickDASH, whereas no significant between-group differences
were found in ROM and grip strength.
6 H. Hamzeh et al. / Journal of Hand Therapy xxx (2020) 1e9

Table 4
Between- and within-group differences, effect of therapy in pain rating

Outcome measure Group Baseline 1 mo 6 mo Difference at 1 mo (mean, 95% CI) Difference at 6 mo (mean, 95% CI)
Mean NPRS 0-10 NDT 4.17 (2.23) 1.22 (1.59) 1.06 (1.75) 3.18a (1.8 to 4.5) 3.18a (1.5 to 4.8)
EXT 3.17 (2.49) 2.97 (2.44) 2.09 (2.43) 0.14 (0.9 to 1.1) 0.77 (0.5 to 2.1)
Worst NPRS 0-10 NDT 7.52 (2.57) 3.17 (2.59) 2.88 (3.39) 4.76a (2.7 to 6.8) 5.00a (2.6 to 7.4)
EXT 7.07 (2.19) 5.10 (2.81) 4.82 (2.81) 2.27a (0.9 to 3.7) 2.36a (0.7 to 4.1)

Between-group differences

Baseline 1 mo 6 mo
Mean NPRS 0-10 P ¼ .14; 1.00 (0.3 to 2.3) P ¼ .005a; 1.75 (2.9 to 0.6) P ¼ .15; 1.03 (2.5 to 0.4)
Worst NPRS 0-10 P ¼ .50; 0.45 (0.9 to 1.8) P ¼ .014a; 1.93 (3.5 to 0.4) P ¼ .06; 1.94 (4.0 to 0.1)

EXT ¼ control group; NDT ¼ the treatment group; NPRS ¼ Numerical Pain Rating Scale.
a
Statistically significant (P < .05).

The neurodynamics approach used in this study combined
neurodynamics manual therapy (ie, nerve-specific mobilization)
with home exercise. To our best knowledge, this is the first time
that the impact of such treatment protocol has been investigated.
Previous studies, which identified its limited effectiveness, have
either investigated the effectiveness of neurodynamics manual
therapy11 or neurodynamics exercise12 separately.
Our findings suggest that combining neurodynamics manual
therapy along with home neurodynamics-based exercise has su-
perior outcomes. These superior outcomes could have resulted
from neurodynamics desensitization effect, which decreases pain
threshold6 combined with home exercise that improve nerve and
joints mobility.11 Exercises that specifically target median nerve
movement have been shown to increase nerve excursion without
straining it.27 Home exercises that were given to participants are
reported to mimic daily functions,20 which could have facilitated
patients' adherence and therefore led to greater functional
improvement.
With regard to the value of the treatment protocol used in this
study, a total of 4 sessions over 4 weeks combined with home
exercise proved to be effective. Studies that used smaller number of
sessions did not achieve matching outcomes.28,29 Conversely,
studies that used 35 and 630 sessions over 3 weeks had comparable
outcomes to this study. Comparable effectiveness to the present
study was also identified by Wolny and Linek14 who provided
subjects with CTS more than 20 sessions of neurodynamics manual
therapy. Therefore, our findings question the economic value of
extending management protocols to more than 6 sessions. The
following sections closely examine the main outcomes of our study.
Symptoms and functional severity
Pain is a subjective experience, and therefore, a self-reported
subjective scale is recommended for pain assessment, including
neuropathic pain.31 Several researchers have demonstrated the
presences of poor correlation between nerve conduction test and
CTS-specific questionnaires, with the evidence suggesting that
BCTSQ is the most valid, reliable, and responsive tool to use as
primary outcome measure.32-34 This enabled us to make an

Table 5
Between- and within-group differences, effect of therapy in wrist range of movement measurements

Outcome measure Group Baseline 1 mo 6 mo Difference at 1 month (mean, 95% CI) Difference at 6 months (mean, 95% CI)
PROM flexion NDT 81.57 (10.54) 86.76 (4.91) 87.24 (6.06) 5.529 (11.4 to 0.3) 6.000 (13.7 to 1.7)
EXT 86.76 (6.98) 89.64 (1.81) 88.35 (4.73) 2.864 (6.8 to 1.1) 1.500 (5.4 to 2.4)
PROM extension NDT 81.13 (9.07) 85.59 (4.93) 85.65 (5.66) 4.118 (9.3 to 1.0) 4.176 (8.4 to 0.1)
EXT 78.97 (8.95) 87.41 (5.30) 85.04 (6.91) 8.136a (12.2 to 4.1) 5.545a (10.2 to 0.9)
PROM adduction NDT 42.74 (5.88) 46.24 (4.07) 43.00 (8.02) 3.706 (8.1 to 0.7) 0.471 (7.2 to 6.3)
EXT 42.17 (5.55) 45.23 (4.41) 46.26 (5.01) 3.273a (6.3 to 0.2) 4.455a (8.2 to 0.8)
PROM abduction NDT 26.39 (5.18) 30.88 (5.48) 33.12 (4.01) 4.824a (8.7 to 1.0) 7.059a (10.7 to 3.4)
EXT 28.21 (3.81) 30.36 (3.96) 29.91 (5.92) 1.727 (4.1 to 0.7) 1.273 (4.8 to 2.3)
AROM flexion NDT 67.04 (7.49) 73.59 (8.35) 77.53 (7.97) 6.765a (11.6 to 1.9) 10.706a (17.7 to 3.7)
EXT 71.03 (8.17) 81.00 (6.72) 80.43 (8.34) 9.591a (14.9 to 4.3) 8.591a (14.2 to 3.0)
AROM extension NDT 65.87 (10.30) 73.18 (6.37) 73.71 (7.27) 5.824a (9.7 to 2.0) 6.353a (11.0 to 1.7)
EXT 61.28 (11.33) 74.00 (9.19) 70.65 (9.94) 11.909a (16.2 to 7.7) 7.727 (16.0 to 0.6)
AROM adduction NDT 36.70 (7.25) 40.76 (5.85) 37.53 (8.30) 4.353 (8.9 to 0.2) 1.118 (8.5 to 6.3)
EXT 34.55 (7.09) 39.36 (5.37) 40.74 (6.59) 4.909a (8.1 to 1.7) 6.409a (9.8 to 3.0)
AROM abduction NDT 20.83 (4.75) 26.18 (5.71) 27.53 (4.56) 5.294a (9.7 to 0.9) 6.647a (10.5 to 2.8)
EXT 24.66 (13.51) 24.09 (5.33) 25.00 (5.08) 1.909 (8.1 to 12.0) 1.000 (8.3 to 10.3)

Between-group differences

Baseline 1 mo 6 mo
PROM flexion P ¼ .038a; 5.19 (10.1 to 0.3) P ¼ .015a; 2.87 (5.2 to 0.6) P ¼ .52; 1.11 (4.6 to 2.3)
PROM extension P ¼ .39; 2.17 (2.9 to 7.2) P ¼ .28; 1.82 (5.2 to 1.5) P ¼ .77; 0.60 (3.6 to 4.8)
PROM adduction P ¼ .72; 0.57 (2.6 to 3.8) P ¼ .47; 1.01 (1.8 to 3.8) P ¼ .12; 3.26 (7.4 to 0.9)
PROM abduction P ¼ .15; 1.82 (4.3 to 0.7) P ¼ .73; 0.52 (2.5 to 3.6) P ¼ .06; 3.21 (0.2 to 6.6)
AROM flexion P ¼ .08; 3.99 (8.4 to 0.4) P ¼ .004a; 7.41 (12.3 to 2.5) P ¼ .27; 2.91 (8.2 to 2.4)
AROM extension P ¼ .14; 4.59 (1.5 to 10.7) P ¼ .75; 0.82 (6.1 to 4.5) P ¼ .29; 3.05 (2.7 to 8.8)
AROM adduction P ¼ .29; 2.14 (1.9 to 6.2) P ¼ .44; 1.40 (2.3 to 5.1) P ¼ .18; 3.21 (8.0 to 1.6)
AROM abduction P ¼ .20; 3.83 (9.8 to 2.1) P ¼ .25; 2.09 (1.5 to 5.7) P ¼ .11; 2.53 (0.6 to 5.7)

AROM ¼ active range of motion; EXT ¼ control group; NDT ¼ the treatment group; PROM ¼ passive range of motion.
a
Statistically significant (P < .05).
 H. Hamzeh et al. / Journal of Hand Therapy xxx (2020) 1e9
Table 6
Between- and within-group differences, effect of therapy in grip strength measurements
Outcome measure Group Baseline 1 mo 6 mo
Grip strength NDT 24.88 (16.59) 32.16 (13.30) 35.41 (13.30)
EXT 23.43 (17.21) 28.42 (17.15) 29.64 (18.67)
Between-group difference
Baseline
Grip strength P ¼ .76; 1.46 (8.0 to 11.0)
EXT ¼ control group; NDT ¼ the treatment group.
a
Statistically significant (P < .05).
informed decision of selecting BCTSQ as a primary outcome
measure.
Compared with baseline values, an improvement of 1.38 for SSS
and 0.78 for FSS was achieved. The minimal clinical important
difference for SSS and FSS was calculated to be 0.46 and 0.28,
respectively, using De Kleermaeker et al’s35 evidence-based
recommendations.
Therefore, our results demonstrate considerable improvement
in symptom severity and function. This improvement is closely
similar to values reported by Bialosky et al30 and better than values
reported by Fernández-de-las Penas et al5 whose intervention
protocol involved 3 sessions of neurodynamics manual therapy.
Disability of the arm, shoulder, and hand
Both groups achieved a reduction in disability score. The
reduction was more than 15.91 points, the minimum clinically
important difference, for QuickDASH.36 The improvement has
peaked at 6 months posttreatment with 44.4 and 30.06 points for
neurodynamics and exercise therapy, respectively. This improve-
ment in upper limb function is higher than values reported at 3
weeks posttreatment.30
Pain
In the study of Bialosky et al,30 worst pain improved by 4.53 at
P < .01. Marginally better results were found in worst pain in this
study at treatment completion (4.77). This improvement was even
better at 6-month follow-up (5.00). These outcomes were superior
to outcomes reported 2 studies5,26 that solely used manual therapy
for 3 weeks. This may be due to combining manual therapy and
exercise, which may lead to further decrease in joint pain.37
Grip strength
Compared with the studies by Wolny and Linek14 and Bialosky
et al,30 who did not find a significant improvement in grip strength
after 20 sessions and 6 sessions of neurodynamics manual therapy,
respectively, this study demonstrated significant improvement in
grip strength at both 1 and 6 months after using combined neu-
rodynamics manual therapy and home exercise. This may be
attributed to exercise therapy effectiveness as both groups achieved
this effect, with no significant difference between them.
Wrist mobility
Significant improvement was identified in AROM more than
PROM. This suggests that ROM limitation in individuals with CTS is
limited by symptoms rather than structural joint problems.
Decreased pain and paresthesia can effectively increase AROM after
treatment. This improved ROM was identified in both groups, with
greater improvement in exercise group in some measurements.
7
Difference at 1 mo (mean difference, 95% CI) Difference at 6 mo (mean difference, 95% CI)
11.00a (20.8 to 1.2) 14.26a (22.7 to 5.8)
6.621 (13.5 to 0.3) 6.773 (17.0 to 3.4)
1 mo 6 mo
P ¼ .46; 3.73 (6.5 to 13.9) P ¼ .28; 5.77 (5.0 to 16.5)
Such discrepancies may be attributed to the fact that exercises in
the exercise group specifically target wrist and hand joint mobility,
whereas neurodynamics exercises use a more general upper ex-
tremity exercise patterns. Tal-Akabi and Rushton38 identified im-
provements in ROM after neurodynamics mobilization similar to
our results.
Surgery
The improvement in pain and function achieved in both groups
was satisfactory, and none of the patients chose to perform
decompression surgery 1 year after recruitment. This augments the
argument of previous studies that conservative treatment must be
the first line of treatment for patients with CTS because of its effi-
cacy and cost-effectiveness.7 In addition to having a comparable
effect to surgery, conservative treatments, such as neurodynamics,
are associated with fewer appointments with health care providers,
reduced cost, and earlier return to paid work.39 Participants in this
study were not subgrouped based on the severity of symptoms;
therefore, no strong conclusion can be given regarding the rela-
tionship between severity and need for surgery based on our re-
sults. In the study of Tal-Akabi and Rushton,38 only 2 patients chose
surgery after receiving treatment.
Long-term effectiveness
Limited number of controlled studies investigated the long-
term effectiveness of neurodynamics approach. Fernández-de-las
Penas et al5 studied the effectiveness of neurodynamics vs surgery
at 1, 3, 6, and 12 months. With regard to BCTQ, they demonstrated
that neurodynamics effectiveness achieved at 1 month is main-
tained at all phases of follow-up. Similarly, Wolny and Linek17
observed that BCTQ values were maintained at 6 months. In both
studies, the neurodynamics approach included manual techniques
without structured home exercise. The addition of home exercise to
the treatment protocol used in this study led to further improve-
ments in BCTQ at 6 months in comparison to 1 month. This is
consistent with several studies that identified the positive impact
of active therapy and self-management in chronic pain condi-
tions.40-42
We found no previous studies that examined the effectiveness
of regular physiotherapy exercises such as stretching and
strengthening in improving symptoms of individuals with CTS. The
level of evidence for exercise therapy is very limited.13 Our study
results showed that exercise therapy might be an effective alter-
native to neurodynamics in case the therapist did not receive a
special training in applying neurodynamics therapy.
Loss to follow-up
Of the 51 participants randomized, 41 only completed the
follow-up, and their results were analyzed. Loss to follow-up is
8 H. Hamzeh et al. / Journal of Hand Therapy xxx (2020) 1e9
calculated as 4 (16%) in the control group and 6 (23%) in the
treatment group (Fig. 1). This loss to follow-up can be regarded as
missing completely as random, which means that the dropout was
not related to the severity of the condition or outcomes of treat-
ment43; the reasons for dropout are detailed in Figure 1. Therefore,
a complete case analysis was applied, in which dropout participants
were excluded from analysis. This resulted in reduced sample size,
but the study was completed till the predetermined sample size
was reached, so estimation of treatment effect was not affected.44
To minimize the bias that may result from different levels of
adherence to therapy, all patients were analyzed in the group they
were randomized irrespective of their level of adherence.45
Limitations
There was no true group that did not receive any treatment, as
this was not ethical given that conservative treatment is known to
be effective.. Therefore, the placebo effect was not accounted for.
This limits the comparison of neurodynamics therapy to no inter-
vention with regard to the effect of natural recovery.
This study lacked participation from people with severe CTS,
although they were not particularly excluded. The effectiveness of
neurodynamics in this subgroup of patients can be explored in
future studies. Moreover, all patients with CTS were treated equally
notwithstanding the severity of their condition. Other studies used
more homogenous groups to give more accurate recommenda-
tions.8 Follow-up at 6 months was regarded as the long-term follow
up in this study, whereas a period of 1 year or longer would be more
appropriate to measure long-term effectiveness of the treatment.
In comparison to similar studies, we believe that we managed to
decrease the Hawthorne effect46 because of the minimum follow-
up and treatment periods (3 face-to-face contacts with assessors
and 4 face-to-face contacts with treating therapist). Participants in
both groups received the same level of therapist and assessors’
contact and attention. Nonetheless, Hawthorne effect might be
present in the form of inflated effect size in the same group. This
patientetherapist relationship is an interesting point to be inves-
tigated further. Future research may compare treatment under
supervision to a home exercise intervention.
Conclusion
The application of neurodynamics-based therapy was more
effective in decreasing pain and improving function and strength
and avoiding surgery in patients with CTS. These improvements
were maintained after 6 months of therapy.
Acknowledgments
This study was funded by Deanship of Scientific Research, the
University of Jordan.
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