Journal of Hand Therapy 33 (2020) 272e280

Contents lists available at ScienceDirect

Journal of Hand Therapy

journal homepage: www.jhandtherapy.org

JHT READ FOR CREDIT ARTICLE #686.

Scientific/Clinical Article

Effective self-stretching of carpal ligament for the treatment of carpal

tunnel syndrome: A double-blinded randomized controlled study
Kazuko Shem MD 1, *, Joseph Wong MD 2, Benjamin Dirlikov MA 3
1
Department of Physical Medicine and Rehabilitation, Santa Clara Valley Medical Center, San Jose, CA, USA
2
Division of Physical Medicine and Rehabilitation, Stanford University School of Medicine, Stanford, CA, USA
3
Rehabilitation Research Center, Santa Clara Valley Medical Center, San Jose, CA, USA

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 the most common nerve entrapment syndrome worldwide.
Received 13 September 2018 There are limited studies on the effectiveness of carpal ligament stretching on symptomatic and electrophysi-
Received in revised form ologic outcomes.
13 December 2019
Purpose of the Study: The purpose of this study was to evaluate the effect of self-myofascial stretching of
Accepted 31 December 2019
the carpal ligament on symptom outcomes and nerve conduction findings in persons with CTS.
Available online 1 May 2020
Study Design: This is a prospective, double-blinded, randomized, placebo-controlled trial.
Methods: Eighty-three participants diagnosed with median mononeuropathy across the wrist by nerve
Keywords:
Carpal tunnel syndrome
conduction study were randomized 1:1 to sham treatment or self-carpal ligament stretching. Partici-
Myofascial release pants were instructed to perform the self-treatment four times a day for six weeks. Seventeen partici-
Therapy pants in the sham treatment group and 19 participants in the carpal ligament stretching group
Manual medicine completed the study. Pre- and post-treatment outcome measures included subjective complaints,
strength, nerve conduction findings, and functional scores.
Results: Groups were balanced on age, sex, hand dominance, symptom duration, length of treatment,
presence of nocturnal symptoms, and compliance with treatment. Even though the ANOVA analyses were
inconclusive about group differences, explorative post hoc analyses revealed significant improvements in
numbness (P ¼ .011, Cohen's d ¼ .53), tingling (P ¼ .007, Cohen's d ¼ .60), pinch strength (P ¼ .007, Cohen's
d ¼ .58), and symptom severity scale (P ¼ .007, Cohen's d ¼ .69) for the treatment group only.
Conclusions: The myofascial stretching of the carpal ligament showed statistically significant symptom
improvement in persons with CTS. Larger comparative studies that include other modalities such as
splinting should be performed to confirm the effectiveness of this treatment option.
Ó 2020 The Authors. Published by Elsevier Inc. on behalf of Hanley & Belfus, an imprint of Elsevier Inc.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).

Introduction pregnancy, rheumatoid arthritis, and repetitive wrist work, among

Median mononeuropathy at the wrist, also known clinically as
carpal tunnel syndrome (CTS), is caused by compression of the
median nerve as it crosses the wrist in the carpal tunnel. With a
prevalence of approximately 10%, it is the most common nerve
entrapment syndrome worldwide and accounts for up to 90% of all
nerve compression syndromes.1 Risk factors include diabetes
mellitus, hypothyroidism, advanced age, obesity, female sex,
* Corresponding author. Department of Physical Medicine and Rehabilitation,
Santa Clara Valley Medical Center, VSC Suite 110, 751 S. Bascom Avenue, San Jose,
CA 95128, USA. Tel.: þ408-885-2100; fax: þ408-885-2028.
E-mail address: kazuko.shem@hhs.sccgov.org (K. Shem).
others.2 Clinically, patients may present with hyperesthesia or
paresthesia in the sensory distribution of the median nerve in the
hand, and in severe cases, weakness in median innervated intrinsic
muscles of the hand.
Various treatment modalities have been studied including
medications, steroid injections, wrist orthotics, therapies, nerve
gliding, and surgical treatment.3-8 Burke et al3 showed that a
“neutral splinting” provided the best symptomatic relief, and
Walker et al7 demonstrated that wearing a static wrist orthosis full-
time is better than wearing one only overnight. It has been sug-
gested that the therapeutic effects of orthosis arise from decreasing
pressure in the carpal tunnel. “Nerve gliding” techniques have been
also studied, but the two review articles on this technique both

0894-1130/Ó 2020 The Authors. Published by Elsevier Inc. on behalf of Hanley & Belfus, an imprint of Elsevier Inc. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
https://doi.org/10.1016/j.jht.2019.12.002
 K. Shem et al. / Journal of Hand Therapy 33 (2020) 272e280
concluded that this technique did not show conclusive evidence to
support its efficacy.9,10
Carpal tunnel pressure has been implicated in the pathophysi-
ology of CTS.11 Various manual therapy interventions have been
studied as treatment option for CTS.12-16 Manipulative therapy in
which a practitioner would hold the patient's dorsal wrist and
manipulate with the intent to stretch the carpal ligament may
theoretically decrease the pressure in the carpal tunnel. This
manipulative maneuver, performed by a practitioner and/or by the
patient with a home self-stretching program, has been illustrated
by Sucher.12-15 In several case reports, manipulative therapy has
been documented to alleviate symptoms of CTS, such as pain,
paresthesia, and numbness.12-15 There are also several case reports
documenting improved electrophysiologic findings in the form of
decreased motor and sensory distal latencies (DLs) and increased
motor and sensory action potential amplitudes (Amp).13 Using
magnetic resonance imaging, Sucher has shown an increase in
carpal tunnel cross-sectional area after treatment with myofascial
manipulative release of the carpal ligament.12 Improvements in
symptoms and nerve conduction parameters have been demon-
strated after treatment.12
Multiple techniques have been developed for manual therapy
intervention performed under guidance from a trained clini-
cian.16,17 Burke et al16 demonstrated efficacy of “Graston
Instrument-assisted soft tissue mobilization” and manual “soft
tissue mobilization” performed by a trained manual therapy clini-
cian. More recently, Talebi et al17 reported “manual therapy” that
consisted of “carpal bone mobilization”, “transverse carpal liga-
ment release” similar to the Sucher's release, pronator teres soft
tissue manipulation, and “median nerve mobilization” to be
more effective in treatment of CTS in patients with diabetes
compared with ultrasound and transcutaneous nerve stimulation
treatment.
To our knowledge, there has only been one study on the effec-
tiveness of a self-administered manual therapy intervention, which
was described by Madenci.18 The “Madenci” massage consisted of
effleurage, friction, petrissage, and shaking that was self-performed
by patients. In addition, the patients were asked to perform a
“tendon gliding exercise” and “nerve gliding exercise” at least three
times per day. The advantages of a self-administered versus
clinician-performed therapy program are several-fold and may
include ease of access to treatment, decreased financial cost, and
increased compliance for patients. One limitation of the Madenci
study is the incorporation of three exercises (massage, tendon
gliding, and nerve gliding), which makes it unclear which exercise
may have helped the most.
The objective of this study was to investigate the efficacy of a
simple one-maneuver carpal stretching that individuals with CTS
can perform by themselves at their convenience. Using a random-
ized, double-blinded, controlled study design, we evaluated the
effectiveness of a self-carpal ligament stretching (CLS) program
versus a sham massage program in the treatment of CTS. We hy-
pothesized that patients undergoing myofascial manipulative
release of the carpal ligament would report lower pain scores,
demonstrate greater strength, and have improved nerve conduc-
tion studies when compared with the sham treatment group at 6
weeks after intervention.
Methods
Study design
A prospective, double-blinded, randomized, placebo-controlled
trial was performed to investigate the short-term efficacy of myo-
fascial stretching of the carpal ligament in alleviating symptoms
273
and improving physical function in patients with median mono-
neuropathy at the wrist. This protocol was approved by the Human
Subjects Committee at the study site, which is a county hospital in a
suburb. All participants were enrolled and completed participation
in this study from 1999 to 2010.
Potential participants were recruited from an electrodiagnostic
medicine clinic. These individuals were referred to the clinic to be
assessed for CTS based on symptoms consistent with CTS. A single
electrophysiologist performed each nerve conduction study at the
baseline and at 6 weeks after treatment and was blinded to the
control and treatment group. Participants were diagnosed with
median mononeuropathy electrodiagnostically with a Neuromax
EMG machine and using a standard protocol of the median nerve
conduction studies.19 Median sensory studies were performed an-
tidromically with stimulation site 14 cm from the recording site at
digit 2 and with distal latency (DL) measured to the peak. Median
motor studies were performed orthodromically with the recording
electrode placed at the abductor pollicis brevis and with stimula-
tion site 8 cm proximal to the recording electrode. The temperature
of each participant's forearm was maintained at greater than 32 C
by applying an electrical warmer as needed. Participants were
diagnosed with median mononeuropathy if the median sensory DL
was equal to or greater than 3.6 ms.19 Ulnar nerve conduction
studies were performed at the baseline to rule out peripheral pol-
yneuropathy. Participants were recruited from the Electro-
diagnostic Medicine Clinic by the principal investigator (KS) who
remained blinded to the group assignment for each participant
until the completion of post-treatment assessment for each
participant.
The inclusion criterion was (1) presence of median mono-
neuropathy across the wrist, diagnosed by Neuromax EMG ma-
chine using standard technique as described previously. The
exclusion criteria were (1) presence of peripheral polyneuropathy,
(2) consistent use of adaptive equipment, such as wheelchair or
cane, and (3) inability to provide informed consent in English.
Although not specifically excluded from the study, participants who
had additional neurological or musculoskeletal conditions, such as
cervical radiculopathy, upper extremity fractures, or brachial
plexus injuries did not participate in this study. Of those eligible to
enroll in the study, two participants refused enrollment indicating
their preference to try other treatment options such as orthosis.
Eligible participants were randomly assigned to undergo either
sham or CLS treatment protocols. Participants randomly selected an
envelope containing intervention allocation, which was then
shown to a study assistant who instructed the intervention as
described in the following. Allocation ratio was 1:1. Participants
remained blinded to the intervention group until completion of the
post-treatment assessment. At the post-treatment follow-up eval-
uation, technique was re-evaluated to confirm that participants
performed their respective treatments correctly. If the participant
was assigned to the sham control group, they were instructed on
the CLS technique at the post-treatment follow-up evaluation. No
changes were made to methods, including eligibility criteria, or
outcomes after trial commencement.
Interventions
Participants in the CLS treatment group were instructed to
perform self-myofascial stretching of the carpal ligament, which
was a slight modification of the myofascial stretching described by
Sucher.12-14 The modification was made to specifically enable the
participants to perform the stretch by himself/herself indepen-
dently, without physiatrist or therapist involvement. Each partici-
pant was instructed to extend his or her wrist at 90 against a wall
and to gently retract the thenar eminence with the contralateral
274 K. Shem et al. / Journal of Hand Therapy 33 (2020) 272e280

hand to stretch the carpal ligament (Fig. 1). Participants in the sham
treatment group were instructed to hold their hands perpendicu-
larly and to massage lightly down the dorsal wrist (Fig. 2). For
control, sham massage similar to stroking massage technique was
designed by the PI (KS) with the intent that the participants needed
to at least be doing a hands-on massage-like maneuver over the
wrist without substantial manipulation of soft tissue. The use of a
sham massage group allowed for a double-blinded study design
and a superior control group compared with orthosis and/or no
treatment control groups.
All participants in both groups were instructed to perform the
self-treatment for 30 seconds at a time, four times a day for six
weeks. Instruction was provided by another member of the study
personnel to maintain blindedness of the principal investigator
(KS). Participants were also provided with written instructions on
their respective self-treatment program and a calendar sheet to log
when they performed self-treatment. No work or activity re-
Fig. 2. Every participant in the placebo group was instructed to hold his/her hand up
strictions were imposed on participants in the sham or CLS treat- perpendicularly and to massage down the dorsal wrist.
ment groups. If participants sought other treatments such as
therapies, injections, or surgeries while participating in this project,
they were withdrawn from the study without any repercussions. latencies (milliseconds; ms) and amplitudes (microvolts, uV for
sensory amplitude; millivolts, mV for motor amplitudes) at the
Outcome assessment baseline and 6-week follow-up were included as outcome mea-
sures. Electrodiagnostically, decrease in the distal latencies and
Baseline data and other characteristics such as hand dominance, increase in the amplitudes constitute as improvements. The prin-
symptomatic side, duration of symptoms, and presence of cipal investigator (KS) collected all data and outcome measures
nocturnal symptoms were collected at the baseline (Table 1). A total while remaining blinded to the intervention assignment.
of 12 outcome measures were collected. Each participant was asked
to complete a questionnaire which included (1) visual analog scale Statistical analysis
(VAS) for wrist pain, hand pain, hand numbness, and hand tingling,
(2) symptom severity scale (SSS), and (3) functional states scale The data were analyzed according to the intent-to-treat prin-
(FSS). Both SSS and FSS have been validated to be reliable symp- ciple. Outcomes measured included subjective complaints (wrist
tomatic scales in patients with CTS.20 The SSS consists of 11 ques- pain, hand pain, numbness, tingling), strength (pinch and grip
tions and the FSS consists of 8 questions, with responses scored on strength), nerve conduction findings (sensory and motor distal la-
a scale of 1 to 5. Lower scores on the SSS and FSS represent no tency and amplitude), and functional scores (SSS and FSS).
symptoms or normal function, respectively. The pinch and grip One participant in the sham treatment group was missing
strengths were also measured on the affected side and calculated
by averaging three measurements; pinch strength was measured
using a standard pinch gauge (B&L Engineering) with 0.5 kg in- Table 1
crements and grip strength was measured using a Jamar Hand Demographics and clinical characteristics of sham and CLS treatment groups at
baseline
Dynamometer (5030J1) with 2 kg increments. At 6 weeks follow-
up, participants were asked to complete the same questionnaires Demographics Sham treatment CLS treatment P-value
and strength testing. Nerve conduction study of the median nerve (n ¼ 17) (n ¼ 19)

was performed also at 6-week follow-up. Sensory and motor distal Age, y
Mean  SD 48.18  7.18 50.05  9.71 .521
Range 31-64 35-66
Sex, n
Male 4 6 .722
Female 13 13
Hand dominance, n
Right 14 14 .702
Left 3 5
Symptomatic side, n
Right 2 4 .422
Left 0 2
Bilateral 15 13
Length of symptoms, years
Mean  SD 2.82  2.89 3.03  2.93 .831
Nocturnal symptoms, n
Yes 15 12 .132
No 2 7
Length of treatment, days
Mean  SD 46.12  9.66 43.11  6.01 .261
Compliance, %
Mean  SD 96.78  4.26 87.13  20.5 .161

CLS ¼ carpal ligament stretching.

Fig. 1. In the self-treatment group of myofascial release, each participant was Table 1 summarizes the means, standard deviations (SD), and counts (n) for the
instructed to extend his/her wrist at 90 degree against a wall and hold the near demographic and clinical characteristics. Superscripts represent either (1) t-test or
eminence with the contralateral hand as to stretch the carpal ligament. (2) Fisher's exact test.
 K. Shem et al. / Journal of Hand Therapy 33 (2020) 272e280 275

post-intervention SSS and FSS total scores, one participant (sham

treatment group) was missing pre-intervention pinch and grip
strength, and one participant (treatment group) was missing pre-
intervention FSS total score. Individuals with missing values were
excluded from the specific outcome measure analysis. Each
outcome measure was analyzed separately using a Group
(treatment  sham treatment)  Time (pre-  post-intervention)
repeated measure ANOVA (rmANOVA). Baseline to post-
intervention within-group effects were further explored using
post hoc t-tests. A P-value cutoff of P  .05 was used to determine
significance (Table 2). Partial eta squared values were included for
significant rmANOVA effects (group, time, and group  time
interaction) and Cohen's d was calculated for each significant post
hoc t-tests. All analyses were conducted in SPSS version 24 except
for Cohen's d and 3  2 (symptom side) Fisher's exact test that was
calculated in excel.

Results

A total of 83 participants were enrolled in the study and ran-

domized according to allocation ratio 1:1 to the sham and CLS
treatment group. Two participants withdrew from the study for
discomfort with the hand exercise, and one participant withdrew
by choosing to get a steroid injection instead. Group allotment for
these participants was unknown because they never returned for a
follow-up assessment to confirm treatment group allocation. The
remainder of participants who did not complete the 6-week
treatment course were lost to follow-up (Fig. 3). Seventeen par-
ticipants in the sham treatment group and 19 participants in the
CLS treatment group completed the study and were included in the
analysis (Table 1). Due to the presence of bilateral median nerve
conduction findings in some participants, there were 32 single
extremities examined in the sham and CLS treatment groups each.
The analysis was performed on the original assigned groups, and
there was no crossover between groups.
There was no significant difference in age (P ¼ .52) or sex
(P ¼ .72), hand dominance (P ¼ .70), symptomatic side (P ¼ .42), or
presence of nocturnal symptoms (P ¼ .13) between sham and CLS
treatment groups. The average duration of symptoms for the sham
treatment and self-treatment group was 2.82  2.89 and 3.03  2.93
years, respectively (P ¼ .83). There was no significant difference in
length of treatment (P ¼ .26) and compliance to prescribed treat-
ment (P ¼ .16) between sham and CLS treatment groups.
Of the 12 outcome measures, the exploratory post hoc analysis
revealed that the treatment group improved on 5 of 12 measures
Fig. 3. Randomization chart. Flow diagram showing study progress for the two
participate groups. CLS ¼ carpal ligament stretching.
while the sham group improved on 1 of the 12 measures. These
results are outlined in the following sections.
Wrist pain
Nineteen treatment and seventeen sham treatment participants
were included in a group (treatment  sham treatment)  time
(pre-  post-treatment) rmANOVA. No significant effects of group
(F [1,34] ¼ 2.40, P ¼ .131), time (F [1,34] ¼ .181, P ¼ .673), or
group  time interaction (F [1,34] ¼ .223, P ¼ .639) were observed.
Follow-up t-tests were performed to investigate the within-group
changes pre- and post-treatment. No significant effects of pre- to
post-treatment were observed in the CLS treatment (P ¼ .518) or
sham treatment group (P ¼ .974) (Table 2).
Hand pain
Nineteen treatment and seventeen sham treatment participants
were included in a group (treatment  sham treatment)  time

Table 2
Summary of within-group post hoc t-tests (baseline compared with follow-up) for rmANOVAs

Variable Sham treatment CLS treatment

N Baseline F/U P-value N Baseline F/U P-value

Wrist pain 17 4.19 (2.98) 4.21 (2.92) .974 19 3.01 (2.96) 2.70 (2.31) .518
Hand pain 17 3.62 (3.23) 4.20 (2.96) .280 19 3.85 (3.30) 3.09 (2.96) .134
Numbness 17 5.59 (2.86) 5.51 (2.80) .892 19 5.66 (3.41) 4.23 (3.03) .011
Tingling 17 5.24 (3.07) 5.29 (3.10) .927 19 5.65 (2.96) 4.08 (2.60) .007
Pinch (kg) 16 6.69 (1.41) 6.92 (1.50) .606 19 7.25 (2.69) 8.41 (3.07) .007
Grip (kg) 16 25.8 (7.82) 26.5 (7.58) .612 19 29.1 (8.97) 29.5 (8.82) .754
Sensory DL (ms) 17 4.95 (1.01) 4.74 (.993) .018 19 5.00 (.864) 4.94 (.889) .513
Sensory Amp (mV) 17 32.2 (19.7) 31.8 (21.1) .920 19 31.9 (20.3) 23.0 (15.5) .021
Motor DL (ms) 17 5.58 (1.27) 5.39 (1.39) .134 19 5.68 (.975) 5.65 (.919) .843
Motor Amp (mV) 17 7.09 (3.23) 7.18 (2.49) .867 19 7.60 (2.31) 7.33 (2.01) .621
SSS 16 32.3 (7.68) 29.3 (7.19) .052 19 30.8 (8.76) 27.0 (10.0) .007
FSS 16 23.3 (10.3) 23.1 (9.57) .925 18 29.3 (9.08) 26.9 (11.3) .062

CLS ¼ carpal ligament stretching; N ¼ count; F/U ¼ post-treatment follow-up; kg ¼ kilogram; DL ¼ distal latency; ms ¼ milliseconds; Amp ¼ amplitude; mV ¼ microvolts;
mV ¼ millivolts; SSS ¼ symptom severity scale; FSS ¼ functional states scale.
Baseline and follow-up (F/U) values represent the means and standard deviations (in parentheses). Bold P-values correspond to P < .05.
276 K. Shem et al. / Journal of Hand Therapy 33 (2020) 272e280

(pre-  post-treatment) rmANOVA. No significant effects of group

(F [1,34] ¼ .205, P ¼ .654), time (F [1,34] ¼ .067, P ¼ .798), or
group  time interaction (F [1,34] ¼ 3.43, P ¼ .073) were observed.
Follow-up t-tests were performed to investigate the within-group
changes before and after treatment. No significant differences
changes were observed in the CLS treatment (P ¼ .134) or sham
treatment group (P ¼ .280) (Table 2).

Numbness

Nineteen treatment and 17 sham treatment participants were

included in a group (treatment  sham treatment)  time (pre- 
post-treatment) rmANOVA. This analysis revealed no significant
effects of group (F [1,34] ¼ .418, P ¼ .522), time (F [1,34] ¼ 3.82,
P ¼ .059), or group  time interaction (F [1,34] ¼ 3.08, P ¼ .088)
were observed. Follow-up t-tests were performed to investigate the
within group changes before and after treatment. A significant
reduction in numbness was observed in the CLS treatment group
(P ¼ .011, Cohen's d ¼ .53), whereas no significant change was Fig. 5. The visual analog scale (VAS) tingling rating at the baseline and after inter-
observed in the sham treatment group (P ¼ .892) (Table 2; Fig. 4). vention for the sham and CLS treatment groups. Higher scores represent worse
tingling. The asterisk represents a significant difference P  .05. CLS ¼ carpal ligament
stretching.
Tingling

Nineteen treatment and 17 sham treatment participants were
included in a group (treatment  sham treatment)  time (pre- 
post-treatment) rmANOVA. This analysis revealed a significant
group  time interaction (F [1,34] ¼ 4.23, P ¼ .048, partial
eta2 ¼ .111); No significant effect of time (F [1,34] ¼ 3.69, P ¼ .063)
or group were observed (F [1,34] ¼ .199, P ¼ .658). Follow-up t-tests
were performed to investigate the within-group changes before
and after treatment. A significant reduction in tingling was
observed (P ¼ .007, Cohen's d ¼ .60) in the CLS treatment group,
whereas no significant change was observed in the sham treatment
group (P ¼ .927) (Table 2; Fig. 5).
significant effects of group (F [1,33] ¼ 1.93, P ¼ .174) or group  time
interaction (F [1,33] ¼ 2.46, P ¼ .126) were observed. Follow-up t-
tests were performed to investigate the within-group changes
before and after treatment. A significant increase in pinch strength
was observed in the CLS treatment group (P ¼ .007, Cohen's
d ¼ 0.58), whereas no significant change was observed in the
sham treatment group (P ¼ .606) (Table 2; Fig. 6).
Grip strength

Pinch strength Nineteen treatment and 16 sham treatment participants were

Nineteen treatment and 16 sham treatment participants were
included in a group (treatment  sham treatment)  time (pre- 
post-treatment) rmANOVA. This analysis revealed a significant ef-
fect of time (F [1,33] ¼ 5.46, P ¼ .026, partial eta2 ¼ .142). No
included in a group (treatment  sham treatment)  time (pre-
post-treatment) rmANOVA. No significant effects of group (F
[1,33] ¼ 1.41, P ¼ .244), time (F [1,33] ¼ .349, P ¼ .559), or
group  time interaction (F [1,33] ¼ .027, P ¼ .871) were observed.
Follow-up t-tests were performed to investigate the within-group
changes before and after treatment. No significant effects of pre-

Fig. 4. The visual analog scale (VAS) numbness rating at the baseline and after
intervention for the sham and CLS treatment groups. Higher scores represent worse Fig. 6. The pinch grip in kilograms (kg) at baseline and post-intervention for the Sham
numbness. The asterisk represents a significant difference P  .05. CLS ¼ carpal liga- and CLS treatment groups. The asterisk represents a significant difference P  .05. CLS ¼
ment stretching. carpal ligament stretching.
 K. Shem et al. / Journal of Hand Therapy 33 (2020) 272e280 277

to post-treatment were observed in the CLS treatment (P ¼ .754) or Cohen's d ¼ .69) but not the sham treatment group (P ¼ .052)
sham treatment group (P ¼ .612) (Table 2). (Table 2; Fig. 7).

Sensory distal latency Functional states scale

Nineteen treatment and 17 sham treatment participants were Eighteen treatment and sixteen sham treatment participants
included in a group (treatment  sham treatment)  time (pre-  were included in a group (treatment  sham treatment)  time
post-treatment) rmANOVA. This analysis revealed a significant ef- (pre-  post-treatment) rmANOVA. No significant effects of group
fect of time (F [1,34] ¼ 5.09, P ¼ .031, partial eta2 ¼ .130). No sig- (F [1,32] ¼ 2.14, P ¼ .153), time (F [1,32] ¼ 1.95, P ¼ .172), or
nificant effects of group (F [1,34] ¼ .172, P ¼ .681) or group  time group  time interaction (F [1,32] ¼ 1.58, P ¼ .217) were observed.
interaction (F [1,34] ¼ 1.82, P ¼ .187) were observed. Follow-up t- Follow-up t-tests were performed to investigate the within-group
tests were performed to investigate the within-group changes changes before and after treatment. No significant effects of pre-
before and after treatment. A significant decrease (improvement) in to post-treatment were observed in the CLS treatment (P ¼ .062) or
sensory distal latency was observed in the sham treatment group sham treatment group (P ¼ .925) (Table 2).
(P ¼ .018, Cohen's d ¼ .77) but not the CLS treatment group
(P ¼ .513) (Table 2).
Discussion
Sensory amplitude
There have been many studies published evaluating the
effectiveness of different modalities in the treatment of CTS.
Nineteen treatment and 17 sham treatment participants were
Corticosteroid injections, oral steroids, surgery, massage, wrist
included in a group (treatment  sham treatment)  time (pre- 
mobilization, and orthoses have been shown to improve symptoms
post-treatment) rmANOVA. No significant effects of group (F
of CTS.3-5,7,8,16-18,21,22 By contrast, literature reviews on median
[1,34] ¼ .611, P ¼ .440), time (F [1,34] ¼ 3.03, P ¼ .091), or
nerve gliding techniques have not conclusively shown the effec-
group  time interaction (F [1,34] ¼ 2.54, P ¼ .120) were observed.
tiveness of such techniques.9,10,18 Most manual therapies are per-
Follow-up t-tests were performed to investigate the within-group
formed by clinicians and not by the patients themselves, which
changes before and after treatment. A significant decrease in sen-
requires access to specialized care to receive treatment. Further-
sory amplitude was observed in the CLS treatment group (P ¼ .021,
more, most studies used combinations of multiple maneuvers, such
Cohen's d ¼ 0.48) but not the sham treatment group (P ¼ .920)
as transverse carpal ligament release, carpal bone mobilization, or
(Table 2).
median nerve mobilization, making it impractical for a patient gain
the sufficient training to do self-treatment.
Motor distal latency
Findings from this study suggest that a single, simple, wrist self-
stretching maneuver may improve sensation (numbness and
Nineteen treatment and seventeen sham treatment participants
tingling), strength (pinch), and overall symptom severity (SSS total
were included in a group (treatment  sham treatment)  time
score). Exploratory post hoc analysis revealed that individuals in
(pre-  post-treatment) rmANOVA. No significant effects of group
the sham group improved on one of 12 measures (sensory distal
(F [1,34] ¼ .230, P ¼ .635), time (F [1,34] ¼ 1.57, P ¼ .219), or
latency), whereas the CLS treatment group improved on five of 12
group  time interaction (F [1,34] ¼ .958, P ¼ .335) were observed.
measures (numbness, tingling, pinch strength, sensory amplitude,
Follow-up t-tests were performed to investigate the within group
and SSS). Future studies are needed to asses changes in the sensory
changes before and after treatment. No significant effects of pre- to
nerve conduction measures because a decrease in sensory ampli-
post-treatment were observed in the CLS treatment (P ¼ .843) or
tude was observed in the context of improving sensory changes of
sham treatment group (P ¼ .134) (Table 2).
numbness, tingling, and overall symptom severity.
Motor amplitudes

Nineteen treatment and seventeen sham treatment participants

were included in a group (treatment  sham treatment)  time
(pre-  post-treatment) rmANOVA. No significant effects of group
(F [1,34] ¼ .202, P ¼ .656), time (F [1,34] ¼ .049, P ¼ .827), or
group  time interaction (F [1,34] ¼ .216, P ¼ .645) were observed.
Follow-up t-tests were performed to investigate the within-group
changes before and after treatment. No significant effects of pre-
to post-treatment were observed in the CLS treatment (P ¼ .621) or
sham treatment group (P ¼ .867) (Table 2).

Symptom severity scale

Nineteen treatment and 16 sham treatment participants were

included in a group (treatment  sham treatment)  time (pre- 
post-treatment) rmANOVA. This analysis revealed a significant ef-
fect of time (F [1,33] ¼ 11.63, P ¼ .002, partial eta2 ¼ .261). No
significant effects of group (F [1,33] ¼ .494, P ¼ .487) or
group  time interaction (F [1,33] ¼ .196, P ¼ .661) were observed.
Fig. 7. The symptom severity scale (SSS) total score at the baseline and after inter-
Follow-up t-tests were performed to investigate the within-group vention for the sham and CLS treatment groups. Higher scores represent worse
changes before and after treatment. A significant improvement in symptom severity. The asterisk represents a significant difference P  .05. CLS ¼ carpal
SSS total scores was observed in the CLS treatment group (P ¼ .007, ligament stretching.
278 K. Shem et al. / Journal of Hand Therapy 33 (2020) 272e280
Previous case studies have documented the success of Sucher's
manual treatment, and it is used frequently in the field of manual
medicine for the treatment of CTS 12-15; however, there has not
been any randomized controlled study examining the effectiveness
of Sucher's manual treatment. This study used a randomized,
controlled, double-blinded design to evaluate the effectiveness of a
single maneuver, self-stretching program on symptomatic and
electrophysiologic outcomes in CTS. The CLS treatment group ma-
neuver utilized myofascial stretching of the carpal ligament, which
was modified from the Sucher's manual treatment to accommodate
for self-stretching without aid from a therapist. In theory, myo-
fascial release of the carpal ligament increases carpal tunnel cross-
sectional area and decreases pressure in the carpal tunnel, thereby
improving CTS symptoms.12 In line with other studies investigating
CTS, this study found significant improvements in overall symptom
severity. Burnham et al23 demonstrated a significant improvement
in symptoms and functional scores as measured by the Boston
Carpal Tunnel Questionnaire (BCTQ) after osteopathic manipulative
treatment once a week for six weeks. However, similar to Sucher's
studies, there was no control group and treatments were admin-
istered by a practitioner trained in osteopathic medicine. Pratelli
et al24 compared fascial manipulation with low-level laser therapy
in patients with CTS and demonstrated significant improvements in
BCTQ and VAS from pre-treatment to 10 days post-treatment. The
improvement was sustainable at 3 months after treatment. Similar
to the Burnham study, Pratelli et al's fascial manipulation was
administered by a health professional once per week over 3 weeks.
The 6-week self-treatment program used in this study circumvents
the need for specialized care and showed similar improvements in
symptom severity. SSS total score changes observed in this sample,
CLS treatment group decreased 3.8 points and sham treatment
group decreased 30 points, are above the previous published clin-
ically important change threshold of 1.04, which may represent
general symptom severity improvements in both groups25 (Fig. 7).
Individuals in the CLS treatment group also demonstrated sig-
nificant improvements in numbness (Fig. 4), tingling (Fig. 5), and
pinch strength (Fig. 6) at 6 weeks after treatment. Although these
improvements were not observed in the sham treatment group
(Table 2), only tingling showed a significant group  time inter-
action; numbness and pinch strength showed significant overall
effect of time. Interestingly, there was a statistically significant
improvement in the median sensory distal latency at 6 weeks in the
sham treatment group; however, the distal latency remained
significantly prolonged (greater than 3.6 ms) 19 and would still be
classified as median mononeuropathy at both time points.
Although we hypothesized improvements in nerve conduction
(sensory and motor distal latencies and amplitudes) and pain (wrist
and hand) in the CLS treatment group, no statistically significant
improvements were observed. More studies should be conducted
to understand the durability of changes and long-term conse-
quences of the CLS treatment.
This study was limited by a high dropout rate resulting in a
relatively small sample size. We surmise that the high dropout rate
may be due to several factors, including frequency of treatments
and difficulty adhering to regimen, lack of response to prescribed
treatment, or desire to seek more invasive treatments such as in-
jection or surgical release. Some participants that dropped out of
the study reported that it was not secondary to discomfort from the
treatment nor an increase in pain. In those participants who
completed the study, the compliance rate was relatively high in
both groups (97% in the sham group and 87% in the CLS treatment
group). No significant demographic differences were observed,
including dropout rates, between groups. This may represent that
the study sample included particularly motivated individuals.
Follow-up studies should include potential confounding factors
such as nonsteroidal anti-inflammatory medication and orthosis
usage, which were not controlled for in this study. Previous studies
have not shown nonsteroidal anti-inflammatory medication as an
effective treatment for CTS.26
Based on this double-blinded randomized study, it can be sug-
gested that patients may improve symptoms of CTS using a tar-
geted self-treatment with myofascial manipulation whereas
patients treated with a sham self-treatment of massage did not.
This may delay more invasive treatments, such as injections or
surgical release of the carpal ligament. However, there was no
significant change in nerve conduction studies after 6 weeks of self-
administered myofascial stretching program. Long-term follow-up
to monitor electrodiagnostic changes and symptoms is needed.
Conclusion
This study is the first double-blinded, randomized control study
to evaluate the effectiveness of myofascial self-stretching treatment
of CTS. The results suggest that a self-myofascial stretching of carpal
ligament can be a conservative and relatively easy treatment option
for patients with CTS. Individuals in the CLS treatment group
showed improvements across multiple measures (numbness,
tingling, pinch strength, sensory amplitude, and SSS), whereas the
sham treatment group only showed improvements in sensory
distal latency. Manual manipulation provided through a trained
health care professional may be more expensive, time-consuming,
and less convenient for a patient than self-treatment administered
at home. Larger studies with longer follow-up and comparative
studies with other modalities such as therapies and orthosis may be
performed to definitively confirm the effectiveness of this treat-
ment option.
Acknowledgments
The authors would like to acknowledge Michael Prutton,
research assistant, for his assistance with the manuscript
preparation.
This was not a funded study.
References
1. Padua L, Coraci D, Erra C, et al. Carpal tunnel syndrome: clinical features,
diagnosis, and management. Lancet Neurol. 2016;15(12):1273e1284.
2. Rempel DM, Diao E. Entrapment neuropathies: pathophysiology and patho-
genesis. J Electromyogr Kinesiol. 2004;14:71e75.
3. Burke DT, Burke MM, Stewart GW, Cambré A. Splinting for carpal tunnel
syndrome: in search of the optimal angle. Arch Phys Med Rehabil. 1994;7511:
1241e1244.
4. Finestone HM, Woodbury GM, Collavini T, Marchuk Y, Maryniak O. Severe
carpal tunnel syndrome: clinical and electrodiagnostic outcome of surgical and
conservative treatment. Muscle Nerve. 1996;19:237e239.
5. Gelberman RH, Aronson D, Weisman MH. Carpal-tunnel syndrome. Results of a
prospective trial of steroid injection and splinting. J Bone Joint Surg. 1980;62:
1181e1184.
6. Irwin LR, Beckett R, Suman RK. Steroid injection for carpal tunnel syndrome.
J Hand Surg Scotl. 1996;21:355e357.
7. Walker WC, Metzler M, Cifu DX, Swartz Z. Neutral wrist splinting in carpal
tunnel syndrome: a comparison of night-only versus full-time wear in-
structions. Arch Phys Med Rehabil. 2000;81:424e429.
8. Celik B, Paker N, Celik EC, Bugdayci DS, Ones K, Ince N. The effects of orthotic
intervention on nerve conduction and functional outcome in carpal tunnel
syndrome: a prospective follow-up study. J Hand Ther. 2015;28(1):34e37.
9. Lim YH, Chee DY, Girdler S, Lee HC. Median nerve mobilization techniques in
the treatment of carpal tunnel syndrome: a systematic review. J Hand Ther.
2017;30(4):397e406.
10. Medina McKeon JM, Yancosek KE. Neural gliding techniques for the treatment
of carpal tunnel syndrome: a systematic review. J Sport Rehabil. 2008;17(3):
324e341.
11. Ibrahim I, Khan WS, Goddard N, Smitham P. Carpal tunnel syndrome: a review
of the recent literature. Open Orthop J. 2012;6:69e76.
 K. Shem et al. / Journal of Hand Therapy 33 (2020) 272e280
12. Sucher BM. Myofascial manipulative release of carpal tunnel syndrome:
documentation with magnetic resonance imaging. J Am Osteopath Assoc.
1993;93:1273e1278.
13. Sucher BM. Myofascial release of carpal tunnel syndrome. J Am Osteopath Assoc.
1993;93(92e94):100e101.
14. Sucher BM. Palpatory diagnosis and manipulative management of carpal tun-
nel syndrome. J Am Osteopath Assoc. 1994;94:647e663.
15. Sucher BM, Hinrichs RN. Manipulative treatment of carpal tunnel syndrome:
biomechanical and osteopathic intervention to increase the length of the
transverse carpal ligament. J Am Osteopath Assoc. 1998;98:679e686.
16. Burke J, Buchberger DJ, Carey-Loghmani MT, Dougherty PE, Greco DS,
Dishman JD. A pilot study comparing two manual therapy interventions for
carpal tunnel syndrome. J Manipulative Physiol Ther. 2007;30(1):50e61.
17. Talebi GA, Saadat P, Javadian Y, Taghipour M. Manual therapy in the treatment
of carpal tunnel syndrome in diabetic patients: a randomized clinical trial.
Caspian J Intern Med. 2018;9(3):283e289.
18. Madenci E, Altindag O, Koca I, Yilmaz M, Gur A. Reliability and efficacy of the
new massage technique on the treatment in the patients with carpal tunnel
syndrome. Rheumatol Int. 2012;32(10):3171e3179.
19. American Association of Electrodiagnostic Medicine, American Academy of
Neurology, and American Academy of Physical Medicine and Rehabilitation.
279
Practice parameter for electrodiagnostic studies in carpal tunnel syndrome:
summary statement. Muscle Nerve. 2002;25(6):918e922.
20. Khosrawi S, Dehghan F. Determination of the median nerve residual latency
values in the diagnosis of carpal tunnel syndrome in comparison with other
electrodiagnostic parameters. J Res Med Sci. 2013;18:934e938.
21. Herskovitz S, Berger AR, Lipton RB. Low-dose, short-term oral prednisone in
the treatment of carpal tunnel syndrome. Neurology. 1995;45:1923e1925.
22. Wolny T, Saulicz E, Linek P, Mysliwiec A, Saulicz M. Effect of manual therapy
and neurodynamic techniques vs ultrasound and laser on 2PD in patients with
CTS: a randomized controlled trial. J Hand Ther. 2016;29(3):235e245.
23. Burnham T, Higgins DC, Burnham RS, Heath DM. Effectiveness of osteopathic
manipulative treatment for carpal tunnel syndrome: a pilot project. J Am
Osteopath Assoc. 2015;115:138e148.
24. Pratelli E, Pintucci M, Cultrera P, et al. Conservative treatment of carpal tunnel
syndrome: comparison between laser therapy and Fascial Manipulation(Ò).
J Bodyw Mov Ther. 2015;9:113e118.
25. Ozyürekog lu T, McCabe SJ, Goldsmith LJ, LaJoie AS. The minimal clinically
important difference of the carpal tunnel syndrome symptom severity scale.
J Hand Surg Am. 2006;31(5):733e738. discussion 739-40.
26. Chang MH, Chiang HT, Lee SS, Ger LP, Lo YK. Oral drug of choice in carpal
tunnel syndrome. Neurology. 1998;51:390e393.
280 K. Shem et al. / Journal of Hand Therapy 33 (2020) 272e280

JHT Read for Credit

Quiz: # 686

Record your answers on the Return Answer Form found on the c. a pseudo trigger point method
tear-out coupon at the back of this issue or to complete online d. performed by the subject’s partner
and use a credit card, go to JHTReadforCredit.com. There is # 4. The self-stretching dose was
only one best answer for each question. a. BID for 2 minutes
b. QID for 30 seconds
# 1. The study design was c. TID for 60 seconds
a. case series d. once a day for 10 minutes
b. qualitative # 5. The results did not support self-stretching for CTS
c. retrospective cohort a. true
d. RCTs b. false
# 2. The inclusionary criterion was
a. positive Phalens test When submitting to the HTCC for re-certification, please batch your
b. positive Mills test JHT RFC certificates in groups of 3 or more to get full credit.
c. positive nerve conduction
d. positive needle EMG
# 3. The sham technique was
a. a form of massage
b. performed with rubber bands