Managing Carpal Tunnel Syndrome using Neurodynamics: A Narrative Review
Correspondence Address :
Dr. Saumya Srivastava,
Associate Professor, Department of Physiotherapy, Nitte Institute of Physiotherapy, NITTE (Deemed to be University), Mangaluru-575018, Karnataka, India.
E-mail: saumyasri2000@nitte.edu.in
Carpal Tunnel Syndrome (CTS) is one of the preeminent types of peripheral neuropathies of the upper limb, where the median nerve is injured in the carpal tunnel, leading to a cascade of symptoms. CTS can cause pain, substantial motor function and sensory impairment, and a weakened ability to perform skilled work. Utilising the Neurodynamic Technique (NDT), a hands-on manual therapy approach can effectively address CTS. This technique focuses on manipulating neural tissues and the adjacent non-neural structures related to the nervous system, to alter pain physiology. The current narrative review aimed to ascertain the effectiveness of NDT in the management of CTS so that it can guide the practitioners in effectively managing and understanding CTS and also help in adding the literature to the existing evidence. The review evaluated outcome measures such as pain intensity, motor issues, physical function, and nerve conduction investigations. The review was done to demonstrate that NDT can offer significant therapeutic advantages and can serve as a practical approach to managing CTS.
Flexor tendon gliding, Manual therapy, Sensation, Sliding, Tensioning
Carpal Tunnel Syndrome (CTS) is the most prevalent form of entrapment neuropathy, affecting approximately 99 out of every 100,000 individuals in the general population (1). Its frequency varies between 7% and 19% globally, with those over 40 years being more susceptible than younger people, particularly women, who account for 65-75% of cases (1). About one in five individuals reporting symptoms like hand pain, numbness, and tingling could potentially be suffering from CTS, as indicated by examinations and nerve conduction studies (2). The increasing incidence of CTS has resulted in a surge of workers’ compensation claims due to work absence, limitations in daily activities, and disability, all of which can significantly deteriorate the quality of life (3),(4). It has been demonstrated that CTS negatively affects one’s Overall Health Status (OHS) (5).
Early diagnosis and treatment are crucial, as untreated CTS can lead to irreversible nerve damage and a worsened quality of life. Thus, finding optimal treatment approaches is essential to improve the lives of those affected by CTS (6). Research indicates that initial treatment often involves non operative interventions, with various treatment techniques available for mild to moderate CTS (7). Incorporating methods such as splinting and manual therapy approaches including NDT, wrist distraction, and transverse carpal ligament stretching (8),(9), along with electrotherapy modalities like ultrasound and laser therapy are common in addressing CTS (4). Neurodynamic Technique (NDT) is a manual therapy technique that helps to reinstate balance within the nervous system and its adjacent structures by mobilising either the nervous system itself or the surrounding anatomical components (10). The main objective of conducting this review is to thoroughly examine existing literature, collecting evidence regarding the effectiveness of NDT in the conservative management of CTS, encompassing various outcome measures such as improved function, pain relief, enhanced flexibility, nerve conduction, functional status, and symptom severity.
Carpal Tunnel Structure
The median nerve and hand flexor tendons are present in the carpal tunnel, which is located between the trapezium, trapezoid, capitate, and hamate carpal bones of the wrist, which constitute the floor, and the transverse carpal ligament, which forms the ceiling (11).
It is essential for the motor and sensory processes in the thumb and finger (11). Compression or enlargement of tendons within the tunnel can lead to CTS, manifesting as disrupted sensations in the digits due to median nerve pressure (12),(13). A diagram of carpal tunnel is shown below (Table/Fig 1).
Cascade of Events Following Median Nerve Compression
Compression of the median nerve in the wrist hinders blood flow, triggering a cascade of events including inflammation, oedema, intra-neural fibrosis, and ultimately demyelination (7). This process culminates in the thickening of connective tissue both around and within the nerve, reducing its flexibility and impairing its mobility. Consequently, this can lead to dynamic compression during movements of the wrist or fingers (7). In cases of median nerve compression within the wrist, the initial consequence is impaired nerve perfusion, primarily resulting in nerve oedema. If the condition advances, this oedema has the potential to progress to fibrosis (8). Notably, this oedema primarily manifests in the form of nerve swelling, particularly at the carpal tunnel inlet and in the vicinity of the proximal carpal tunnel (14).
Risk Factors and Causes of CTS
The most frequent occupational risk factors for CTS are repetitive wrist and finger movements or holding uncomfortable wrist positions for extended periods (8). In the fingers, a thickened transverse carpal ligament, a distal radial fracture or dislocation, lipoma, diabetes, hyperthyroidism, rheumatoid arthritis, and pregnancy can be considered as some more risk factors for CTS (15),(16). CTS typically has an idiopathic cause, however, trauma, metabolic disorders, infections, neuropathies, and others are considered as secondary causes for CTS (17),(18),(19),(20). Flexor tenosynovitis is another non occupational cause of patients with CTS (8).
Signs and Symptoms of CTS
Pain, abnormalities of multiple senses, and reduction in hand functions are some of the well-known symptoms in CTS patients (21). Additionally, relevant manifestations include burning, numbness, and tingling in the ventral aspect of the hands, particularly after work or at night (20). A 50% to 70% of patients report having noticeable nocturnal symptoms (21).
Individuals often wake up during the night or in the early hours of the morning and resort to shaking their hands as a means to alleviate these symptoms (21). These symptoms may only affect the thumb and the first two or three fingers, or they may be reported to affect the entire hand in extreme cases (21). Paired with a reduction in blood supply to the median nerve, increasing nerve stress may worsen symptoms and further reduce circulation (10). Further, the OHS is affected in patients diagnosed with CTS (5).
Treatment Techniques for the Management of CTS
A myriad of treatment options are available for the conservative management of CTS, which include bracing or splinting, electrotherapy modalities, and manual therapy (4). Among manual therapy, NDT is a widely studied and utilised technique for managing patients with CTS (22). Various treatment techniques for CTS are shown below (Table/Fig 2) (4),(7),(8),(23),(24),(25).
NEURODYNAMIC TECHNIQUE (NDT)
What is NDT?
Shacklock M was the initial proponent to elucidate the concept of NDT. Neurodynamics is the study of the physiological and mechanical interactions between the musculoskeletal system, neural system, and one another (26). This approach is designed to reinstate balance within and adjacent to the nervous system, achieved by mobilising either the nervous system itself or the encompassing structures (10). The neural mobilisation enables movement between neural components and their neighbouring interface (10).
The three-part system is chosen for its precision and its role in establishing a systematic framework for the application of neurodynamics (27). The three-part system (mechanical interface, neural structures, and innervated tissues) classifies body tissues based on their relationship to the nervous system (27). Furthermore, this perspective enables the categorisation of neural dynamics according to pertinent components, aiding in the derivation of diagnosis and treatment from causal mechanisms (27).
Role of NDT in Rectifying Altered Neurodynamics in Patients with CTS
Utilising neural mobilisation and tendon gliding exercises in the treatment of unfavourable neurodynamics in a patient with CTS, aims primarily to re-establish a dynamic equilibrium between the movement of neural tissues and their adjacent mechanical interfaces (28). This restoration, in turn, enables decreased inherent pressures on neural tissue, thereby enhancing optimal physiological functioning (28). The anticipated advantages of employing such techniques encompass aiding nerve gliding, improving neural vascularity, dispersing harmful fluids, diminishing nerve adhesions, and optimising axoplasmic flow in patients with CTS (28).
Impact of NDT on CTS
Reverse heightened immune responses after nerve injury NDT has a significant impact, as it can reduce intraneural oedema, enhance the dispersion of intraneural fluid, alleviate thermal and mechanical hyperalgesia, and reverse heightened immune responses following nerve injuries (10). It stimulates inherent pain-relieving neural pathways and makes it less sensitive to mechanical pressure through adjustment and gradual acclimatisation (7).
Treatment Techniques in NDT- Neural Gliding and Neural Tensioning
The execution of neural mobilisation can involve either employing a stretching technique (tensioning) to promote movement or optimising the sliding of peripheral nerves in relation to neighbouring structures (gliding) (29). The treatment techniques falling within the scope of NDT are illustrated below (Table/Fig 3) (27),(30).
REVIEW OF LITERATURE
The present review encompasses a comprehensive analysis of various studies as presented in (Table/Fig 4) and investigates the efficacy of NDT in the management of CTS (5),(8),(9),(22),(31),(32),(33),(34),(35),(36),(37). The reviewed studies collectively shed light on the potential benefits of manual therapy, specifically NDT, as a conservative management for alleviating pain, improving functional status, enhancing nerve conduction, and addressing other symptoms associated with CTS.
To conclude, the accumulated evidence from these studies provides strong support for incorporating NDT as a valuable therapeutic strategy in CTS management. As a manual therapy intervention, NDT exhibits promise in pain alleviation, improved nerve conduction, enhanced hand sensation, and overall functional enhancement. Nevertheless, further investigation is warranted to pinpoint practical NDT approaches for diverse CTS patient profiles and establish optimal treatment protocols. The findings contribute significantly to the growing evidence base endorsing NDT’s effectiveness in CTS management, carrying meaningful implications for enhancing the quality of life for individuals grappling with this condition. The technique can thus be incorporated as a standalone method of management by the practitioners with confidence in patients with CTS.
The authors express their gratitude to Prof. Dr. Dhanesh Kumar KU and the University for granting the opportunity to conduct the study.
DOI: 10.7860/JCDR/2023/64196.18734
Date of Submission: Mar 22, 2023
Date of Peer Review: Jul 07, 2023
Date of Acceptance: Sep 28, 2023
Date of Publishing: Nov 01, 2023
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? NA
• For any images presented appropriate consent has been obtained from the subjects. NA
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Mar 27, 2023
• Manual Googling: Aug 16, 2023
• iThenticate Software: Sep 26, 2023 (8%)
ETYMOLOGY: Author Origin
EMENDATIONS: 8
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