805213

research-article2018
CRE0010.1177/0269215518805213Clinical RehabilitationWolny and Linek

CLINICAL
Original Article REHABILITATION

Clinical Rehabilitation

Is manual therapy based on 1­–10

© The Author(s) 2018
Article reuse guidelines:
neurodynamic techniques sagepub.com/journals-permissions
DOI: 10.1177/0269215518805213
https://doi.org/10.1177/0269215518805213

effective in the treatment of journals.sagepub.com/home/cre

carpal tunnel syndrome? A

randomized controlled trial

Tomasz Wolny and Pawel Linek

Abstract
Objective: The aim of this study was to evaluate the efficacy of manual therapy based on neurodynamic
techniques in conservative treatment of carpal tunnel syndrome.
Design: Randomized controlled trial.
Setting: Several medical outpatient clinics in the south of Poland.
Participants: The study included 103 patients with mild and moderate carpal tunnel syndrome
(mean age = 53.95, SD = 9.5) years, who were randomly assigned to a neurodynamic techniques group
(experimental group, n = 58) or a group without treatment (control group, n = 45).
Intervention: Neurodynamic techniques were used in the experimental group. Treatment was conducted
twice weekly (20 sessions). Control group did not receive treatment.
Main measures: Nerve conduction study, pain, symptom severity and functional status of Boston
Carpal Tunnel Questionnaire, and strength of cylindrical and pincer grips were assessed at baseline and
immediately after treatment (nerve conduction study one month after treatment).
Results: Baseline assessment revealed no group differences in any assessed parameters (P > 0.05). There
were significant differences between groups after treatment, including nerve conduction (e.g. sensory
conduction velocity: experimental group: 38.3 m/s, SD = 11.1 vs control group: 25.9 m/s, SD = 7.72,
P < 0.01). Significant changes also occurred in pain (experimental group: 1.38, SD = 1.01 vs control group:
5.46, SD = 1.05, P < 0.01), symptom severity (experimental group: 1.08, SD = 0.46 vs control group: 2.87,
SD = 0.68, P < 0.01), and functional status (experimental group: 1.96, SD = 0.64 vs control group: 2.87,
SD = 1.12, P < 0.01). There were no group differences in strength (P > 0.05).
Conclusion: The use of neurodynamic techniques in conservative treatment for mild to moderate forms
of carpal tunnel syndrome has significant therapeutic benefits.

Keywords
Carpal tunnel syndrome, manual therapy, physical therapy

Received: 19 April 2018; accepted: 15 September 2018

Corresponding author:
Department of Kinesiotherapy and Special Methods in
Pawel Linek, Department of Kinesiotherapy and Special
Physiotherapy, The Jerzy Kukuczka Academy of Physical
Methods in Physiotherapy, The Jerzy Kukuczka Academy
Education in Katowice, Katowice, Poland
of Physical Education in Katowice, Mikolowska 72B, 40-065
Katowice, Poland.
Email: linek.fizjoterapia@vp.pl
2 Clinical Rehabilitation 00(0)
Introduction
Carpal tunnel syndrome is the most common
peripheral mononeuropathy, characterized by local
sensory and motor disorders.1,2 A multitude of
symptoms lead to impairment of the manual func-
tional capacity, deterioration of overall health, and
coupled with a high incidence,3 has serious social
and economic consequences. Therefore, it is
important to research effective and inexpensive
treatments for this condition.4
Treatment of carpal tunnel syndrome includes a
surgical approach, as well as conservative treat-
ment, but the scientific evidence on the effective-
ness of various methods is contradictory.1
Advocates of surgical treatment emphasize its high
clinical and economic efficacy.5 Proponents of
conservative treatment emphasize the high level of
safety, beneficial effects, and low costs associated
with these approaches.6,7 Some authors have stated
that conservative treatment should be used as the
first type of therapy.4,8 At the same time, a large
proportion of carpal tunnel syndrome patients
(about 61%) try to avoid surgical treatment and
seek other therapies.9 Therefore, research is needed
to determine the best therapeutic agents for con-
servative treatment of carpal tunnel syndrome.
Neurodynamic techniques are frequently used
in conservative treatment of carpal tunnel syn-
drome,4,10 but their efficacy has not been fully
proven.11–13 Discussions of carpal tunnel syndrome
often refer ‘entrapment syndrome’, which implies
a problem with the nerve’s free slide against the
surrounding tissues. In the latest systematic review,
five of the six studies indicated limited longitudinal
excursion, and four studies indicated transverse
excursion of the median nerve.14 Therefore, it
seems reasonable to use neurodynamic techniques
in conservative treatment of carpal tunnel syn-
drome, which can restore the dynamic balance
between the relative motion of the nerve and sur-
rounding tissues, improving sliding of the median
nerve. This, in turn, may improve the neurophysi-
ological functions of the median nerve15 and reduce
the symptoms of the patients.
Most studies evaluating the efficacy of neurody-
namic techniques in the treatment of carpal tunnel
syndrome include different methodologies of ther-
apeutic intervention, rendering it difficult to draw
definitive conclusions.11–13 In some of these works,
neurodynamic techniques were used as a pro-
gramme of autotherapy; in others, they were
administered by a therapist or were only a single
component of a comprehensive therapeutic pro-
gramme. Large methodological discrepancies in
these studies have inhibited a clear assessment of
the efficacy of neurodynamic techniques. To date,
only three studies have evaluated the efficacy of
neurodynamic techniques used as the sole thera-
peutic agent in treatment of carpal tunnel syndrome
patients.16–18 In each of these studies, a positive
therapeutic effect was obtained. However, the stud-
ies were conducted on small groups of patients,
and the description of therapeutic techniques was
not clear. Currently, there are no reasonable large-
scale trials assessing the effectiveness of neurody-
namic techniques in the treatment of carpal tunnel
syndrome. Therefore, we performed studies assess-
ing the effectiveness of neurodynamic techniques
on large groups of patients and with a thoroughly
described methodology of the treatment applied.
The purpose of this study was to evaluate the effi-
cacy of neurodynamic techniques as the sole thera-
peutic agent in the conservative treatment of mild
and moderate forms of carpal tunnel syndrome.
Methods
The study was authorized by the Bioethics Com­
mittee for Scientific Studies at the Academy of
Physical Education in Katowice on 08 March 2012
(Decision No. 7/2012), annexed on 28 February
2017 (No. KB/6/17). All study procedures were per-
formed according to the Declaration of Helsinki of
1975 regarding human rights, modified in 1983. The
clinical trial was registered at Australian New
Zealand Clinical Trials Registry (ANZCTR), num-
ber ACTRN12617000672358. The trial was started
on 10 May 2017, and the final data were collected
on 13 April 2018.
This was a randomized, parallel-group clinical
trial performed in several medical outpatient clinics
in the Silesia province in Poland in 2017/2018. Each
consecutive patient with carpal tunnel syndrome
Wolny and Linek 3
was examined in terms of eligibility criteria. Only
persons diagnosed by a physician as having mild or
moderate carpal tunnel syndrome were qualified
for further study. Qualification for mild and moder-
ate forms of carpal tunnel syndrome was based
on the Historical-Objective scale.19,20 Participants
were randomly allocated to two groups: experi-
mental group, in which neurodynamic techniques
were applied, and control group, in which no treat-
ment was used. If the patient had bilateral carpal
tunnel syndrome, both hands were evaluated and
treated. The experimental group received 20 treat-
ments twice weekly for 10 weeks; during the same
time period, the control group had no treatment. All
patients were informed about what the study would
involve and told that they could withdraw at any
stage without giving a reason. Written informed
consent was obtained from all participants.
The carpal tunnel syndrome diagnosis was
made by a physician on the basis of data collected
from the interview, nerve conduction study, and
clinical examinations. The nerve conduction study
was performed in an independent electroneurogra-
phy laboratory. Only participants who had dimin-
ished nerve conduction velocity (<50 m/s) and/or
increased motor latency (>4 m/s) based on the
nerve conduction study were included. The clinical
diagnosis of carpal tunnel syndrome was based on
the criteria that Chang et al.21 proposed:
1. Numbness and tingling in the area of the median
nerve;
2. Night-time paraesthesia;
3. Positive Phalen’s test;
4. Positive Tinel’s sign;
5. Pain in the wrist area radiating to the shoulder.
According to these criteria, the diagnosis of carpal
tunnel syndrome was based on the presence of two
or more symptoms.21
The exclusion criteria were as follows: lack of
consent; lack of cooperation from the patient; pre-
vious surgical, conservative, or pharmacological
therapy; cervical radiculopathy; diabetes; rheuma-
toid diseases; pregnancy; past trauma to the wrist;
and muscular atrophy of the thenar eminence.
Each patient who met the diagnostic criteria was
included for further study. Carpal tunnel syndrome
patients were randomly allocated to the groups:
experimental group (neurodynamic techniques) or
control group (no treatment). The allocation was
made before the data collection began using a ran-
dom number generator computer programme.
Those who were randomly assigned ‘1’ were
placed in the experimental group, and those who
were randomly assigned ‘2’ were placed in the con-
trol group. Group assignments were sealed in
opaque envelopes. Randomization and allocation
were performed by two research assistants who
were not otherwise involved in the trial.
The necessary sample size was calculated based
on preliminary results from 10 participants. To
determine the sample size, we used the following
variables: pain and symptom severity and func-
tional status of Boston Carpal Tunnel Questionnaire.
Pain had the highest value. Calculation of sample
size was based on an alpha of 0.05 and a statistical
power of 0.8. Based on this calculation, we aimed
to recruit about 50 patients for each treatment
group.
The nerve conduction study was performed in
an independent laboratory as a standard proce-
dure, and staff were not informed about the con-
ducted experiment. The physician who diagnosed
carpal tunnel syndrome did not know to which
group patients were placed. Then, patients were
examined by four physiotherapists who performed
physical examinations and watched as patients
filled out the relevant questionnaires: Boston
Carpal Tunnel Questionnaire and Numerical Pain
Rating Scale. They were also blinded to the group
allocations. The physiotherapy procedures in the
experimental group were performed by other eight
physiotherapists. All investigators had more than
10 years of experience with carpal tunnel syn-
drome patients. After therapy, patients were re-
examined by the physiotherapist who had
conducted their initial examination. Nerve con-
duction was reassessed in the same electroneurog-
raphy laboratory, at the same site. The same
procedures and record forms were used during the
baseline and final examinations.
4 Clinical Rehabilitation 00(0)
Primary outcome measures were as follows:
1. Nerve Conduction Study;
2. Numerical Pain Rating Scale;
3. Boston Carpal Tunnel Questionnaire.
Secondary outcome measure was as follows:
1. Strength of cylindrical and pincer grips.
Median nerve conduction study was performed
in an electroneurography laboratory by experi-
enced personnel by order of the physician. Neuro-
Mep electrodiagnostic equipment was used to
perform the examinations, using an antidromic
method with superficial electrodes. The following
values were accepted as normal, as recommended
by the laboratory reference guideline in which the
studies were performed: sensory conduction veloc-
ity ⩾50 m/s, motor conduction velocity ⩾50 m/s,
and distal motor latency ⩽4.0 m/s. The nerve con-
duction study was performed at baseline and one
month after treatment.
Pain assessment was done with Numerical Pain
Rating Scale (0 = no pain, 10 = maximum pain).22
For pain assessment, patients were asked to high-
light the strongest pain from the previous week.
The pain in each hand was evaluated separately in
patients with bilateral carpal tunnel syndrome. Pain
was assessed at baseline and immediately after
treatment.
To assess symptom severity and physical capac-
ity, the Boston Carpal Tunnel Questionnaire was
used.23 Patients with bilateral carpal tunnel syn-
drome completed a separate Boston Carpal Tunnel
Questionnaire for each hand. All patients com-
pleted a Boston Carpal Tunnel Questionnaire at
baseline and immediately after treatment.
The strength of the cylindrical and pincer grips
were measured using Jamar dynamometers.24
Strength was measured in kilogrammes (kg). If
carpal tunnel syndrome was bilateral, the strength
was measured separately for each hand. The
strength was assessed at baseline and immediately
after treatment.
Physiotherapy for the experimental group was
based on neurodynamic techniques directed at the
median nerve. Both sliding and tensioning tech-
niques were used. All techniques were performed
in a supine position. The neurodynamic sequence
was as follows: (1) initial position; (2) arm abduc-
tion to 90°; (3) arm external rotation; (4) wrist and
fingers extension; (5) forearm supination; and (6)
elbow extension (Supplementary Figure S1). In
this sequence, sliding and tensioning techniques
were performed in the proximal and distal direc-
tions: (1) one-direction proximal sliding mobiliza-
tion (movement – elbow extension – large
amplitude of motion) (Supplementary Figure S2);
(2) one-direction distal sliding mobilization (move-
ment – wrist extension – large amplitude of motion)
(Supplementary Figure S3); (3) one-direction
proximal tensioning mobilization (movement –
elbow extension – small amplitude of motion at the
end of the movement) (Supplementary Figure S4);
and (4) one-direction distal tensioning mobiliza-
tion (movement – wrist extension – small ampli-
tude of motion at the end of the movement)
(Supplementary Figure S5). The standard protocol
consisted three series of 60 repetitions of sliding
and tensioning neurodynamic techniques separated
by inter-series intervals of 15 seconds, twice a
week for 20 sessions. The therapy was performed
by physiotherapists with more than 10 years of
experience in neurodynamic techniques. The
approximate duration of each session was 20 min-
utes. There was no pain during the therapy. The
study participants had no other therapy apart from
neurodynamic techniques. No treatment was per-
formed in the control group. The follow-up period
was the same as the experimental group.
Statistical analysis
Data were analysed using the Statistica 13.1 soft-
ware package. The basic parameters were com-
pared between groups using the independent t-test
(age, body mass, height, and body mass index –
kilogrammes per square metre) and the chi-square
test (gender distribution, side of hand dominance,
side of asymptomatic and symptomatic hand, and
the number of affected carpal tunnel syndrome
hands – one hand or both hands). A one-way
analysis of variance (ANOVA) for repeated
Wolny and Linek 5
measurements was used to evaluate the main effects
in nerve conduction study, pain, symptom severity,
functional status, and strength between groups. For
between-group differences, Tukey’s post hoc test
was used. Significant results are presented as the
mean difference and 95% confidence interval (CI).
For all analyses, the threshold of the P-value con-
sidered as significant was set at <0.05.
Results
In total, 158 subjects were considered for inclusion
in the study. Of these 158 subjects, 36 were
excluded because they did not meet the inclusion
criteria or declined to participate. The remaining
group of participants were randomly allocated to
experimental or control groups. The whole proto-
col accomplished with completed data from 103
participants (Figure 1). Thus, the final analysis
involved 103 participants (58 in experimental and
45 in control group). At baseline, the groups were
similar with regards to sex, age, body mass, body
mass index, symptomatic/asymptomatic hand,
hand dominance, and Historical-Objective scale. In
both groups, Phalen’s test and Tinel’s sign were
similarly presented. Detailed data are shown in
Table 1. In all 103 (100%) cases, subjects experi-
enced numbness and tingling in the area of the
median nerve and nocturnal paraesthesia.
The ANOVA for all measured parameters (with
exception of cylindrical and pincer grips) revealed
statistically significant main effects (P < 0.01).
Detailed post hoc analysis showed that baseline
measurements in all cases were the same in both
groups (Table 2).
After 10 weeks of experiment, compared with
control group, patients in the experimental group
had a 12.4 m/s (95% CI = 9.1–15.6) higher value of
sensory conduction velocity and 0.92 m/s (95%
CI = 0.58–1.23) lower value of motor latency. The
pain level measured after the experiment was
diminished by 4.08 points (95% CI = 3.73–4.43) in
the experimental group compared to control group.
In both components of Boston Carpal Tunnel
Questionnaire, the results of symptom severity and
functional status in experimental group (compared
to control group) after 10 weeks of experiment
were lower by 1.79 (95% CI = 0.91–1.31) and 0.91
(95% CI = 0.78–1.24), respectively (Table 2).
Discussion
The results provide evidence for the efficacy of
neurodynamic techniques in the conservative treat-
ment of carpal tunnel syndrome. Statistically sig-
nificant main effects were obtained in nerve
conduction, pain and symptom severity, and func-
tional status. There were no statistically significant
main effects in the assessment of muscle strength in
examined both grips. After the treatment, a signifi-
cant improvement of nerve conduction occurred in
the experimental group. Mean motor changes were
very subtle and potentially caused in only a few
patients. Hence, limited improvement can be
expected for the motor parameters, since they are
presumably within normal limits for most patients.
Significant relief from pain and symptom severity
occurred. Functional status also improved consider-
ably. The lowest change occurred in the study of
muscle strength. There were no substantial between-
group changes in the assessment of either grip.
In our previous study, we compared the effec-
tiveness of a therapeutic programme consisting of
neurodynamic techniques, wrist mobilization, and
functional massage with a programme that included
laser and ultrasound in carpal tunnel syndrome
patients.2 After the treatment, improvement in nerve
conduction and functional status, as well as reduc-
tion in pain and symptom severity, occurred in both
groups, with greater results in the group receiving
neurodynamic techniques. Although the current
experiment omitted functional massage and wrist
mobilization, a similar therapeutic effect emerged.
Therefore, one may assume that neurodynamic
techniques made the biggest contribution towards
improvement among the studied parameters.2
To date, nerve conduction study is the ‘gold
standard’ for carpal tunnel syndrome diagnostics.25
Premoselli et al.26 observed that in mild and moder-
ate carpal tunnel syndrome, the conduction veloc-
ity in sensory fibres was the first to be negatively
affected. Jablecki et al.27 also indicated that the
decrease in nerve conduction onsets earlier in sen-
sory fibres, yet the reason remains unknown. In our
6 Clinical Rehabilitation 00(0)
Figure 1.  Flow diagram of phases through clinical trial.
study, initial conduction velocities were worse in
sensory fibres and motor latency. Greater improve-
ment was achieved after the treatment cycle, which
may indicate the beneficial effects of the applied
neurodynamic techniques.
The use of neurodynamic techniques produced
a significant reduction in pain. The mechanism of
such a significant reduction seems to be multifac-
torial and may be due to decreased pressure in the
carpal tunnel and decreased tissue oedema.
Schmit et al.28 showed that nerve compression
causes chronic inflammation that can cause
carpal tunnel syndrome symptoms. We hypothe-
size that use of neurodynamic techniques may
increase blood supply, reduce mechanical irrita-
tion and improve nerve sliding to improve its
physiological function, that is, reduce intraneural
oedema, improve axonal transport, and decrease
intraneural pressure, thereby reducing mechani-
cal sensitivity.
Neurodynamic techniques also produced a
decrease in symptom severity and improvement of
functional status. The reduction of subjective
symptoms may be explained by both the significant
pain reduction and the improvement of nerve
conduction in sensory fibres. Sensory disturbances
and impairment of conduction velocity in sen-
sory fibres are the earliest manifestations of carpal
Wolny and Linek 7

Table 1.  Group means and between-group comparisons for participant characteristics at baseline.

Experimental group (n = 58) Control group (n = 45) P-value

Women, n (%) 52 (90) 40 (89) 0.90a
Age (SD), year 54.6 (9.1) 53.1 (10.1) 0.42b
Body mass (SD), kg 70.7 (10.9) 79.3 (13.2) 0.56b
Height (SD), cm 163 (6.51) 164 (7.33) 0.59b
BMI (SD) 26.5 (4.21) 25.5 (4.08) 0.22a
Carpal tunnel syndrome
Unilateral, n (%) 41 (55) 28 (45) 0.27a
Bilateral, n (%) 34 (45) 34 (55)
Symptomatic hand
Right, n (%) 53 (71) 39 (63) 0.33a
Left, n (%) 22 (29) 23 (37)
Asymptomatic hand
Right, n (%) 5 (12) 6 (21) 0.30a
Left, n (%) 36 (88) 22 (79)
Dominant hand
Right, n (%) 55 (95) 44 (98) 0.44a
Left, n (%) 3 (5) 1 (2)
Positive Phalen’s test, n (%) 36 (62) 29 (64) 0.81a
Positive Tinel’s sign, n (%) 29 (50) 22 (48) 0.84a
Hi-OB Scale (hands), n (%) 1 6 (8) 9 (14) 0.33a
2 53 (71) 37 (60)
3 16 (21) 16 (26)

Hi-OB, Historical-Objective scale; n, number of participants; BMI, body mass index.

aChi-square test.
bStudent’s t-test.

Table 2.  Group means (standard deviations) for outcomes measured before and after 10 weeks of experiment
with P-value from between-group comparison.

Group Between group

differences (P-value)
  Experimental Control

  Baseline 10 weeks later Baseline 10 weeks later Baseline 10 weeks later

SCV (m/s) 24.9 (15.1) 38.3 (11.1) 25.80 (7.81) 25.90 (7.72) 0.97 <0.01*
MCV (m/s) 51.10 (5.15) 55.80 (6.92) 53.1 (3.44) 53.60 (4.08) 0.10 0.83
MT (t(ms)] 5.62 (1.11) 4.49 (0.72) 5.51 (1.17) 5.41 (1.18) 0.93 <0.01*
NPRS (0–10) 5.86 (1.46) 1.38 (1.01) 5.71 (1.34) 5.46 (1.05) 0.89 <0.01*
BCTQ-SSS 3.03 (0.65) 1.08 (0.68) 2.92 (0.71) 2.87 (0.68) 0.78 <0.01*
BCTQ-FSS 2.82 (0.71) 1.96 (0.64) 2.99 (0.67) 2.87 (0.71) 0.54 <0.01*
Cylindrical grip (kg) 28.10 (6.11) 28.80 (5.62) 29.4 (6.02) 30.1 (5.74) NA NA
Pincer grip (kg) 8.11 (1.51) 8.36 (1.44) 8.04 (1.26) 8.33 (1.34) NA NA

NA, not applicable as P-value for main effect ANOVA was above 0.05; SCV, sensor conduction velocity; MCV, motor conduc-
tion velocity; MT, motor latency; NPRS, Numerical Pain Rating Scale; BCTQ, Boston Carpal Tunnel Questionnaire; SSS, Symptom
Severity Scale; FSS, Functional Status Scale.
*Statistically significant difference.
8 Clinical Rehabilitation 00(0)
tunnel syndrome, and following treatment, they
disappear earlier than motor symptoms.29
No significant change in muscle strength (in
both grips) manifested after the use of neurody-
namic techniques. Studies show that muscle
strength in mild and moderate carpal tunnel syn-
drome is not yet impaired; hence, the subjects
were able to maintain normal strength.29 Nerve
conduction velocity in motor fibres was normal,
with no indication that strength would be
impaired. In our previous study, there were also
no significant differences between carpal tunnel
syndrome patients and healthy people in pincer
grip and only a slight difference in cylindrical
grip.2 It should be emphasized, however, that
people with only mild carpal tunnel syndrome
have been studied.30
Tal-Akabi and Rushton16 showed in their
research of carpal tunnel syndrome patients that
the greatest therapeutic effect occurred using
neurodynamic techniques. In other studies, sig-
nificantly better results also occurred in the
group using neurodynamic techniques as the sole
treatment component.17,18 However, the problem
with these studies is, they sometimes described the
methodology for applying neurodynamic tech-
niques too briefly, which is difficult to reproduce in
a clinical setting.
Coppieters et al.31,32 observed that the use of
various neurodynamic techniques may affect the
nerve differently and may have other biomechani-
cal effects. Previously mentioned studies16–18 and
this study show that passive therapy performed by
a physiotherapist yielded greater therapeutic out-
comes than control groups (without treatment or
treated with a different therapeutic programme).
In the case of using neurodynamic techniques as
an autotherapy programme, some studies have
shown a positive effect of therapy,10 and some stud-
ies have lacked positive therapeutic effect.33 The
effectiveness of neurodynamic therapy in the
treatment of carpal tunnel syndrome has also been
evaluated in recent systematic reviews, but the
results are inconclusive.12,13 This indicates that
greater benefits may emerge through the use of
neurodynamic techniques by a therapist, com-
pared without autotherapy.
The limitation of this work is primarily the
absence of a placebo control group. Such a
group would eliminate the placebo effect that
could have occurred as the sole result of partici-
pation in the therapy and not because of the
therapeutic programme used. The limitation of
these studies is the possibility that other non-
specific factors influenced the effect of therapy.
Another limitation is the use of up to 20 thera-
peutic sessions, which makes the therapy less
economical. The limitation here is that it rated
only the short-term outcome and follow-up only
for nerve conduction study. An additional
research limitation is that the findings may be
due to an immediate effect from the last inter-
vention session, if indeed the outcome measures
were taken immediately after the last treatment.
Nevertheless, nerve conduction was tested one
month after the therapy, and the effect was sta-
tistically significant.
We think that the strength of our study is the
clear and understandable methodology for both
the diagnosis and treatment of patients with car-
pal tunnel syndrome. Diagnostic criteria were
comprehensive and included interview, func-
tional tests, and nerve conduction study. The
treatment protocol of neurodynamic techniques
was described in detail, so it can be easily used
in clinical practice by physiotherapists and also
repeated by scientists in subsequent experi-
ments. The study encompassed a relatively large
number of patients, thus the results are more
likely to be reproduced in a clinical setting.
Finally, the study shows the positive effect of
neurodynamic techniques, which can improve
the clinical results in conservative carpal tunnel
syndrome treatment in rehabilitation/physio-
therapy wards and private practices. In further
studies, it could be worthwhile to evaluate the
effectiveness level of neurodynamic therapy and
compare it with other physiotherapy methods/
techniques such as exercise therapy or electro-
physical modalities. In addition, we believe
that future studies should compare sliding
and tensioning neurodynamic techniques to get
information about their separate treatment
potentials.
Wolny and Linek 9
Conclusion
In conclusion, the use of neurodynamic techniques
in conservative treatment of mild to moderate forms
of carpal tunnel syndrome has significant therapeu-
tic benefits in the short term. Improvement in nerve
conduction and functional status, as well as reduc-
tion of pain and symptom severity, emerged. The
use of neurodynamic techniques did not improve
muscle strength in cylindrical and pincer grips.
Clinical Messages
•• Manual therapy based on neurodynamic
techniques has a positive effect on pain
relief and subjective carpal tunnel syn-
drome symptoms.
•• Neurodynamic techniques improve hand
functions.
•• Neurodynamic techniques have a posi-
tive effect on nerve conduction.
Acknowledgements
The paper was prepared as part of statute research by the
Department of Kinesiotherapy and Special Methods of
Physiotherapy of the Jerzy Kukuczka Academy of
Physical Education in Katowice.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest
with respect to the research, authorship, and/or publica-
tion of this article.
Ethical approval
Local Ethics Committee, The Jerzy Kukuczka Academy
of Physical Education in Katowice Ethics Committee
approved this study. Participants gave written informed
consent before data collection began.
Funding
The author(s) received no financial support for the
research, authorship, and/or publication of this article.
ORCID iD
Pawel Linek https://orcid.org/0000-0002-8542-8123
References
1. Padua L, Coraci D, Erra C, et al. Carpal tunnel syndrome:
clinical features, diagnosis, and management. Lancet
Neurol 2016; 15(12): 1273–1284.
2. Wolny T, Saulicz E, Linek P, et al. Efficacy of manual
therapy including neurodynamic techniques for the treat-
ment of carpal tunnel syndrome: a randomized controlled
trial. J Manipulative Physiol Ther 2017; 40(4): 263–272.
3. Atroshi I, Gummesson C, Johnsson R, et al. Prevalence
of carpal tunnel syndrome in a general population. JAMA
1999; 282(2): 153–158.
4. Brininger TL, Rogers JC, Holm MB, et al. Efficacy of a
fabricated customized splint and tendon and nerve gliding
exercises for the treatment of carpal tunnel syndrome: a
randomized controlled trial. Arch Phys Med Rehabil 2007;
88(11): 1429–1435.
5. Korthals-de Bos IB, Gerritsen AA, van Tulder MW, et al.
Surgery is more cost-effective than splinting for carpal
tunnel syndrome in the Netherlands: results of an eco-
nomic evaluation alongside a randomized controlled trial.
BMC Musculoskelet Disord 2006; 7: 86.
6. Gerritsen AA, de Vet HC, Scholten RJ, et al. Splinting vs
surgery in the treatment of carpal tunnel syndrome: a rand-
omized controlled trial. JAMA 2002; 288(10): 1245–1251.
7. Naeser MA, Hahn KA, Lieberman BE, et al. Carpal tunnel
syndrome pain treated with low-level laser and microam-
peres transcutaneous electric nerve stimulation: a controlled
study. Arch Phys Med Rehabil 2002; 83(7): 978–988.
8. Padua L, Padua R, Aprile I, et al. Multiperspective fol-
low-up of untreated carpal tunnel syndrome: a multicenter
study. Neurology 2001; 56(11): 1459–1466.
9. Jarvik JG, Comstock BA, Kliot M, et al. Surgery versus non-
surgical therapy for carpal tunnel syndrome: a randomised
parallel-group trial. Lancet 2009; 374(9695): 1074–1081.
10. Akalin E, El O, Peker O, et al. Treatment of carpal tunnel
syndrome with nerve and tendon gliding exercises. Am J
Phys Med Rehabil 2002; 81(2): 108–113.
11. Medina McKeon JM and Yancosek KE. Neural gliding
techniques for the treatment of carpal tunnel syndrome: a
systematic review. J Sport Rehabil 2008; 17(3): 324–341.
12. Ballestero-Pérez R, Plaza-Manzano G, Urraca-Gesto A,
et al. Effectiveness of nerve gliding exercises on carpal
tunnel syndrome: a systematic review. J Manipulative
Physiol Ther 2017; 40(1): 50–59.
13. Lim YH, Chee DY, Girdler S, et al. Median nerve mobiliza-
tion techniques in the treatment of carpal tunnel syndrome:
a systematic review. J Hand Ther 2017; 30(4): 397–406.
14. Ellis R, Blyth R, Arnold N, et al. Is there relationship
between impaired median nerve excursion and carpal tun-
nel syndrome? A systematic review. J Hand Ther 2017;
30(1): 3–12.
15. Shacklock M. Clinical Neurodynamics. New York;
Oxford: Elsevier; Butterworth Heinemann, 2005.
16. Tal-Akabi A and Rushton A. An investigation to compare
the effectiveness of carpal bone mobilisation and neuro-
10 Clinical Rehabilitation 00(0)
dynamic mobilisation as methods of treatment for carpal
tunnel syndrome. Man Ther 2000; 5(4): 214–222.
17. Hiral SR and Leena SR. A comparative study to deter-
mine the effectiveness of carpal bone mobilization vs
neural mobilization for carpal tunnel syndrome. Indian J
Physiother Occup Ther 2015; 9: 123–128.
18. Mohamed FI, Hassan AA, Abdel-Magied RA, et al.
Manual therapy intervention in the treatment of patients
with carpal tunnel syndrome: median nerve mobilization
versus medical treatment. Egypt Rheumatol Rehabil 2016;
43: 27–34.
19. Giannini F, Cioni R, Mondelli M, et al. A new clinical
scale of carpal tunnel syndrome: validation of the meas-
urement and clinical-neurophysiological assessment. Clin
Neurophysiol 2002; 113(1): 71–77.
20. Mondelli M, Giannini F and Giacchi M. Carpal tunnel
syndrome incidence in a general population. Neurology
2002; 58(2): 289–294.
21. Chang WD, Wu JH, Jiang JA, et al. Carpal tunnel syn-
drome treated with a diode laser: a controlled treatment
of the transverse carpal ligament. Photomed Laser Surg
2008; 26(6): 551–557.
22. Jensen MP, Turner JA, Romano JM, et al. Comparative
reliability and validity of chronic pain intensity measures.
Pain 1999; 83: 157–162.
23. Levine DW, Simmons BP, Koris MJ, et al. A self-
administered questionnaire for the assessment of severity
of symptoms and functional status in carpal tunnel syn-
drome. J Bone Joint Surg Am 1993; 75: 1585–1592.
24. Watanabe T, Owashi K, Kanauchi Y, et al. The short-term
reliability of grip strength measurement and the effects
of posture and grip span. J Hand Surg Am 2005; 30(3):
603–609.
25. Johnson EW. Diagnosis of carpal tunnel syndrome the
gold standard. Am J Phys Med Rehabil 1993; 72(1): 1.
26. Premoselli S, Sioli P, Grossi A, et al. Neutral wrist
splinting in carpal tunnel syndrome: a 3- and 6-months
clinical and neurophysiologic follow-up evaluation of
night-only splint therapy. Eura Mediophys 2006; 42(2):
121–126.
27. Jablecki CK, Andary MT, So YT, et al. Literature review
of the usefulness of nerve conduction studies and elec-
tromyography for the evaluation of patients with carpal
tunnel syndrome. AAEM Quality Assurance Committee.
Muscle Nerve 1993(12): 1392–1414.
28. Schmid AB, Coppieters MW, Ruitenberg MJ, et al. Local
and remote immune-mediated inflammation after mild
peripheral nerve compression in rats. J Neuropathol Exp
Neurol 2013; 72(7): 662–680.
29. MacDermid JC and Doherty T. Clinical and electrodi-
agnostic testing of carpal tunnel syndrome: a narrative
review. J Orthop Sports Phys Ther 2004; 34(10): 565–
588.
30. Wolny T, Saulicz E, Linek P, et al. Kinesthesia of force
and motion and tactile discrimination in patients with a
mild form of carpal tunnel syndrome. Phys Med Rehab
Kuror 2015; 25: 101–107.
31. Coppieters MW and Butler DS. Do ‘sliders’ slide and
‘tensioners’ tension? An analysis of neurodynamic tech-
niques and considerations regarding their application.
Man Ther 2008; 13(3): 213–221.
32. Coppieters MW, Hough AD and Dilley A. Different
nerve-gliding exercises induce different magnitudes of
median nerve longitudinal excursion: an in vivo study
using dynamic ultrasound imaging. J Orthop Sports Phys
Ther 2009; 39(3): 164–171.
33. Horng YS, Hsieh SF, Tu YK, et al. The comparative effec-
tiveness of tendon and nerve gliding exercises in patients
with carpal tunnel syndrome: a randomized trial. Am J
Phys Med Rehabil 2011; 90(6): 435–442.