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Targeted Lumbrical Splinting and Stretching Versus Standard Treatment on Functional Outcomes in Persons with Mild to Moderate Carpal Tunnel Syndrome
Krissy K. Moehling, MPH1; Elaine N. Rubinstein, PhD2; Ronit Wollstein, MD3; Norman P. Gustafson, MS, CHT, OTR/L1; Mark E. Baratz, MD4; Nancy A. Baker, ScD, MPH, OTR/L1
1Department of Occupational Therapy, University of Pittsburgh, Pittsburgh, PA; 2Department of Measurement and Evaluation of Teaching, University of Pittsburgh, Pittsburgh, PA; 3Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; 4Allegheny Orthopedics Association, Allegheny General Hospital, Pittsburgh, PA

Background: The treatment of carpal tunnel syndrome (CTS) includes splinting and exercise. The lumbrical muscles appear to affect carpal tunnel canal pressure and CTS symptoms. We hypothesized that a lumbrical “intensive” treatment of nocturnal splinting and stretching would provide greater improvement in hand function compared to protocols that focus to a lesser extent on the lumbricals.

Methods: A randomized controlled 2x2 factorial design study was conducted with four groups: Lumbrical splint/Lumbrical stretch (Lsp/Lst); General splint/Lumbrical stretch (Gsp/Lst); Lumbrical splint/General stretch (Lsp/Gst); General splint/General stretch (Gsp/Gst). Appropriate patients were recruited by 2 hand surgeons.

Assessments were obtained at baseline and 4 weeks after an at-home regimen of splinting and exercise. Grip strength and lateral and palmar pinch were measured. The average of three trials was used for each test.  Dexterity was evaluated using the Purdue Pegboard; the total number of objects successfully placed during each task was recorded.

2-way ANOVAs were performed using SPSS 18 with group as the between-subjects factor and time as the within-subjects factor. Post hoc analyses used pairwise comparisons on difference scores for significant between-group outcomes with alpha set at .05.  Within-in group measures of effect size (d) were calculated.

Results: The average age of this cohort (N=103) was 53.3±11.8 years. The majority were female (71.8%), Caucasian (91.2%), with chronic carpal tunnel symptoms ≥ 3 months (85.7%). As CTS was most prevalent for the right hand(43.7%) and the majority were right handed (91.3%), only right-sided results are provided for strength measurements (Table 1). There were no significant differences in demographics between groups.

The main effect of time was significant for all but Purdue - both hands. Significant group by time interactions were found only for right lateral pinch (p=.03) with greatest improvement in the Gsp/Gst group, and Purdue - left hand only (p=.03) with greatest improvement in the Lsp/Lst group.

Conclusion: All groups showed significant improvements over time.  Intensive lumbrical treatment was significantly better only for Purdue - left hand; however, dexterity tasks such as Purdue - both hands and Purdue - assembly also showed greater improvement for this group. It appears, based upon effect sizes, that a more intensive lumbrical treatment may affect dexterity rather than strength at 4 weeks follow-up. This may be due to a musculotendinous effect rather than a direct effect on median nerve pressure. Future research should examine the effects of more intensive lumbrical treatments on impairment with longer follow-up.

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