1540
Ultrasound Therapy Effect in Carpal Tunnel Syndrome
Ozgur Oztas, MD, Betul Turan, MD, Ibrahim Bora, MD, Munir Kerim Karakaya, MD
ABSTRACT. Oztas 0, Turan B, Bora I, Karakaya MK.
Ultrasound therapy effect in carpal tunnel syndrome. Arch Phys
Med Rehabil 1998;79: 1540-4.
Objective: To investigate the overall effect of repeated
ultrasound treatment in carpal tunnel syndrome (CTS).
Design: Patient-blinded, placebo-controlled, before-after
treatment trial.
Setting: University hospital PM&R department outpatient
clinic and neurology department electromyography laboratory.
Patients: Eighteen women with diagnosis of CTS in 30
hands.
Interventions: Three groups, each with 10 cases of CTS,
were randomly established. Continuous ultrasound therapy,
with intensities of 1.5W/cm2 (group A), 0.8W/cm2 (group B),
and 0.0W/cm2 (group C), was applied to palmar carpal tunnel
area for 5 minutes, 5 days a week, for 2 weeks.
Outcome Measures: Patients were evaluated clinically and
electrophysiologically before and after the treatment.
Results: At the end of treatment, statistically significant
improvement was obtained in clinical parameters in all groups:
pain (p < .05), pain/paresthesia at night/day (p < .OS), and
frequency of awakening at night (p < .05). Although there was
no statistically significant before-after difference in electrophysi-
ologic studies, slightly decreased motor nerve conduction
velocity and increased motor distal latency were noted in
groups A and B, but not in group C.
Conclusion: Ultrasound therapy in CTS was comparable to
placebo ultrasound in providing symptomatic relief, and the
probability of a negative effect on motor nerve conduction
needs to be considered.
0 1998 by the American Congress of Rehabilitation Medi-
cine and the American Academy of Physical Medicine and
Rehabilitation
U LTRASOUND IS A physical therapy agent commonly
used to increase temperature in deep tissue. The biologic
effects observed when mammalian tissues are exposed to
ultrasound include changes in blood flow rates, tissue metabo-
lism, nerve function, the extensibility of connective tissue, and
the permeability of biologic membranes.lp3 The rate of nerve
regeneration can be influenced by temperature.4 The mechani-
cal and heating properties of ultrasound affect the ability of
nerve fibers to propagate an action potential, but the physiologic
mechanisms responsible for this effect are not clear.1-3,5-11
There
is, however, agreement that nerve is selectively heated by
ultrasound.1-3 Continuous application has been reported to
From the Physical Medicine and Rehabilitation Department (Drs. Oztas. Turan,
Kamkaya) and Neurology Department (Dr. Eon), Uludag University Medical School,
Bum, Turkey.
Submitted for publication December 19, 1997. Accepted in revised form July 24,
1998.
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit upon the authors or upon any
organization with which the authors are associated.
Reprint requests to Ozgur Oztas, MD, 1685 Knollwood Drive, No. 641, Mobile, AL
36609.
0 1998 by the American Congress of Rehabilitation Medicine and the American
Academy of Physical Medicine and Rehabilitation
0003-9993/98/7912-4782$3.00/O
Arch Phys Med Rehabil Vol 79, December 1998
increase sensory nerve conduction velocity (NCV)10-12and to
both increase6a9 and decrease6,8,9motor NCV in healthy function-
ing nerves. It is suggested that ultrasound effects on motor NCV
are intensity-dependent and could be the result of the relation
between the thermal and nonthermal effects of insonation.6*8,9
Hong and colleagues13 conducted an animal experiment in
which bilateral tibia1 nerve compression was produced in rats. It
was found that at a dose of 1W/cm2 and at a frequency of
lMHz, the recovery rate of nerve conduction was decreased,
whereas at an intensity of 0.5W/cm2 the recovery rate in-
creased. They concluded that low doses of ultrasound may
facilitate recovery of experimental acute compression neuropa-
thy. In another study, Hong14 reported that in patients with
painful peripheral neuropathy, a reversible conduction block as
a result of acute ultrasound may occur; however, this was not
observed in painless peripheral neuropathy.
Since there is no report in the literature evaluating the effect
of ultrasound therapy on entrapment neuropathy in human
beings, we investigated the overall therapeutic effect of differ-
ent intensities of repeated ultrasound application compared to
placebo ultrasound on a common chronic entrapment neuropa-
thy, carpal tunnel syndrome (CTS).
METHODS
Patients
Eighteen women, ranging in age from 37 to 66 years
(mean 2 SD = 51.5 2 7.05), 30 with clinical and electrophysi-
ologic evidence of CTS, were studied. The aim and methods of
the study were explained to all patients before their informed
consent was given. The duration of symptoms had been from 6
to 240 months (mean ? SD = 84.0 t 61.7). CTS was bilateral
in 12 patients (66.6%), four on the left side and two on the right
side. Diagnosis of CTS was made according to the American
Neurology Academy criteria for CTS.15
History criteria. The likelihood of CTS increases with the
number of symptoms and provocative factors listed below:
Symptoms. (1) Dull, aching discomfort in the hand, fore-
arm, or upper arm. (2) Paresthesia, weakness, or clumsiness of
the hand. (3) Dry skin, swelling, or color changes in the hand.
(4) Occurrence of any of these symptoms in the median
distribution.
Provocative factors. (1) Sleep, sustained hand or arm
positions. (2) Repetitive actions of the hand or wrist.
Mitigating factors. (1) Changes in hand posture. (2) Shak-
ing the hand.
Physical examination criteria. Findings may be normal, or
there may be sensory loss in the median nerve distribution;
symptoms may be elicited by the Tine1 sign and/or the Phalen
sign; there is weakness or atrophy in the thenar muscles; and the
skin of the thumb, index, and middle fingers is dry.
Selection criteria for our study. (1) Patients had been
complaining for at least 6 months. (2) There were no other
predisposing etiologic factors (such as diabetes mellitus, rheu-
matic diseases, acute trauma, pregnancy). (3) The patient had
not had physical or medical therapy in the previous month. (4)
The patient had not had a corticosteroid injection in the
previous 3 months. (5) The patient had no serious medical
problems that might have interfered with electrophysiologic
 ULTRASOUND IN CARPAL TUNNEL
testing during the study. (6) The patient had no medical
problems that would have been contraindicated for ultrasound
therapy. (7) There was no muscle atrophy, anesthesia, or
intractable pain due to CTS. (8) Electrophysiologic testing
showed the presence of median nerve sensory and motor
responses. (9) Electromyographic examination of the abductor
pollicis brevis (APB) muscle found no spontaneous activity or
markedly reduced firing frequency.
Categorization of symptoms. All patients were examined
by one physician and symptoms were categorized as follows:
Severity of pain was recorded by patients before and after the
treatment. A 100~mm horizontal visual analogue scale (VAS)
was used, with one end labeled “no pain” and the other
“unbearable pain.” Presence of symptoms at night and/or day
pain and/or paresthesia was scored as follows: 0 = no
symptoms (only after treatment), 1 = mild (nocturnal and
diurnal paresthesias), 2 = moderate symptoms (nocturnal pain),
3 = severe (nocturnal and diurnal pain). Frequency of awaken-
ing from symptoms at night per week was scored: 0 = never
wake up, 1 = awaken 1 to 2 times a week, 2 = 3 to 6 times a
week, 3 = 7 times or more.16
Physical examination and tests. Normal findings of the
neck, absence of neck pain, cervical X-ray indicating normal
results, a physical examination that affirmed CTS, and positive
EMG findings for CTS enabled us to rule out C6 radiculopathy.
To prevent any distress in our patients, no further EMG
examination was conducted. To distinguish possible systemic
problems that may cause CTS, hemogram, erythrocyte sedimen-
tation rate, routine biochemical blood analysis, protein electro-
phoresis, C-reactive protein, rheumatoid factor, thyroid func-
tion test, and bilateral wrist X-ray analysis were performed.
Electrophysiologic Evaluation
The electrophysiologic tests were performed by one physi-
cian. The electromyography equipment used was the Medelec
Sapphire 4MEA.a Subjects were studied in the supine position
and the room temperature was kept at 22” to 24°C. The
electrophysiologic evaluation included median nerve motor
distal latency (MDL) and sensory distal latency (SDL), median
nerve motor forearm NCV, and sensory nerve NCV.
Compound muscle action potentials of the APB muscle were
recorded, induced from supramaximal electric stimulation on
the median nerve at the wrist 8cm to the recording electrode.
Distal motor latency and motor NCV study from wrist to APB
muscle were done within a distance of 8cm. Sensory latency
and sensory nerve conduction study was done from the second
digit antidromically to the wrist with a distance of 14cm. The
onset latencies of negative potentials were taken into consider-
ation. For sensory testing, sweep-speed velocity was set at
lOmsec, whereas for motor testing sweep-speed was set at
30msec, and the duration of stimulus was O.lmsec in both
studies. The voltage was increased until action potentials
reached maximal amplitude. The patients with a median motor
distal latency of 5.0msec or more and a median sensory latency
of 3msec or more were enrolled in the study.17Electromyogra-
Table 1: Demographic Data of Patients
Intensity of No. of No. of
Groups Ultrasound Patients CTS Limbs
A 1 .5Wlcm2 7 IO
B 0.8W/cm2 9 IO
C 0.0W/cm2 9 IO
SYNDROME, Oztas 1541
phy of two muscles of the hand APB and abductor digiti minimi
was performed.
Eighteen patients who were found to have a total of 30
idiopathic cases of CTS were randomly divided into three
groups, each with 10 cases of CTS. The number of patients in
groups A, B, and C was 7, 9, and 9, respectively. Nine patients
with bilateral CTS had different treatments for each hand. Of
the nine, one patient was in both groups A and B, one was in
both groups A and C, and seven were in both groups B and C.
Ultrasound Treatment
The recommended therapeutic dosage of ultrasound is gener-
ally 0.1 to 2W/cm2.1-3 In this study, continuous ultrasound
therapy in circular fashion was performed with intensities of
1.5W/cm2, 0.8W/cm2, and 0.0W/cm2 (without energy emission)
in groups A, B, and C, respectively. An Enraf Nonius Sonopuls
464b ultrasound machine with a frequency of 3MHz and a
0.5-cm2 soundhead, in conjunction with a coupling media of
Aquasonic ultrasound transmission geLc were used. The trans-
mission gel and ultrasound soundhead were at room tempera-
ture before treatments. The size of the sonation area was
approximately 2cm X 4cm. The size of the sonated area with
respect to soundhead area and therapy duration was within
recommended limits.1,6All therapies were applied to the palmar
carpal tunnel area, which expands from the wrist crease to the
palmar region and covers an area of 3 to 5cm in length and 2 to
2.5cm in width. This ultrasound therapy lasted 5 minutes per
session, 5 days a week, for 2 weeks, and patients were unaware
of treatment groups.
Clinical and electrophysiologic evaluations were performed
before and 5 days after 2 weeks of treatment, so the interval
between evaluations was 20 days. Taking medications or
physical therapy was not allowed during the study; therefore,
patients were reviewed daily to determine any worsening in
symptoms or desire to discontinue the study.
Statistical Analysis
The means and standard deviations were calculated for all
subjects in each group for each parameter. The student t test was
used to compare the before and after treatment values among
groups. One-way ANOVA was used to compare the differences
among the values between groups. Ap < .05 was considered
statistically significant.
RESULTS
The demographic characteristics of patients in the three
groups are shown in table 1. During the study none of the
patients reported progressive worsening in symptoms or reluc-
tance for therapy. When severity of symptoms was compared
before and after treatment, there was statistically significant
improvement in clinical parameters (p < .05) in all groups. No
statistically significant difference was observed between groups
(p > .05) (table 2).
As shown in table 3, comparing electrophysiologic param-
in the Three Treatment Groups
Duration of
Age Range Symptoms, Months
(Mean -t SD) (Mean i- SD)
45-61 (53.2 2 6.5) 24-180 (87.6 t 58.0)
37-66 (51.3 2 7.2) 6-240 (89.4 t 67.1)
41-59 (49.0 + 6.3) 6-240 (70.2 ? 76.2)
Arch Phys Med Rehabil Vol 79, December 1998
 1542 ULTRASOUND IN CARPAL TUNNEL SYNDROME, Oztas

Table 2: Comparison of the Clinical Parameters MDL

Before and After Ultrasound Treatment 6.2
pValue
Clinical Group A Group B Group C (Between
6.0
Parameters (1.5W/cm*) (0.8W/cm2) (0.0W/cm2) Groups)

Pain VAS
BT 6.10 t 2.50 7.10 + 2.38 7.90 2 1.80 5.8
AT 2.90 2 1.69 3.60 t 1.90 4.00 2 2.40
p Value (ET/AT) <.05* <.05* <.05* >.05+ 6.6
Night pain/
paresthesia
BT 2.30 -t .68 2.60 I! .70 2.60 + .69 5.4
AT 1.40 + .52 1.70 i .82 1.40 k .97
p Value (BTIAT) 1.05” 1.05” <.05* >.05+
5.2
Frequency of
awakening
BT 2.30 ” .95 1.90 2 1.10 2.30 + .94 5.0
AT .90 2 .88 .50 k .97 .90 2 1.20
pValue (BT/AT) <.05* <.05* <.05* >.05 +
4.8 -
Abbreviations: ET, before treatment; AT, after treatment; VAS, visual group A group B group C
analogue scale.
* Statistically significant.
+ Statistically insignificant. Fig 1. Comparison of median MDL between groups before (Cl) and
after (0) treatment showed a slight increase in MDL in the ultra-
sound-treated groups (group A = 1.5W/cm2 and B = 0.8W/cm2)
compared to the placebo ultrasound group (group C).

eters before and after treatment and among groups did not
reveal any statistically significant difference (p > .05). How- DISCUSSION
ever, statistically nonsignificant but mathematically significant Patients with CTS often complain of hand and arm pain and
differences were found in median MDL and motor NCV in other sensory disturbances. CTS occurs most commonly in
groups A and B when compared to placebo group C. There was adults older than 30 years, particularly women, and involves
a slight increase in MDL and a decrease in motor NCV at both compression of the median nerve at the wrist, affecting both
intensities 1.5W/cm2 and 0.8W/cm2 (figs 1 and 2). sensory and motor branches.l5 The classical symptom of CTS is
dysesthesia in the first three fingers of the hand, which is
commonly exacerbated at night. Treatments include nonsteroi-
dal anti-inflammatory drugs, diuretics, splints, steroid injec-
Table 3: Comparison of the Electrophysiologic Parameters tions into the carpal tunnel, and surgical release of the flexor
Before and After Ultrasound Treatment retinaculum.15;*7 In this study we investigated the therapeutic
pValue
Electrophysiologic Group A Group B Group C (Between motor NW
Parameters (1 .5W/cmz) (0.8W/cm2) (O.OW/cm*) Groups) 54
MDL 1
BT 5.85 i 1.87 5.90 2 1.29 5.60 5 1.61 53
AT 6.00 ? 1.95 6.10 t 1.46 5.36 t 1.48
Mean difference +.15 +0.2 -.24 52
pValue (BTIAT) >.05+ >.05+ >.05+ >.05+
MNCV 51
BT 51.4 t 6.80 53.3 t 7.19 48.2 + 4.36
AT 49.5 +- 7.45 49.9 t 4.81 49.7 2 6.00
50
Mean difference -1.9 -3.4 +1.5
p Value (BT/AT) >.05+ >.05+ >.05+ Y-.05+
SDL
48
BT 4.06 + 1.39 3.64 t .64 3.77 2 .89
AT 3.81 t 1.39 3.53 t .81 3.66 + 1.05 48
Mean difference -.25 -.I1 -.I1
pValue (BT/AT) >.05+ >.05+ >.05+ >.05+ 47
SNCV
BT 33.5 i 8.77 43.5 t 12.1 37.9 + 10.4 46
AT 36.6 + 11.1 45.1 t 12.6 38.7 i 11.2
Mean difference +3.1 +I.6 +0.8 45
pValue (BT/AT) >.05+ >.05+ >.05+ >.05+
group A group B group C
Abbreviations: MDL, motor distal latency; MNCV, motor nerve con-
duction velocity; SDL, sensory distal latency; SNCV, sensory nerve Fig 2. Comparison of median motor NCV between the groups
conduction velocity; BT, before therapy; AT, after therapy. before (0) and after (0) treatment. A decrease in motor NCV at
* Statistically significant. intensities 1.5W/cm2 (group A) and O.SW/cm* (group B) was ob-
+ Statistically insignificant. served.

Arch Phys Med Rehabil Vol 79, December 1998

 ULTRASOUND IN CARPAL
effectiveness of repeated ultrasound therapy as a conservative
treatment agent in CTS. After 2 weeks of 5 minutes’ daily
continuous ultrasound therapy, all three clinical parameters due
to pain and paresthesia showed significant improvement in both
treatment groups with intensities of 1.5W/cm2 and O.SW/cm*;
however, the same significant improvement was also found in
the placebo ultrasound group.
The underlying mechanisms of tissue regeneration by ultra-
sound are not clear.*s3Szumskii8 summarized the effects of
ultrasound on nervous tissue as follows: it selectively heats
peripheral nerves; may alter or block impulse conduction; and
may increase membrane permeability and tissue metabolism.
He pointed out that any of the above-mentioned mechanisms
may be due to the thermal effect of ultrasound and may cause
pain relief. Numerous clinical studies describe the effectiveness
of ultrasound in relieving pain of different types of musculoskel-
eta1 disease.19-2iUltrasound was shown to increase pain thresh-
olds in human subjects similar to the level produced by raising
tissue temperature by other means. When ultrasound and
infrared were applied to the area of the ulnar nerve at the elbow,
an analgesic effect was found distally in the area supplied by
this nerve. It was concluded that nerve conduction can be
temporarily blocked by heat application or by the rise of
temperature, which occurred as a result of the absorption of
ultrasonic energy.5 There is an inverse relationship between
fiber size and sensitivity to ultrasound: the smallest C fibers are
more sensitive and the larger A fibers are less affected.7 Since
fully reversible blocking can be obtained with carefully graded
doses of ultrasound, this selective absorption by smaller fibers
may allow a decrease in pain transmission. Symptomatic
improvement could also be due to change in sympathetic fibers.
Standard techniques for measuring NCV give only information
on the largest and fastest conducting myelinated nerve fibers;
therefore, we were not able to detect any change in function of
small, unmyelinated nerve fibers.
Since the significance of pain improvement in the treatment
groups was similar to that of the placebo group, the role of the
placebo effect should be considered. Pain relief after treatment
with a placebo is a well-recognized phenomenon that may be
due to changes in pain perception mediated by circulating
opioids.22 Placebo ultrasound may cause relief of pain by its
local massage effect. Previous studies have reported that the
application of ultrasound of 0.5 to 2W/cmZ on a peripheral
nerve may cause an increase of conduction velocity due to a
thermal effect.6,9-i2,23In particular, studies performed on sen-
sory nerves are more supportive of a parallel relationship
between increased temperature and increased sensory
NCV.10-12,23The thermal effect of ultrasound on NCV is
temporary. At the end of the treatment, NCV usually returns to
its original value as soon as temperature returns to normal.
However, similar to our study, Costentina and associates,24after
applying ultrasound to the forearm, did not find any significant
difference in NCV of the sensory median nerve between the
control and treated groups, but did find a nonsignificant
decreaseof NCV in the latter groups.
Kramer25 reported that sensory and motor NCV respond to
ultrasound treatment, but their responseswere not identical. It is
suggested that ultrasound effects on motor NCV are intensity-
dependent and could be a result of both thermal and nonthermal
effects of insonation.6~8~9 Motor NCV may increase or decrease,
depending on ultrasound intensity, increase in tissue tempera-
ture, and duration. It is suggested that a decrease in motor NCV
may be attributed to the mechanical effect of ultrasound rather
than to the thermal effect. 8,9Zanke18 suggested that lowering
motor NCV in clinical doses may be due to a change in rate of
TUNNEL SYNDROME, Oztas 1543
exchange of transmembranal electrolytes in which the micromas-
sage action (mechanical) plays a major role. The decrease of
NCV caused by high-dose ultrasound treatment may also be
reversible up to 30 minutes after treatment8 Decreased veloci-
ties associated with placebo ultrasound were attributed to a
thermal cooling effect of the transmission gel, which in our
study was observed to be nonsignificant.24
Conduction in peripheral nerves can be blocked reversibly or
irreversibly by focused ultrasound in appropriate dosages.7
There was evidence of reversible conduction block with
increased temperature in demyelinated fibers in studies of
animalsz6 and of patients with multiple sclerosis.27An injured
nerve may be even more sensitive to thermally induced
conduction blockage due to reduced safety factorz6 In an
experimental study by Hong,13 it was shown that lower doses of
ultrasound thermotherapy could facilitate recovery of compres-
sion neuropathy, but higher doses could induce an adverse
effect. The authors suggested that increased local blood flow
induced by lower-dose ultrasound treatment may contribute to
nerve regeneration or recovery of nerve conduction in entrap-
ment neuropathy. The inhibition of recovery of high-dose
ultrasound treatment may be due to overheating or mechanical
damage.13
Since the underlying pathology in CTS is focal demyelin-
ation caused by compression, the demyelinated part of the
median nerve probably was more sensitive to the ultrasound
treatment. However, we were unable to find any other ultra-
sound study that would support our comment. In an experimen-
tal study, Davis and Jacobson27demonstrated that there was an
increased susceptibility to thermally induced conduction block
in pressure-injured and demyelinated nerve. According to
Davis,27 the precise mechanism for this temperature phenom-
enon is not known. In another study, Hong14 reported a
reversible conduction block as a result of acute ultrasound
treatment in patients with painful peripheral neuropathy but not
in painless peripheral neuropathy. The lack of data regarding
the amplitude changes before and after treatment in our study
limits our comprehension regarding conduction block or ampli-
tude changes. According to Rasminsky,26 at less severely
affected internodes an increased temperature causesa reduction
in internodal conduction time, as at normal internodes. Since
subjects in this study were not severely affected, and we were
able to get all the responsesafter the treatment, we suppose that
an irreversible conduction block did not occur. However, the
nonsignificant decrease in motor NCV might have arisen from
the summated notorious effect of repeated reversible conduc-
tion block as well as from the mechanical effects of ultrasound.
CONCLUSION
Patients with CTS showed statistically significant symptom-
atic improvement after 2 weeks of treatment both with therapeu-
tic ultrasound and placebo ultrasound. Although no significant
electrophysiologic change was observed after the treatment,
there was a slight nonsignificant decrease in motor NCV in the
therapeutic ultrasound-treated groups.
The efficacy and safety of ultrasound therapy in CTS needs
further investigation. An electrophysiologic study (involving
myelinated and unmyelinated fibers) both immediately after
ultrasound application and after treatment, and a longer-term
follow-up might be helpful in observing acute and chronic
effects of ultrasound on neuropathic nerve.
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Suppliers
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b. Enraf Nonius, Rontgen Weg #l, 2600 AZ Delft, Netherlands
c. Parker Laboratories, 286 Eldridge Road, Fairfield, NJ 07004.