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International Journal of Advanced Research and Publications Manual Therapy

Interventions For Carpal Tunnel Syndrome: A Review

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 International Journal of Advanced Research and Publications
ISSN: 2456-9992

Manual Therapy Interventions For Carpal Tunnel

Syndrome: A Review
N.D.P.U. Nakandala
University of Peradeniya, Peradeniya, Sri Lanka
Department of Physiotherapy, Faculty of Allied Health Sciences
nakandalap@gmail.com

ABSTRACT: Carpal Tunnel Syndrome (CTS) is a debilitating condition which affects majority of the middle aged people in the
community. This condition is predominant in females than the males. The condition may be affecting the patient‘s single hand (unilateral)
or both hands (bilateral). The functional outcomes are very poor and patient may be deteriorating psychologically as well. Signs and
symptoms of the CTS can be varied from mild to moderate to severe. This includes numbness or paresthesia along the distribution of the
median nerve of hand, pain, atrophy of muscles, reduced hand grip strength etc. The people who are experiencing mild or moderate
symptoms usually seek for conservative therapies including elctro therapeuatic modalities and manual therapy techniques. When the
condition becomes chronic, the concern is more towards the surgical approaches that involves the carpal tunnel release and thereby
releasing the median nerve compression. But majority of the patients with CTS are reluctant to follow the surgical interventions. This is
mainly due to economic problems and secondary complications of the surgery. Therefore the evaluation of the effectiveness of the
conservative therapies should be a major concern which are cost effective and lack of secondary complications. Many research have been
conducted to see the efficacy of various conservative therapies. This includes electrotherapeutic modalities, manual therapy interventions,
oral supplements and medications, wrist immobilizations such as with splints so on. Among all the aforementioned therapies, manual
therapy interventions alone are known to be more effective in treating CTS. There are various manual techniques with primary focus on
reducing the compression on median nerve and thereby inducing the optimum gliding of the nerve in the carpal tunnel. This is done by
stretching the adhesions developed between the median nerve and the surrounding structures, removing the myofascial restrictions,
improving the pliability and flexibility of the flexor tendons by eliminating the inflammation of the tendon sheaths. In summary this review
focus on research which are conducted to evaluate the efficacy of manual therapy interventions in treating the CTS. Since a combination of
various techniques is more advantageous than a single treatment alone, emphasis should be given to develop a protocol including manual
therapy techniques with other conservative modalities in rehabilitating the patients with CTS.

Key words: Hand Grip Strength, median nerve, conservative treatments, numbness

1. INTRODUCTION
Carpal tunnel syndrome (CTS) can be defined as a
compression neuropathy where the median nerve is
entrapped at the carpal tunnel. Prevalence of the median
nerve injury is much higher than the other compression
neuropathies [1] where it accounts for 90% of all
neuropathies [2]. Four to five percent (4- 5%) of the
population who are aged between 40 and 60 years are
affected by this [3]. Females are more predisposed to this
neuropathy than the male counterparts [2], [3]. Certain
etiological factors are identified in literature including
medical and occupational factors [4]. Medical factors
further can be classified into intrinsic and extrinsic factors
[5]. Chammas, (2014) [3] had classified them as
idiopathic where the exact cause is unknown, and
secondary CTS in which the abnormalities are associated
with the contents. Idiopathic CTS is more common in
females (65-80%) [6] and it has been shown that the age,
gender, genetic factors and the anthropometric factors are
the most influencing factors towards it [7]. Secondary
CTS can be due to the abnormalities of carpal bones,
distal radius or any pathologies of the wrist joint [3].
Abnormalities of fluid distribution such as in pregnancy
[8] also can be taken under this. Dynamic CTS is
identified as one of the most common occupational
pathologies which affects the workers who are involved
with repetitive manual work and are exposed to vibration
repeatedly [2].
2. ANATOMY
2.1. Carpal tunnel
Carpal tunnel is an outlet made of flexor retinaculum and
the carpal bones. Base of the tunnel is bounded medially
by the pisiform bone and the hook of the hamate, and
laterally by the scaphoid and trapezium bones. The roof of
the tunnel is formed by the transverse carpal ligament
which is a fibrous connective tissue ligament connecting
the medial and lateral sides of the base of the tunnel [9].
Nine flexor tendons including four tendons of flexor
digitorum profundus and four tendons of flexor digitorum
superficialis and the tendon of flexor pollicis longus travel
through this tunnel along with the median nerve. Other
than this, carpal tunnel contains two tenosynovium of
flexor tendons, two synovial bursae and subsynovial
connective tissue, which lies between the flexor tendons
and the visceral synovium of the ulnar tenosynovial bursa
[10].
3. PATHOPHYSIOLOGY
Median nerve enters the tunnel in the mid line or
somewhat radial to it. It is vulnerable to compression
inside the tunnel 2- 2.5cm distal to the origination of the
canal where that area is more tapered [11]. Median nerve
is located more anteriorly to the tendons within the canal
[9]. Thenar motor branch of the median nerve branches
off distal to the transverse carpal ligament (TCL), which is
the intermediate part of the flexor retinaculum. Sensory
branch of the median nerve supplies the three radial digits
and the radial half of the fourth digit. As palmar sensory
cutaneous branch which supplies the cutaneous skin of the

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palm originates proximally to the TCL, it is not affected in
CTS [11]. However the diagnosis is based on the
clinical symptoms such as numbness, tingling sensation in
the area of median nerve distribution of the hand etc. [12].
It is being concluded that this compression neuropathies
are consequences of repetitive activity of the hands where
it causes increased thickening of the synovial sheath of the
tendons and thereby exerting more pressure on the nerves
[12]. During the surgical release of the carpal tunnel, it is
reported that the nerve is adhered to the flexor retinaculum
by loose fibrous tissue [13]. This can be occurred also as a
result of increased fluid pressure (eight to ten times) than
the normal pressure thus causing compression of the nerve
[14].
4. MANUAL THERAPY INTERVENTIONS
Interventions or treatment methods can be mainly surgical
or non-surgical though there is no any consensus
regarding the effectiveness of the treatment approach [14].
Conservative methods or non-surgical methods include
the use of electro physical modalities such as magnetic
field therapy [15], ultrasound [16], extracorporeal shock
wave therapy [17], and low intensity laser therapy [18].
Development of multidisciplinary guidelines is essential
in improving the quality of life of the patients with CTS
[19]. Therefore, adequate evidences that support the
effective treatment methods are needed to develop these
guidelines [14]. Most of the people tend to use
conservative therapies despite of less evidences of their
efficacy [20] and avoid the surgical approaches [21]. For
this reason this review primarily focuses on the scientific
literature, which provide the evidences for the
effectiveness of various manual therapy interventions to
treat the CTS.
4.1 Osteopathic manipulation
Osteopathic structural examination and osteopathic
manipulative treatment approaches are very essential in
diagnosing and treating the CTS [22]. This treatment
approach is known to be effective in relieving the
compression over the median nerve and thereby
decreasing the pain and numbness of the patients with
CTS [23].
4.1.1 Opponens roll manuever
Opponens roll maneuver along with the self-stretching
exercises have been introduced to a group of patients who
were diagnosed with CTS with palpatory assessment
methods and nerve conduction tests [23]. In this procedure
patient‘s thumb was abducted, slightly extended and was
brought into lateral rotation along the axis of the first
metacarpal bone. This brings the thumb into a position
opposite to the opposition which is known as retro
position. In this case, maximum rotation occurs at the first
carpo metacarpal joint as it is a saddle joint which imparts
a wide range of mobility to the thumb. Subsequently
vigorous lateral rotation of the thumb had been introduced
which had resulted in traction force on the opponens
pollicis as well as the abductor pollicis muscles.
Furthermore, the TCL was elevated up off the median
nerve relieving the direct pressure on the nerve itself. The
results have shown an increased range of motion of the
wrist joint with a reduction of the palpatory restrictions.
Also it has been shown that several electro diagnostic test
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improvements including a decrease in sensory and motor
latency and an increase in response amplitudes. This in
turn indicates the improvement of nerve conduction
velocities and decrease of conduction blocks by improving
the nerve axons functions. Another study was done by
Sucher et al., (2005) [24] using 20 cadaver limbs (ten
males and ten females). The method was performed with
four study protocols introducing static loading (weights)
and osteopathic manipulation (OM) and reversing of the
sequence of procedures in order to see the effect on the
transverse carpal ligament by measuring the width of the
transverse carpal arch. Greater responses were noted for
all the interventions specifically for the female group.
Furthermore, application of OM prior to the weights was
founded to be more effective in lengthening of the TCL
than the reverse method. This OM had included distal and
proximal transverse carpal extensions which applied a
transverse distraction force across the carpal canal in order
to lengthen the TCL. Secondly, Guy-wire maneuver which
involved maximum abduction along with the extension to
the thumb and the little finger adding a greater stretch to
flexor pollicis longus and flexor digitorum profundus
tendon of the little finger pulling TCA further apart.
Thirdly opponens roll maneuver which was described
earlier [23]. Out of all the maneuvers, combined distal
transverse extension with Guy-wire maneuver had shown
the greatest response as the manual technique.
4.1.2 Carpal mobilization
Carpal bone mobilization is a technique used in physical
therapy which focuses on increase wrist extension or
flexion either by gliding proximal carpal row dorsally or
palmarly respectively. However the efficacy of this
technique in reducing the symptoms has been evaluated in
several studies [25]-[27). A study had done by Gunay, and
Alp, (2015) [25], using 40 patients diagnosed with CTS
clinically as well as electro physiologically. Carpal
mobilization including 3 techniques; dorsal-palmar glide
at radio carpal joint and distraction at the mid-carpal and
radio-carpal joints was used in combination with neutral
volar wrist splint.
(a) Dorsal-palmar glide
Patient‘s hand was rested on a table extending off the
surface. Distal radio-ulnar joint was stabilized. Dorsal or
palmar glides had been provided at the radio carpal joint
by holding the proximal carpal row in order to improve
the extension or flexion respectively.
(b) Mid carpal distraction
Styloid processes were stabilized and the distraction was
given at the distal carpal row.
(c) Radio-carpal distraction
Styloid processes were stabilized and the distraction was
given at the proximal carpal row.
The results have shown significant improvements in
functional activities, pinch grip strength, symptom
severity, distal sensory latency and sensory nerve action
potentials of the median nerve. It is also demonstrated that
the application of mid carpal distraction along with the
median nerve neuro-mobilization than the neuro-
mobilization alone [28]. Another study has evaluated the
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scaphoid and hamate bone mobilizations along with
splinting in CTS [26]. Forty participants with CTS were
given the treatment three times a week for eight weeks.
Ventral surface of the forearm was placed on a table and
the hand was placed out of the table surface.
(d) Scaphoid mobilization
Distal radius was stabilized and the volar or dorsal glide
was provided on the scaphoid bone
(e) Hamate mobilization
Proximal carpal bone was stabilized and the hamate bone
had been glided volarly or dorsally on the triquetrum.
Pain and severity symptoms and functional status had
been significantly improved though there was no any
significant difference in sensory and motor latencies
between the intervention group and the splinting alone
group.
4.2 Active release technique
A pilot study had been carried out to see the efficacy of
active release technique on CTS in five patients (four
females, one male) who were diagnosed with CTS [29].
Treatment protocol was performed by taking the tissue
into a shorten position. And then while maintaining a
manual contact with the tissue being treated, active
lengthening of the tissue was performed. Treatment was
applied to the median nerve at the sites of thenar muscles,
carpal tunnel, flexor digitorum superficialis, pronator teres
and ligament of struthers. Symptom severity (SS) and
functional status (FS) both had been improved according
to the Boston Carpal Tunnel Questionnaire (BCTQ). But
nerve conduction studies had shown no improvement.
This also may be due to an application of a single
treatment session. Quality of the study and the validity of
the results have to be improved by increasing the number
of patients and can be generalized to all the patients with
CTS.
4.3 Soft tissue manipulation
4.3.1 Fascial manipulation
It is concluded that various manual techniques have an
effect on reinstating the normal physiological state of the
fascia, though there is less scientific evidence [30]. In
literature it has been shown that lengthening and thereby
restoring the myofascial tissue can release the pressure on
nerves [31], blood vessels [32] and also restore the
mobility of joints [33]. Poorly coordinated muscle fiber
can be resulted in developing inflammation in the tendons.
Therefore small areas of transformed fascia should be
identified and isolated. However this transformation of
connective tissue is not an isolated process but also can be
occurred in muscle chains or myofascial sequences [30].
This myofascial sequences are made by joining the
biarticular muscles with the unidirectional myofacial units
[34], [35]. A myofascial unit is consisted of monoarticular
and biarticular muscle fibers and surrounding fascia.
Fascia is made up of collagen and elastic fibers which are
arranged in separate layers and in different directions
within the each layer. Fascia is considered as a three
dimensional structure in fascial manipulation technique
[36]. Fascial manipulation (FM) is a manipulation process,
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which works on deep muscular fascia [37]. In this
technique, the body is divided into 14 segments; head,
neck, thorax, lumbar, pelvis, scapula, shoulder, elbow,
forearm, hand, hip, knee, ankle and feet [33]. Pratelli et
al., (2016) [36] had compared the effectiveness of facial
manipulation (FM) Versus Low Level Laser Therapy
(LLLT) in the treatment of CTS. One set of patients who
were diagnosed with CTS according to the clinical and
electro physiological diagnosis were given FM for 45
minutes once a week in three sessions and was continued
for three weeks. Deep friction was given over definite
points which were identified as Centers of Coordination
(CC) and Centers of Fusion (CF) confirmed by palpation
for facial density, patient‘s response and FM guidelines.
CCs are located in deep fascia at the points where the
vectoral forces of muscles in a particular movement are
converged. CFs are confined in intermuscular septa and
retinacula [30]. Deep friction was provided by elbow and
knuckles and it was maintained for 2-4 minutes. The
patients had shown significant (p<0.001) improvements in
Boston Carpal Tunnel Questionnaire (BCTQ) and Visual
Analogue Scale (VAS) and FM technique was effective
than LLLT. Myofascial continuation develops between
flexor carpi retinaculum, palmar aponeurosis antebrachial
and brachial fascia as a thickening along the fascia [38].
This emphasizes how a treatment over a more proximal
CC or CF points on brachial fascia can be resulted in
improvements over the rest of the continuous fascia [36].
4.3.2 Massage therapy
Massage therapy is known to reduce the sympathetic
activity and increase the vagal activity. Also it increases
serotonin levels which result in reduction of pain [39]. It is
found that patients anxiety and depression levels
associated with diseases also can be decreased with
massage therapy [40]. Significant improvement in pain,
hand grip strength, median nerve peak latency scores had
also been noted [41]. To evaluate the efficacy of the
massage therapy on the CTS, a new hand massage
technique had been introduced by [42]. It had included
30s-effleurage, 60s-friction, 30s-petrissage, 30s-shaking
and was ended by another set of 30s-effelurage for total of
three minutes. Throughout the procedure, the patient‘s
neck and shoulder remained neutral, elbow in 90 degree
flexion and supination. The patient was asked to hold the
each position for 5s and to repeat each 10 times at least
three times a day. Results have shown significant
improvements in pain scores, hand grip strength scores
and as well as in electrophysiological parameters. The
effectiveness of each of these techniques have been
identified [43]. Accordingly, effleurage is known to have
a muscle relaxing and sedation effect on the nerves.
Friction massage induces the lymphatic and venous
drainage and consequently relieving the edema. This also
has an effect on scar tissue and adhesions as well.
Petrissage results in prevention of atrophy of the muscles
by removing metabolic products which are collected in the
muscles. Shaking has an analgesic and strengthening
effect.
4.4 Exercises
Median nerve is connected with the peritendinious
subsynovial connective tissue (SSCT) [44] which lies
inside the carpal tunnel as previously described. It is
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found that this tissue is thickened in CTS which may
cause limitation of the median nerve gliding in both
transverse and longitudinal planes [45], [46]. Application
of gliding exercises are known to stretch the adhesions
and increase the gap between the TCL and the median
nerve, facilitating the venous return from the nerve bundle
and reducing the carpal tunnel pressure [47]-[49].
Therefore, this tendon and nerve gliding exercises are
used as a conservative method in rehabilitation programs.
4.4.1 Tendon gliding exercises
A study was conducted by Akalin et al., (2002) [47] using
total of 28 patients (26 females, two males) with clinical
and electrophysiological evidence of CTS. In tendon
gliding exercises, patients were demonstrated five separate
finger positions including straight, hook, fist, table top and
straight fist positions. During this procedure, shoulder and
neck were held in neutral, elbow was supinated and 90
degree flexed. Each position was maintained for five
seconds. Each exercise was performed five sessions daily
and ten times per each session. Efficacy of the
interventions had been evaluated according to patient
satisfaction questionnaire, symptom severity scale and
functional status scale. Small number of patients and lack
of electrophysiological evidences are considered as
limitations of the study. Significant changes have been
found in the cross sectional area (CSA) of the median
nerve during the movement from straight to hook position
and from hook to fist position in tendon gliding exercises.
CSA was increased in straight finger position, where the
fingers were extended fully. CSA was decreased in
subsequent hook and fist positions, where the fingers were
flexed, inducing maximum tendon gliding [44]. Although
it is found that the hook, fist and straight fist positions
increase the maximum gliding of both the flexor
digitorum superficialis and profundus tendons [50],
making a strong fist could even increase the compression
of the median nerve. This position encourages the
lumbricals to be moved into the carpal tunnel [44].
According to Yoshii et al., (2009) [51], when the fingers
are involved in making a fist, the median nerve moves
away from the flexor tendons and moves either ulnar or
radial direction. Then it is compressed against the flexor
retinaculum by flexor tendons which were displayed
palmarly. Since strong fist can exacerbate the condition, it
is avoided during the exercises [44]. This tendon
movements are associated with synovial and extrasynovial
structures located inside the carpal tunnel, and thereby
stretching the subsynovial connective tissue. Also these
tendon movements increase synovial fluid lubrication in
the carpal tunnel bursae. Moreover, the gliding exercises
provide adequate movement between the tendons and
hence reduce the adhesions [52].
4.4.2 Neural gliding exercises
Certain upper extremity joint movements are capable of
increasing or decreasing the strain on the median nerve
[53]. It was demonstrated that the shoulder abduction,
elbow extension, wrist and finger extension are the
movements that induce the strain on the median nerve
[53], [54], exerting the maximum strain of 3.5% during
the elbow extension [53]. Nerve stretching of more than
15.7% can cause complete occlusion of blood flow to the
nerve, where the blood flow is impaired when the strain is
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5-10% [55]. Moreover, the strain on the nerve can even
affects the axonal transport [56] and nerve conduction
[57] as well. It is documented that a minimum of 3%
stretch could be adequate for a nerve with local neural
inflammation to be fired optimally with limb movements
[58]. Coppieters, and Alshami, (2007) [59], have
evaluated the longitudinal exertion and strain on the
median nerve during collective movements of wrist and
elbow joints using cadavers. In this study, neural sliding
techniques had been assessed, in which one particular
movement that increases the strain on the median nerve is
counteracted by another movement done concurrently
which causes decrease strain on the nerve. In tension
techniques, similar movements performed simultaneously
in adjacent joints had been evaluated. Six techniques were
evaluated in embalmed cadavers (five males, one female),
with no prior trauma to the spine or extremities. In first
technique, elbow extension (loading) with wrist flexion
(unloading) was followed by elbow flexion (unloading)
with wrist extension (loading). Loading and unloading of
the nerve were performed at two particular joints with
simultaneous movements which resulted in increased and
decreased strain on the median nerve respectively. In the
second technique, elbow extension with wrist extension
which caused loading of the nerve was followed by elbow
flexion with wrist flexion which caused unloading of the
nerve. In third, wrist flexion and extension were
performed with elbow flexion. Fourth technique involved
wrist flexion and extension while the elbow was fixed in
extension. In fifth technique, elbow was moved with wrist
in neutral where the sixth involved elbow movements with
wrist in extension. All the techniques were performed five
times, where the strain was calculated in final three
repetitions and the range of motion remained same for all
the techniques. Results have shown that optimum gliding
can be occurred by concurrent motions of nearby joints
while loading was counteracted by unloading. It was
revealed that the increased strain on the median nerve was
achieved distally by wrist extension at wrist with
simultaneous elbow flexion, where the nerve strain was
reduced proximally. In contrast, decreased strain on the
median nerve was achieved distally by wrist flexion at
wrist with simultaneous elbow extension, where the nerve
strain was increased proximally. However, it was found
that simultaneous extension in the two adjacent joints can
be resulted in limited nerve stretching or strain either
proximally or distally such as with tension technique.
Anyway, the emphasis should be given to the nerve
gliding exercises which are not aggravating the patients‘
clinical symptoms in the rehabilitation set up [60].
Therefore, it is concluded that the sliding techniques have
the largest longitudinal excursion and the optimum gliding
without having any deteriorating effect on the nerve [59].
The results were confirmed by Coppieters, and Butler,
(2008) [61], indicating that the greatest excursion of the
median nerve occurs with sliding than the tensioning
technique (12.6mm and 6.1mm respectively) and
relatively a greater strain on the nerve was achieved in
vise versa (6.8% , 0.8% for tensioning and sliding
respectively). A study done by Akalin et al., (2002) [47],
have also evaluated the efficacy of median nerve gliding
exercises other than the tendon gliding exercises. In the
median nerve gliding session, 6 different hand positions
had been introduced. They were; 1. Wrist in neutral;
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fingers and thumb in flexion, 2. Wrist in neutral; thumb
and fingers in extension, 3. Wrist and fingers in extension;
thumb in neutral, 4. Wrist, fingers and thumb in extension,
5. Forearm in supination, opposite hand applies a stretch
on the thumb. During this procedure also, shoulder and
neck were held in neutral, elbow was supinated and 90
degree flexed. Each position was maintained for five
seconds. Each exercise was performed five sessions daily
and ten times per each session. Significant improvements
were noted in patient satisfaction questionnaire, symptom
severity scale and functional status scales. Studies also
have been implemented to see the position of wrist with
lowest carpal tunnel pressure. It is found that carpal tunnel
pressure was increased with flexion and extension of the
wrist joint where it was lowered with wrist in neutral
position [62], [63]. Weiss et al., (1995) [62] also have
shown that the traditional wrist splints that hold the wrist
in slight (20-30 degree) extension increases the pressure
of the carpal tunnel. Furthermore, neutral wrist position
had been recognized as the optimum position to alleviate
the symptoms of CTS. In contrast, some studies have
indicated that the alternative active flexion and extension
exercises of the wrist joint can decrease the pressure
inside the carpal tunnel [64].
4.5 Combination of manual therapy techniques
Combination of several manual therapy interventions in a
single treatment also have been evaluated [65]. In this
regard, 22 patients (20 females, two males) who were
diagnosed with CTS clinically and electro physiologically
were provided with four sessions of manual therapy
interventions. In the first session, deep transverse massage
was used in cranio-caudal direction to treat the most
thickened tissue of the hand palmar surface, wrist and
forearm anterior surfaces for ten minutes. In the second
and third sessions, radio-carpal and radio-ulnar joints were
passively mobilized and the palmar surface of metacarpo-
phalangeal joints were opened by maintaining the hand in
the traction for fifteen minutes. Fourth session had
included passive flexion, extension and transverse
movements to improve the range of motion of the joints
by maintaining the hand in traction. Moreover while the
hand was maintained in open and extended position,
palmar aponeurosis and the pollical and first palmar
interroseus muscles were treated for additional fifteen
minutes. The patients‘ symptoms such as pain, paresthesia
which were assessed according to BCTQ had improved
significantly. But the nerve conduction studies had shown
no improvements. This may be due to the short duration of
treatment and the absence of home exercise program. This
ensures the importance of maintaining manual
interventions even after the initial treatment as well. Study
quality was reduced due to reduced number of patients,
absence of a control group and short period of follow up.
5. CONCLUSION
Various manual therapy techniques have been evaluated in
literature in order to see the effectiveness on CTS. This
includes Osteopathic manipulation, Active release
technique, Soft tissue manipulation, Tendon and nerve
gliding exercises. Studies have been conducted in vivo as
well as in embalmed cadavers. Manual therapy techniques
were more effective in reducing the patients‘ symptoms
and consequently improving the functional levels. All the
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techniques were known to have a positive outcome
towards the pain scores, symptom severity scales,
functional status scales and hand grip strength. Some
studies have shown the improvements in eletro
physiological parameters including sensory and motor
latancies of the median nerve. Maintenance or follow up
of these techniques for a period of time even as a home
based exercise program is very crucial. Furthermore it is
evident that, among all the conservative therapies, manual
therapy interventions are more beneficial. Thus, the
employment of different manual therapy techniques along
with the other conservative therapies would be more
promising in treating CTS.
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Author Profile
Ms N.D.P.U. Nakandala received the
B.Sc. (Hons) in Physiotherapy, from
Faculty of Allied Health Sciences,
University of Peradeniya, Sri Lanka in
2018. From January, 2018 to December,
2018, she worked as a Demonstrator in
the Department of Basic Sciences,
Faculty of Allied Health Sciences,
University of Peradeniya, Sri Lanka. Currently she is
working as a Demonstrator in the Department of
Physiotherapy, Faculty of Allied Health Sciences,
University of Peradeniya, Sri Lanka.

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