EFFECTIVENSS OF ULTRASOUND AND LOW LEVEL LASER THERAPY WITH MEDIAN

NERVE MOBILIZATION ON PAIN AND IMPROVING FUNCTIONAL OUTCOME IN

SUBJECTS WITH CARPEL TUNNEL SYNDROME

A project proposal

Submitted to

SAVEETHA COLLEGE OF PHYSIOTHERAPY

SIMATS, Chennai 602 105

In partial fulfillment of requirement for the degree of

BACHELOR OF PHYSIOTHERAPY

by

KHIZAR HUSIN.F

(182101038)

BPT III YEAR

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CONTENTS

S.No. Headings Page No.

1. Title of the Research Project 4

2. Research Question 4

3. Summary of Proposal 5

4. Introduction 6

5. Background and Need for the Study 7

6. Review of Literature 8

7. Subjects and Methods 9

8. Data analysis 11

9. Timeline 11

10. References 11

11. Appendix 12

12. Informed consent form 13

EFFECTIVENSS OF ULTRASOUND AND LOW LEVEL LASER THERAPY WITH

MEDIAN NERVE MOBILIZATION ON PAIN AND IMPROVING FUNCTIONAL
OUTCOME IN SUBJECTS WITH CARPEL TUNNEL SYNDROME
Name of the Researcher:

Khizar husin.F,
BPT III year
Saveetha College of physiotherapy,
Thandalam,
Chennai – 602105.

Name of the Supervisor:

DR. K. Ramana,
Asst. Professor,
Saveetha College of physiotherapy,
SIMATS,
Thandalam,
Chennai – 602105.

Name of the co-guide:

DR. Sakthisiva,

Tutor,

Saveetha College of physiotherapy,

Thandalam,

Chennai – 602105

Title of the research project : EFFECTIVENSS OF ULTRASOUND AND LOW LEVEL LASER
THERAPY WITH MEDIAN NERVE MOBILIZATION ON PAIN AND IMPROVING FUNCTIONAL

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OUTCOME IN SUBJECTS WITH CARPEL TUNNEL SYNDROME

1. Research Question: Is there any significant comparison on assessing the effectiveness of

Ultrasound and low level Laser therapy with median nerve mobilization on pain and improving
functional outcome in subjects with carpel tunnel syndrome?

2. Summary of the proposal:

AIM : The aim of the study is to find the effects of Ultrasound and low level Laser therapy with
median nerve mobilization on subjects with carpel tunnel syndrome.
OBJECTIVE :
To determine the effects of Ultrasound and with median nerve mobilization on pain and
improving functional outcome of carpal tunnel syndrome.
To determine the effects of low level laser therapy with median nerve mobilization on pain and
improving functional outcome of carpal tunnel syndrome.

STUDY DESIGN : Comparative study

STUDY PROCEDURE : A total of 30 subjects will be selected using convenient sampling

technique based on inclusion and exclusion criteria. The study will be explained to subjects and
written consent will be obtained from subjects. The patient will be done into two groups (Group
A-15 and Group B-15). Group A will be treated with ultrasound with median nerve mobilization
and Group B will be treated with low level laser therapy with median nerve mobilization.

MATERIALS REQUIRED : Ultra sound and Low level Laser Therapy.

OUTCOME MEASURE : Boston carpal tunnel questionnaire, sollemann hand functioning test,
Numerical pain rating scale.

INTENDED STATISTICAL PROCEDURE : Paired t test, Unpaired t test.

3. Introduction:
Carpal tunnel syndrome (CTS) represents the most prevalent form of peripheral nerve
entrapment syndrome¹. It manifests through the compression of the median nerve at the wrist joint,

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leading to diminished nerve function in that area². Carpal tunnel syndrome arises when the canal
narrows or when there’s swelling in the palmar tendons or their sheaths. This constriction within the
canal puts pressure on the median nerve, leading to symptoms such as altered sensation, usually
affecting the radial 3½ digits. However, these symptoms can advance, causing atrophy and weakness
in the thenar muscles, ultimately resulting in a diminished pinch grip³.Many factors such as
irregularities of the flexor tendons, synovium, and lesions may raise the pressure inside the carpal
tunnel and lead to median nerve compression ⁷. It is the most commonly reported nerve Compression
syndrome and these sensations may occur in the thumb, index finger, middle finger and radial side of
the middle finger². This CTS is a musculoskeletal condition that is linked to work activity in those
who are affected. Repetitive motion and strain are the causes of this condition, which makes manual
labourers susceptible to it. This syndrome causes pain, numbness and tingling sensation in the wrist
and hand region. The painful sensations may be leads to grip strength and hand function reduction¹.
The symptoms of carpal tunnel syndrome (CTS) can vary significantly among patients, leading to
classifications based on severity: mild, moderate, and severe. This variability encompasses a spectrum
of manifestations, ranging from occasional tingling and numbness in the hand and fingers to persistent
pain, weakness, and loss of function. Mild cases may involve intermittent discomfort or minor
sensory disturbances, while moderate presentations often include more frequent or pronounced
symptoms affecting daily activities. Severe instances of CTS typically entail intense and prolonged
pain, significant weakness, and marked impairment of hand function, necessitating prompt and
comprehensive medical evaluation and management(4).

Although carpal tunnel syndrome (CTS) is primarily considered an idiopathic syndrome,

meaning its exact cause is often unknown, several risk factors have been identified that are
associated with its prevalence. These risk factors contribute to the likelihood of developing
CTS and can exacerbate its symptoms. Among the key risk factors are obesity, which
increases pressure on the median nerve within the carpal tunnel; engaging in monotonous
wrist activities, such as prolonged typing or repetitive assembly line work, which can lead to
strain and compression of the median nerve; pregnancy, due to hormonal changes and fluid
retention that can increase pressure on the carpal tunnel; genetic heredity, with some
individuals having a predisposition to developing CTS based on family history; and
rheumatoid inflammation, which can cause swelling and inflammation within the carpal
tunnel, further compressing the median nerve. Understanding and addressing these risk
factors are essential for both preventing and managing CTS effectively⁴.

The reported incidence of carpal tunnel syndrome (CTS) falls within the range of 0.125% to
1%. An estimated 4% and 5% of people suffer from CTS worldwide, most frequently
between the ages of 40 and 60, with a disproportionate impact on women, affecting them ten
times more often than men. Among females, the prevalence of CTS ranges from 3% to 3.4%,
whereas among males, it varies between 0.6% and 2.7%. These statistics underscore the
gender disparity in CTS occurrence and highlight its significance as a prevalent
musculoskeletal disorder, warranting attention in both clinical practice and public health
initiatives aimed at prevention and management ⁵. In Europe, 60% of work-related disorders
were attributed to CTS⁷. Workrelated CTS prevalence in different occupational studies varies,
ranging from 1 to 61%. The highest CTS prevalence of 61% was reported among industrial
workers mostly utilising grinding tools, while about 1% of industrial workers with vigorous
but low repetitive hand use acquired CTS⁶. Over $2 billion is spent on CTS yearly, making it
the most costly upper extremity musculoskeletal condition in the US. According to Dale et
al., industrial workers, women, and the elderly are more likely to have CTS, which has an
incidence of 5.8% and a prevalence of 7 to 19% in the United States ⁸. Patients with diabetes
have a lower onset of nerve damage, which makes them more susceptible to developing CTS.
The incidence rate in people with diabetes is 14% in those without diabetes and 30% in those
with diabetic neuropathy; the prevalence rate during pregnancy is estimated to be 2%⁴.

Currently, there are several treatment methods for CTS such as: (1) non-steroidal
antiinflammatory drugs (NSAIDs); (2) injection of medications; (3) immobilization by
splinting; (4) rehabilitation modalities (therapeutic ultrasound, ASTM AdvantEDGE™
stretching and strengthening); and (5) surgery by carpal tunnel release ⁹. When treating
patients with mild to moderate idiopathic carpal tunnel syndrome, the short- to medium-term
results of ultrasound therapy were shown to be satisfactory¹ ⁰. This study aimed to investigate
the efficacy of ultrasound and laser therapy with median nerve mobilization on pain and
improving functional outcome in the treatment of CTS.

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5. Background and Need for the study :
Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy, resulting
from compression of the median nerve at the wrist. Clinical manifestations include
numbness, tingling, burning, and/or pain linked to the median nerve being compressed
locally at the wrist, which causes mechanical compression or local ischemia. Patients
report weakness in the abduction of the thumb and paraesthesia (with or without
numbness or pain) in the fingers innervated by the median nerve. At night, symptoms
worsen and frequently cause the sufferer to wake up. Majorly women are affected by CTS
ten times more frequently than males and it typically strikes between the ages of 40 and
60. In females, it is prevalent between 3% and 3.4%, whereas in males, it is between
0.6% and 2.7%. Currently there is no study about the effectiveness of ultrasound and low
level laser therapy with median nerve mobilization on pain and improving functional
outcome in subjects with carpal tunnel syndrome.

Hypothesis:
NULL HYPOTHESIS : There will be no significant effect of ultrasound and low level
laser therapy with median nerve mobilization on pain and improving functional outcome
in subjects with carpal tunnel syndrome.
ALTERNATE HYPOTHESIS: There will be significant effect of ultrasound and low level
laser therapy with median nerve mobilization on pain and improving functional outcome
in subjects with carpal tunnel syndrome.

6. Review of Literature:
1. Gerold R Ebenbichler., (2010) - Concluded that the study indicates that in
individuals with mild to moderate idiopathic carpal tunnel syndrome, ultrasound
treatment is helpful in the short term and can even produce satisfying results in the
medium term. More research is needed to independently validate these results, assess the
best treatment plans using this approach, and determine whether early decompression
may lead to better long-term outcomes with fewer eventual neurological deficits, or
whether ultrasound treatment or one of the non-surgical treatments alone or in
combination is superior.
2. Amir H Bakhtiary., (2004) -.Concluded that Our clinical investigations
demonstrated that for patients with mild to moderate carpal tunnel syndrome, ultrasound
treatment is more beneficial than low level laser treatment. The long-term effectiveness of

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 ultrasound vs laser therapy, as well as whether the combination of these two treatments is
more effective than either treatment alone, require more research.
3. Yi Huey Lim., (2017) - Stated that Three methods of median nerve mobilization
were described in the CTS literature by the review’s findings. Treatment outcomes seem
to be impacted differently by various methods of median nerve mobilization. To ascertain
each mobilization technique’s relative efficacy in compared to control or comparator
interventions, however, requires more research. To fully grasp the true efficacy of median
nerve mobilization in the treatment of CTS, future research must address the
methodological difficulties that have been identified in the current body of work.
4. Alessia Genova., (2020) - States that One of the most often documented cases of
compression of the median nerve is CTS, a prevalent medical ailment. When the median
nerve is crushed or constricted while passing through the wrist, CTS results. Hand
discomfort, numbness, and tingling along the median nerve’s distribution are the
hallmarks of the illness. An overview of CTS with a focus on anatomy, epidemiology, risk
factors, pathophysiology, stages of CTS, diagnosis, and management options has been
presented by this study of the literature.
5. Iain A Rankin., (2017) - Concluded that any data to suggest any therapeutic effect
of LLLT in treating CTS, and the quality of the evidence is very low. Only VAS pain and
finger-pinch strength met previously published MCIDs; however, considering the limited
trials and considerable risk of bias, these are probably overestimates of effect. Based on
short-term, clinically meaningful improvements in discomfort and finger-pinch strength,
there is low- to very low-quality evidence suggesting that ultrasonography is a more
effective treatment for chronic total weakness than LLLT. For the management of CTS,
there is not enough data to determine if LLLT is superior to or inferior to any other kind
of non-surgical treatment. Any more LLLT research ought to be conclusive, blinded, and
of the highest caliber.
6. Patrycja Żaneta Bobowik., (2019) - Concluded that the papers that have been
evaluated demonstrate that physiotherapy treatments have a major positive impact and
help with hand CTS symptoms. More efficient conservative treatment for carpal tunnel
syndrome (CTS) is now possible thanks to advancements in physiotherapy and
rehabilitation research. This raises the possibility of postponing or avoiding surgery.

7. Subjects and Methods

a. Subjects: Individuals with carpal tunnel syndrome

b. Sampling technique: Conventional sampling

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c. Sample size: 30 samples
d. Inclusion criteria:
(i) Both gender, male and female
(ii) Age group of 30 to 60 subjects were included.
(iii) NPRS score more than 6.
(iv) Patients with symptoms in CTS-6 criteria.
e. Exclusion criteria:
(i) Previous surgery.
(ii) Traumatic injury of wrist.
(iii) Diabetic neuropathy or peripheral neuropathies.

f. Study procedure :
A total of 30 subjects will be selected using conventional sampling technique
based on inclusion and exclusion criteria. The study will be explained to subjects
and written consent will be obtained from subjects. The patients will be divided
into two groups (group A- 15, group B- 15). Group (A) will be treated with
Ultrasound with median nerve mobilization and group (B) will be treated with
Low Level Laser Therapy with median nerve mobilization.
GROUP A : Ultrasound with median nerve mobilization:
The program administrates Ultrasound with median nerve mobilization
which was assigned to the participants, which included ultrasound and
median nerve mobilization (distal nerve tensioning, upper quarter nerve
tensioning and nerve sliding).
GROUP B : Low Level Laser Therapy with median nerve mobilization :
The program administrates Low Level Laser Therapy with median nerve
mobilization which was assigned to the participants, which includes low level
laser therapy and median nerve mobilization (distal nerve tensioning, upper
quarter tensioning and nerve sliding).

GROUP A : Ultrasound with median nerve mobilization

Ultrasound :
The subjects in the group A will receive ultrasound treatment at the area of
the carpal tunnel and at the hand, finger regions. Participants are instructed
not to perform any other exercises before the intervention period. Before
the Exposure of deep heating modality, the therapist will evaluate the
patient from ultrasound group thoroughly and will carry out necessary

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 operating and safety checks of the Ultrasound Therapy. Patients thermal
sensation of the body part will be recorded and local metal objects,
synthetic material and electronic devices from the body part to the treated
should be removed. Ultrasound using with aquasonic gel as couplant will
given at the frequency of 1 MHz and intensity of 1.0 W/cm² with pulse
mode and a transducer area of 5cm². The treatment was initially
conducted for 15 minutes/ session, 4 times a week for 3 weeks.

Median nerve mobilization :

After the ultrasound treatment session the participants in the group A are
informed to receive median nerve mobilization techniques.
Distal nerve tensioning : The distal part of the affected extremity is mobilized in
the 6 different position technique.
• Make the wrist in neutral position with full Finger and thumb flexion
and hold the position.
• Full extension of Fingers and Thumb and hold the position.
• Add wrist extension.
• Add thumb extension.
• Position the forearm in supination.
• Apply slight tension to the thumb.
These positions are done at the frequency of 5-10 repetitions for 3-5
sessions a day. Each positions should maintained or hold for 7-10
seconds.

Upper quarter tensioning : The affected upper extremity is treated by giving

following method.
• Make the participants to do slight glenohumeral abduction.
• Depress the shoulder girdle.
• Extend the elbow.
• Make the whole arm for the lateral rotation.
• Extend the wrist, fingers and thumb.
This technique is done at the frequency of 5-10 repetitions for 3-5
sessions a day and each stretch should be maintained for the 5-7
seconds.

Nerve sliding :

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 • The distal part of the affected extremity undergoes extension of wrist
and finger flexion and then alternate flexion of wrist and finger
extension.
• The distal part of the affected extremity undergoes flexion of elbow
with wrist extension and then alternate extension of elbow and flexion
of wrist.
This technique is done at the frequency of 10 repetitions for 10
sessions a day.

GROUP B : Low Level Laser Therapy with median nerve mobilization

Low level Laser Therapy :
The subjects in the group B will receive low level laser therapy at the area
of carpal tunnel and at the hand and finger regions. Participants are
instructed not to perform any other exercises before the intervention
period. Before the Exposure of deep heating modality, the therapist will
evaluate the patient from laser therapy group thoroughly and will carry
out necessary operating and safety checks of the Laser Therapy. Patients
thermal sensation of the body part will be recorded and local metal
objects, synthetic material and electronic devices from the body part to the
treated should be removed. Low level laser therapy will be applied at the
affected area in a scanning method at low intensity of (9J), with infrared
laser diode (830nm) at five points (1.8J/point) over the area of carpal
tunnel and median nerve. The treatment was conducted for 15
minutes/session, 4 times a week for 3 weeks.

Median nerve mobilization :

After the ultrasound treatment session the participants in the group A are
informed to receive median nerve mobilization techniques.
Distal nerve tensioning : The distal part of the affected extremity is mobilized in
the 6 different position technique.
• Make the wrist in neutral position with full Finger and thumb flexion
and hold the position.
• Full extension of Fingers and Thumb and hold the position.
• Add wrist extension.
• Add thumb extension.
• Position the forearm in supination.
• Apply slight tension to the thumb.

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 These positions are done at the frequency of 5-10 repetitions for 3-5
sessions a day. Each positions should maintained or hold for 7-10 seconds.

Upper quarter tensioning : The affected upper extremity is treated by giving

following method.
• Make the participants to do slight glenohumeral abduction.
• Depress the shoulder girdle.
• Extend the elbow.
• Make the whole arm for the lateral rotation.
• Extend the wrist, fingers and thumb.
This technique is done at the frequency of 5-10 repetitions for 3-5 sessions
a day and each stretch should be maintained for the 5-7 seconds.

Nerve sliding :
• The distal part of the affected extremity undergoes extension of wrist
and finger flexion and then alternate flexion of wrist and finger
extension.
• The distal part of the affected extremity undergoes flexion of elbow
with wrist extension and then alternate extension of elbow and flexion
of wrist.
This technique is done at the frequency of 10 repetitions for 10
sessions a day.

8. Data Analysis: All of the data will be tabulated and statistically analysed. The outcome measure is
done with the single leg balance test and star excursion balance test.

9. Time line:

a. Proposal development : 2 weeks

b. Subject recruitment : 2 month
c.Intervention : 1 month
d. Analysis and report writing : 1 month
e. Dissemination : 1 month

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10. References
1. Wright AR, Atkinson RE. Carpal tunnel syndrome: An update for the primary care
physician. Hawai’i journal of health & social welfare. 2019 Nov;78(11 Suppl 2):6.

3.Newington L, Harris EC, Walker-Bone K. Carpal tunnel syndrome and work. Best practice
& research Clinical rheumatology. 2015 Jun 1;29(3):440-53.

4. Genova A, Dix O, Saefan A, Thakur M, Hassan A. Carpal tunnel syndrome: a review of

literature. Cureus. 2020 Mar 19;12(3).

5.Soyuer F. Effectiveness of current physiotherapy in carpal tunnel syndrome. Int J Fam

Commun Med. 2021;5(3):87-9.

6.Ealth, 21(1), pp.1-10. Feng B, Chen K, Zhu X, Ip WY, Andersen LL, Page P, Wang Y.
Prevalence and risk factors of self-reported wrist and hand symptoms and clinically confirmed
carpal tunnel syndrome among office workers in China: a cross-sectional study. BMC Public
Health. 2021 Dec;21(1):1-0.

7.Gadkari PD, Dahikar GD, Ganjiwale RO. A review on carpal tunnel syndrome. Research
Journal of Pharmacy and Technology. 2020;13(10):4961-5.

8.Wright AR, Atkinson RE. Carpal tunnel syndrome: An update for the primary care
physician. Hawai’i journal of health & social welfare. 2019 Nov;78(11 Suppl 2):6.

9.Wilson JK, Sevier TL. A review of treatment for carpal tunnel syndrome. Disability and
rehabilitation. 2003 Jan 1;25(3):113-9.
10. Bakhtiary AH, Rashidy-Pour A. Ultrasound and laser therapy in the treatment of carpal tunnel
syndrome. Aust J Physiother. 2004;50(3):147-51. Doi: 10.1016/s0004-9514(14)60152-5. PMID:
15482245.

11. Appendix

A. Scales and scores

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B. Information sheet

1. Title of the research project: Effectiveness of Ultrasound and Low Level Laser Therapy
with median nerve mobilization on paint and improving functional outcome with carpal
tunnel syndrome.

2. Description of the study: To evaluate the effects of ultrasound and laser therapy with
median nerve mobilization on pain and improving functional outcome using NPRS and
BCTQ scale and sollermann hand functioning test.

3. Possible risk of the participant: No risk is involved in this study.

4. Benefit of the study: Individuals will be benefited from this study.

5. Compensation to the participant: No compensation will be provided during or at the End

of the study.

6. Confidentiality: Information received from the patients will be kept safe and only used
For research purposes.

7. Participant right to withdraw from the study: Individuals can withdraw at any time Of the
study.

8. Complaints regarding the study should be reported to: Any complaints regarding The
study can be informed to the Clinical In charge of Saveetha physiotherapy Department,
SMCH

9. Detailed information and clarification can be obtained from: Khizar husin.F , UG, 5Th
semester, SCPT, SIMATS

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 10. Khizar husin.F has explained clearly to the participant all the above details. All questions
and clarifications by the participant have been fully answered.

11. Signature of the Participant investigator with date:

C. Informed Consent Form

I agree to take part in the study, conducted by

Khizar husin.F undergraduate students, Saveetha College of Physiotherapy,
SIMATS.

TITLE: EFFECTIVENSS OF ULTRASOUND AND LOW LEVEL LASER THERAPY WITH

MEDIAN NERVE MOBILIZATION ON PAIN AND IMPROVING FUNCTIONAL
OUTCOME IN SUBJECTS WITH CARPEL TUNNEL SYNDROME.

I acknowledge that the study has been explained to me and I agree to participate and I am willing
to provide information about my health status to the investigator. I allow the investigator to have
access to my medical records, pertaining to the purpose of the study. Participate in the analysis
program. Make myself available for further analysis required. I have been informed about the
purpose producers and measurements involved in the study and my queries towards the study
have been clarified. I have been informed that this study consists of a group and I also agree to
come regularly for the study period of 4week.

I Provide consent to the investigator to use the still photographs with masked face for educational
purposes only. No funds / fees / remuneration is taken from the subjects on the course of the
study.

I understand that my participation is voluntary and can with draw at any stage of the study.

Place:
Date:

Signature:

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SAVEETHA COLLEGE OF PHYSIOTHERAPY

SIMATS, Chennai-602105

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