Running Head: MMT for CTS

Commented [AT1]: overall your proposal is very well

done – there are some suggested edits and corrections
if you chose to revise/resubmit

Efficacy of Using a Multimodal Treatment Including Splinting for Adults with Carpal Tunnel

Syndrome

Todd Banks

Gareth Loosle

Lexi Sybrowsky

University of Utah
MMT for CTS

Introduction

Carpal tunnel syndrome (CTS) is a condition affecting the median nerve where the nerve

is compressed due to inflammation from within the carpal tunnel. The carpal tunnel is an

anatomical area where the median nerve is surrounded by the tendons of hand muscles in a

tightly enclosed space. Carpal tunnel syndrome treatment is a highly researched medical

condition with studies dating back to the 1960’s. There is ample evidence supporting splinting

for the treatment of CTS. Many studies compare conservative treatment such as splinting to no

treatment; conservative treatment to surgery; and many studies neglect the severity of CTS

(Yildiz, 2007; Yagci, 2009; Sutton, 2016; Page 2012; Mahmoodian, 2016; Chung, 2016). Commented [AT2]: incorrect APA citation

However; in the real world it is rare to find only one treatment modality being used for mild to

moderate cases of CTS. Commented [AT3]: this is a thing of beauty

There is a lot of emerging research examining the available and developing modalities for

the treatment of CTS such as low level laser therapy, ultraviolet stimulation, electro stimulation,

nerve gliding, steroid injections, electroacupuncture, and there is evidence supporting many of

these treatments including versus in comparison to no treatments, or examining splinting and a

treatment versus splinting alone (Yildiz, 2007; Yagci, 2009; Sutton, 2016; Page 2012;

Mahmoodian, 2016; Chung, 2016). This is expected as these are easy studies to create compared Commented [AT4]: incorrect APA citation

to the alternative. However, there is a lack of research comparing these different modalities with

each other to determine the best possible treatment for CTS.

We are proposing a study that compares multimodal treatments in order to determine the

most effective treatment for CTS. This study is an important step to take because it addresses the

need for updated research for non-surgical treatment of mild to moderate CTS that compares

multiple treatment approaches that all include splinting. Splinting paired with additional
MMT for CTS

treatments have demonstrated to be more effective than utilizing only splinting. There are few

existing articles comparing multiple modalities within one study and consequently is is difficult

to say which multimodal treatment is the most effective. Current research shows that many CTS

studies have limitations in sample size which threatens the external validity of the studies. Our

study will seek a minimum of 120 participantslarger sample size and compare multiple

modalities to address this clear gap in the literature. Commented [AT5]: I still think this would read better in
the objective
Because mild to moderate CTS affects occupational engagement and satisfaction; we

plan to use the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) to measure symptom

severity and current functionality. Expected results of this study include the greatest increase in

function and reduction of symptom severity to be those within the splinting and steroid injection

experimental group with overall improvement measured in all other multimodal groups.
Background
Carpal tunnel syndrome (CTS) affects approximately 3% of the adult population in the
Commented [AT6]: so as I’d mentioned in the draft
(and I think I spoke with some of you about this in
person, too), this would likely be better in the objective
because you haven’t presented any background yet in
which to group this reasoning and as such, it comes
out of nowhere… if you chose to do a revision, I
strongly recommend you put this with the objective
after you present relevant background info

United States (Carpal Tunnel Syndrome Fact Sheet, 2017). Women are three times more likely to

develop CTS than men and severity of the disease increases with age (Wipperman & Goerl,

2016). The pain and other symptoms associated with CTS can interfere or inhibit an individual's

function in everyday activities and occupations like work, school or home responsibilities and

can significantly impact a person’s quality of life (How does carpal tunnel syndrome affect a

person's quality of life, 2009).

Different treatment approaches have been introduced to individuals with CTS. In cases of

mild to moderate carpal tunnel where surgery isn’t necessary, non-surgical or conservative

treatments are introducedthe preferred treatment option?. These treatments can include splinting,

exercise, oral medication, locally injected steroids, acupuncture and ultrasound (Mahmoodian,
MMT for CTS

Khosrawi, & Emadi, 2016). The most commonly utilized non-surgical treatment is splinting

(Carpal tunnel syndrome, 2017). The effects of splinting for CTS has been researched for

decades and evidence collected in a systematic review shows that splinting is an effective form

of treatment (Piazzini et al., 2007). This systematic review oflooked at 33 randomized control

trials and evaluated the current available evidence for treating CTS, which showed that though

splints were shown to be an effective form of treatment, more current research shows that multi-

modal treatments that include splinting may have better outcomes. Commented [AT7]: I’m a bit confused by this
statement. Did the review show that multi-modal
treatments may have better outcomes? Or other
Splinting plus low level laser therapy studies that have come out since the review suggest
this?
Research done by Dincer, Cakar, Kiralp, Kilac, and Dursun (2009) found that splinting Commented [AT8]: I prefer to see research studies
with the citation in parentheses as opposed to saying
so and so found and research done by so and so ….
plus low-level laser therapy was more effective at reducing symptoms than splinting alone. just because it reads very list-y. Otherwise I like how
you summarized across studies
Additional research done by Yagci et al. (2009) had similar findings and concluded that though

both groups in their study showed improvements in function and symptom severity, the addition

of laser therapy had superior results to splinting alone. Participants in both studies that received

splinting and low-level laser therapy showed improvements in their symptom severity and

functionality scores post treatment. These two studies emphasize the importance of using a

multimodal treatment that includes splinting for individuals with CTS. Commented [AT9]: this is great

Splinting plus tendon nerve gliding exercises

Brininger et al. (2007) conducted a randomized control trial that looked atexamined the

efficacy of customized splints coupled with tendon nerve gliding exercises used to treat CTS.

This study suggests that a splint combined with a home exercise program including tendon nerve

glides showed a greater reduction in overall symptoms than splinting alone. This study found

significant improvement in both BCTQ outcomes for the group that received splinting and

tendon nerve glide exercises. Commented [AT10]: are these saying the same thing
(i.e., redundant?)
MMT for CTS

Splinting plus electroacupuncture

Chung et al. (2016) conducted a large randomized control trial that included 174

participants with mild to moderate carpal tunnel syndromeCTS. Participants that received

electroacupuncture in addition to splinting showed greater improvements in symptom severity

and function compared to the splinting alone group. Additional findings showed that

electroacupuncture produced greater changes in symptoms when added to a traditional splinting

treatment.

Splinting plus local steroid injection

Mahmoodian, Khosrawi, and Emadi (2016) conducted a randomized control trial that

compared the effectiveness of two commonly used conservative treatments for CTS, splinting

and splinting plus local steroid injection. Results of this study found that using combination

therapy or a multimodal approach was a more effective treatment for long-term functional

improvements and symptom severity.

Splinting plus education

Hall et al. (2013) completed a randomized control trial that evaluated the effects of

splinting alone compared to a splinting plus education group in individuals with CTS. The results

suggest that splinting combined with an education program showed a reduction in pain

symptoms and improved overall functional status more than splinting alone.

General multimodal approaches

Luchetti et al. (2017) completed an observational study that evaluated the current

conservative treatments available for individuals with CTS. This study concluded that

approaching individuals with a multimodal and multidisciplinary approach to treatment can

account for a greater improvement in patient outcomes. One specific multimodal approach was
MMT for CTS

not found to be more effective than another, but overall, having a multimodal treatment for this

population has been shown to be effective.

Studies with limited sample size

A limitation in the current research surrounding multimodal treatments that include

splinting is the small sample sizes within the available studies. Of the 13 studies found

supporting a multimodal approach, three of them had sample sizes under 50 (Dincer, Cakar,

Kiralp, Kilac, and & Dursun, 2009; Mahmoodian, Khosrawi, and & Emadi, 2016; Yagci et al.,

2009). More studies need to be done with larger sample sizes to better transfer and generalize the

results to a larger majority of people with CTS. The gap in the research our proposed study will

try to fill includes a larger sample size with the hopes of generalizing the results to more people.

An increased sample size will also help to increase the power of our statistics and prevent a type

II error in our research. Our proposal hopes to fill this gap in the current research while

simultaneously determining which multimodal approach is the most effective for treating CTS.

Objective

Current research has shown that splinting coupled with other modalities is more effective

in treating mild to moderate carpal tunnel syndromeCTS than splinting alone. Though the current

research regarding splinting combined with another multimodal treatment is level one research,

the specific combination of splinting with the multimodal treatment that will provide the most

improvement in function and reduction in pain has yet to be determined. Our research question

seeks to examine which multimodal treatment that includes splinting is most effective for adults

with mild to moderate carpal tunnel syndrome in reducing symptom severity and increasing

function. By conducting this study, we will have a better understanding of which modality

combined with splinting is the most effective in reducing symptom severity and increasing
MMT for CTS

functionality. Once this is identified, occupational therapists will be able to provide this group of

people with the most effective, evidence-based treatment available. Utilizing the most effective

treatment will help clients better participate in their daily occupations and not be limited by their

carpal tunnel syndrome symptoms.

We expect to find that the most effective multimodal treatment for CTS will be splinting Commented [AT11]: what is this based on given that
you presented research supporting a variety of
multimodal treatments for CTS?
plus steroid injection for reduction of symptom severity and increased functionality as assessed

by the Boston Carpal Tunnel Questionnaire (BCTQ). Commented [AT12]: no extra space between sections

Methods

This study will involve a quasi-experimental design with six groups to determine which

combination of treatments will be the most effective in increasing participant’s function and

decreasing symptoms of CTS. Participants in this study will participate in only one of the six

groups determined by random? group allocation.

Participants

Inclusion criteria:

· Mild to moderate CTS diagnosed by a physician.

· 18 years and older.

· No more than mild cognitive impairments (must be able to understand and follow

directions).

· Ability to read and understand English.

· Carpal tunnel syndrome as the primary diagnosis.

Exclusion criteria:

· Individuals with severe carpal tunnel syndrome.

MMT for CTS

· Individuals that have undergone CTS release surgery.

· CTS is not a secondary condition to another diagnosis.

Recruitment

One hundred and twenty participants older than 18 years, with a diagnosis of carpal

tunnel syndromeCTS, referred by their physician and are receiving treatment will be recruited

from the participating clinics. Potential participants will be screened by the investigators, then

assessed for eligibility before being enrolled in the study. Informed consent will be obtained

from all participants prior to treatment beginning.

Measures

Demographic information will be collected from participants before baseline

measurement. This will include diagnosis, age, severity of symptoms, participant functionality,

as well as additional basic medical information. Severity of symptoms and functionality

measures will be gathered using the Boston Carpal Tunnel Questionnaire (BCTQ). The BCTQ is

a 19 item disease-specific measure of self-reported symptom severity and functional status that

uses a 5 point likertLikert scale. (Bakhsh, Ibrahim, Khan, Smitham, & Goddard, 2012). The first

11 items address symptom severity with the scores ranging from 1 (normal) to 5 (very serious).

The last 8 items address functional status with the scores ranging from 1 (no difficulty) to 5

(cannot perform the activity at all). It is frequently used for the assessment of outcomes of

treatments for carpal tunnel syndrome. This assessment was chosen due to its validity and

reliability in assessing outcome measures.

Procedures

IRB approval will be obtained prior to recruitment. The study will begin by randomizing Commented [AT13]: don’t start sentence with
abbreviation
each treatment to the different participating clinics. All of the therapists within a clinic will
MMT for CTS

provide the same treatment to their patients with CTS. The investigators will gather basic

medical information and obtain baseline measures using the BCTQ for each participant. Six

groups will be included in this study, including a control group. Each group will receive a

different multimodal treatment including splinting following randomization. The treatment

groups will include:

· Splinting plus low level laser therapy

· Splinting plus tendon nerve glide exercises

· Splinting plus electroacupuncture

· Splinting plus steroid injection

· Steroid plus education Commented [AT14]: this seems like it needs

· Control group receives splinting alone
Reliability training of treatment administrators and assessor
justification given that you are trying to determine which
treatment combo with splinting is most effective…. i.e,,
unless you explain your rationale for including this, it is
not directly related to your splinting research question

The therapists providing treatment will be experienced occupational therapists, who have

undergone formal training regarding the specific treatment assigned to their clinic. All assessors

will undergo training regarding standardized use of outcome measures. At the end of our

treatment period and before discharge, the BCTQ will be administered again to gather data to

compare to the baseline measures previously collected. Once treatment is complete, a three-

month follow up assessment of the BCTQ will be given again to assess treatment effectiveness

as well as a participant satisfaction questionnaire. We feel it is important to gather this

information to analyze the areas of our study that worked well and what could be improved. This

information will also be used to assess ways the study could be improved.

Analysis
MMT for CTS

Participant measures will be analyzed using repeated measures ANOVA with statistical

significance set at p <0.05. A repeated measures ANOVA will be used across all groups to assess

a change in the measurements from baseline data to post treatment data as well as follow-up

data. A post-hoc test will be run to determine where the change is across the groups over time.

Data from all enrolled participants will be analyzed on an intention to treat basis.
MMT for CTS

References

Brininger, T. L., Rogers, J. C., Holm, M. B., Baker, N. A., Li, Z., & Goitz, R. J. (2007). Efficacy

of a fabricated customized splint and tendon and nerve gliding exercises for the treatment

of carpal tunnel syndrome: A randomized controlled trial. Archives of Physical Medicine

and Rehabilitation, 88(11), 1429-1435. doi:10.1016/j.apmr.2007.07.019

Carpal Tunnel Syndrome Fact Sheet. (2017). Retrieved September 6, 2017, from

https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Carpal-

Tunnel-Syndrome-Fact-Sheet#3049_5

Carpal Tunnel Syndrome. (2017). Retrieved September 28, 2017, from

http://www.mayoclinic.org/diseases-conditions/carpal-tunnel-syndrome/diagnosis-

treatment/treatment/txc-20313944

Chung, V. C., Ho, R. S., Liu, S., Chong, M. K., Leung, A. W., Yip, B. H., & Wong, S. Y.

(2016). Electroacupuncture and splinting versus splinting alone to treat carpal tunnel

syndrome: A randomized controlled trial. Canadian Medical Association Journal,

188(12), 867-875. doi:10.1503/cmaj.151003

Dincer, U., Cakar E., Kiralp M. Z., Kilac H., & Dursun H. (2009). The effectiveness of

conservative treatments of carpal tunnel syndrome: Splinting, ultrasound, and low-level

laser therapies. Photomedicine and laser Laser surgerySurgery, 27(1), 119 -125.

doi:10.1089/pho.2008.2211

Hall, B., Lee, H. C., Fitzgerald, H., Byrne, B., Barton A., & Lee, A. H. (2013). Investigating the

effectiveness of full-time wrist splinting and education in the treatment of carpal tunnel

syndrome: A randomized controlled trial. American Journal of Occupational Therapy,

67, 448–459. doi.org/10.5014/ajot.2013.006031

MMT for CTS

How does carpal tunnel syndrome affect a person's quality of life? | Carpal Tunnel Syndrome.

(2009). Retrieved October 29, 2017, from https://www.sharecare.com/health/carpal-

tunnel-syndrome/how-carpal-tunnel-affect-life

Leite, J. C., Jerosch-Herold, C., & Song, F. (2006). A systematic review of the psychometric

properties of the Boston Carpal Tunnel Questionnaire. BMC Musculoskeletal Disorders,

7, 78–79. http://dx.doi.org/10.1186/1471-2474-7-78

Levine, D. W., Simmons, B. P., Koris, M. J., Daltroy, L. H., Hohl, G. G., Fossel, A. H., & Katz,

J. N. (1993). A self-administered questionnaire for the assessment of severity of

symptoms and functional status in carpal tunnel syndrome. Journal of Bone and Joint

Surgery, 75, 1585–1592.

Luchetti, R., Tognon, S., Cacciavillani, M., Ronco, S., Buzzelli, N., & Lanni, G. (2017).

Observational multicentric survey on carpal tunnel syndrome: Demographic and clinical

data from 34 Italian centers. Eur Rev Med Pharmacol Sci, 21(2), 460-469. Retrieved Commented [AT15]: write out complete name of
journal
September 1, 2017.

Mahmoodian, A., Khosrawi, S., & Emadi, M. (2016). Effectiveness of splinting and splinting

plus local steroid injection in severe carpal tunnel syndrome: A randomized control

clinical trial. Advanced Biomedical Research, 5(1), 16-24. doi:10.4103/2277-

9175.175902

Page, M. J., Massy-Westropp, N., O'connor, D., & Pitt, V. (2012). Splinting for carpal tunnel

syndrome. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.cd010003

Piazzini, D., Aprile, I., Ferrara, P., Bertolini, C., Tonali, P., Maggi, L., & Padua, L. (2007). A

systematic review of conservative treatment of carpal tunnel syndrome. Clinical

Rehabilitation, 21(4), 299-314. doi:10.1177/0269215507077294

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Sutton, D., Gross, D. P., Côté, P., Randhawa, K., Yu, H., Wong, J. J., & Taylor-Vaisey, A.

(2016). Multimodal care for the management of musculoskeletal disorders of the elbow,

forearm, wrist and hand: A systematic review by the Ontario Protocol for Traffic Injury

Management (OPTIMa) Collaboration. Chiropractic & Manual Therapies, 24(1).

doi:10.1186/s12998-016-0089-8

Wipperman, J., & Goerl, K. (2016). Carpal Tunnel Syndrome: Diagnosis and Management.

Retrieved September 28, 2017, from http://www.aafp.org/afp/2016/1215/p993.html Field Code Changed

Formatted: No underline
Yagci, I., Elmas, O., Akcan, E., Ustun, I., Gunduz, O. H., & Guven, Z. (2009). Comparison of

splinting and splinting plus low-level laser therapy in idiopathic carpal tunnel syndrome.

Clinical Rheumatology, 28(9), 1059-1065. doi:10.1007/s10067-009-1213-0

Yildiz, N., Atalay, N. S., Gungen, G. O., Sanal, E., Akkaya, N., & Topuz, O. (2011).

Comparison of ultrasound and ketoprofen phonophoresis in the treatment of carpal tunnel

syndrome. Journal of Back and Musculoskeletal Rehabilitation, 24(1), 39-47.

doi:10.3233/bmr-2011-0273
 MMT for CTS

Appendix Commented [AT16]: yay! this is great – thanks for

including 
Appendix I: Boston Carpal Tunnel Questionnaire

Symptom severity scale (11 items):

1 2 3 4 5

1. How severe is the hand or wrist pain that you Normal Slight Medium Severe Very serious
have at night?

2. How often did the hand or wrist pain wake you Normal Once 2 to 3 times 4 to 5 times More than 5 times
up during a typical night in the past two weeks?

3. Do you typically have pain in your hand or No pain Slight Medium Severe Very serious
wrist during the daytime?

4. How often do you have hand or wrist pain Normal 1-2 3-5 More than 5 Continued
during daytime? times/day times/day times

5. How long on average does an episode of pain Normal <10 10-60 >60 minutes Continued
last during the daytime? minutes continued

6. Do you have numbness (loss of sensation) in Normal Slight Medium Severe Very serious
your hand?
7. Do you have weakness in your hand or wrist? Normal Slight Medium Severe Very serious

8. Do you have tingling sensations in your hand? Normal Slight Medium Severe Very serious

9. How severe is numbness (loss of sensation) or Normal Slight Medium Severe Very serious
tingling at night?
10. How often did hand numbness or tingling Normal Once 2 to 3 times 4 to 5 times More than 5 times
wake you up during a typical night during the
past two weeks?
11. Do you have difficulty with the grasping and Without Little Moderately Very Very difficulty
use of small objects such as keys or pens? difficulty difficulty difficulty difficulty

Functional status scale (8 items):

 MMT for CTS

Cannot perform the activity

Moderate Intense
No difficulty Little difficulty at all due to hands and
difficulty difficulty
wrist symptoms

Writing 1 2 3 4 5

Buttoning of clothes 1 2 3 4 5

Holding a book while 1 2 3 4 5

reading

Gripping of a telephone 1 2 3 4 5
handle

Opening of jars 1 2 3 4 5

Household chores 1 2 3 4 5

Carrying of grocery 1 2 3 4 5
basket

Bathing and dressing 1 2 3 4 5

(Levine et al., 1993)

Appendix II: Post-treatment Participant Satisfaction Questionnaire

MMT for CTS

Question 1: My therapist was competent and understood the treatment he/she was administering.

Possible answers: Strongly agree, agree, neutral, disagree and strongly disagree.

Question 2: I feel the treatment was effective in reducing symptom severity.

Possible answers: Strongly agree, agree, neutral, disagree and strongly disagree.

Question 3: I feel the treatment improved my overall function.

Possible answers: Strongly agree, agree, neutral, disagree and strongly disagree.

Question 4: How has this treatment impacted your function in daily life? Please provide a short

summary.