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Novelty in Biomedicine
NBM 201 Novelty in Biomedicine 2019, 4, 201-9
Original Article
The Assessment of Acupuncture and Exercise Therapy in Patients
with Carpal Tunnel Syndrome: Randomized Clinical Trial
Shahin Salehi1, Omid Hesami2, Amir Rashed1*, Mohammad Hassabi1, Mehrshad Poursaeidesfahani1, Amir
Hosein Abedi Yakta1, Hamid Mahdavi Mohtasham1, Shahrzad Khosravi1, Shahram Mohaghegh1, Mohammad
Reza Sohrabi3
1 Department of Sports Medicine, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2 Department of Neurology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
3 Department of Community Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
Received: 28 April 2019; Accepted: 21 September 2019
Abstract
Background: The efficacy of acupuncture and exercise therapy in the treatment of carpal tunnel syndrome
(CTS) has been investigated in limited studies with controversial results. The purpose of this study was to
compare the short-term efficacy of acupuncture and exercise therapy in patients with mild to moderate CTS.
Materials and Methods: This study was a randomized controlled clinical trial study conducted on 60 patients
(55 women) with mild to moderate CTS referring to Imam Hossein Hospital in Tehran in 2017. The patients
were randomly divided in to 3 equal groups; groupa1: only night splint was used for 6 weeks (control), group2:
splint with tendon and nerve gliding exercises (2 times a day for 6 weeks) were applied, group3: splint and
electroacupuncture was performed for 12 sessions (2 sessions/week). The score on the Boston Carpal Tunnel
Questionnaire (BCTQ) for Functional Status and Symptom Severity (BCTQ FUNCT and SYMPT) and visual
analog scale (VAS) score were evaluated at baseline and after the treatment.
Results: At the final follow up, significant improvements in all parameters of quality of life and VAS were
found in third groups (p<0.05). Acupuncture affected the score on the BCTQ FUNCT and SYMPT, the VAS
score more than exercise therapy. In addition, the efficacy of splint alone was less than intervention groups
in all parameters.
Conclusion: Acupuncture with splint has a high effect on reducing pain and improving the quality of life in
patients with mild to moderate CTS and could be adopted in the management of these patients.
Keywords: Carpal tunnel syndrome, Splint, Exercise, Acupuncture, Quality of life
*Corresponding Author: Amir Rashed, MD; Resident, Department of Sports Medicine, School of Medicine, Shahid Beheshti University
of Medical Sciences, Tehran, Iran; Tel: (+98) 9379313372. Email: a.rashed1353@gmail.com
Please cite this article as: Salehi Sh, Hessami O, Rashed A, Hassabi M, PourSaeid Esfehani M, Abedi Yakta, A et al. The Assessment
of Acupuncture and Exercise Therapy in Patients with Carpal Tunnel Syndrome: Randomized Clinical Trial. Novel Biomed.
2019;7(4):201-9.
Introduction
Carpal tunnel syndrome (CTS) is the most common
form of nerve trapping syndrome in the organs,
which is due to compression of the median nerve in
the wrist and involve millions around the world.
Annual prevalence percentage is estimated to be 3.8%
in the general population and it can occur in all ages1.
However, now 40 to 60 years old is the most common
age of this disease. It is estimated that 9% of female
and 6% of male affected by this syndrome in their
life2. CTS is bilateral in 59% of patients3.
Salehi et al. The Assessment of Acupuncture and Exercise Therapy in Patients with Carpal Tunnel …
NBM 202 Novelty in Biomedicine 2019, 4, 201-9
The main symptoms of this syndrome include pain,
numbness, and irritation in the median nerve
distribution pathway. In advanced stages this
syndrome results in weakness and atrophy of the
thenar muscle, decreased muscle strength, decreased
sensation, and positivity of the irritation tests which
leads to hand dysfunction and disability to be
active3,4.
CTS risk factors are as follow: occupational
conditions, such as repetitive and repeated
movements of hands when using computer, health
conditions including obesity, non-inflammatory
synovial fibrosis, metabolic syndrome, diabetes,
pregnancy, OCP, menopause, increased age, using
tobacco, caffeine, alcohol and inflammatory arthritis,
hypothyroidism and renal dialysis5.
Without timely treatment, CTS sometimes causes
permanent damage to the median nerve (some or all
nerve fibers are destroyed) and results in transient or
permanent sensory or motor disorder for the patient6.
So, choosing proper treatment for CTS is important
for improving life quality and decreasing medical
costs.
So far, several methods have been proposed to treat
this syndrome. Generally, treatment for carpal tunnel
syndrome is done in both surgical and non-surgical
procedures. Non-surgical procedures are as follow:
avoid activities which cause disease, using brace,
ultrasound, and night splint for limiting wrist
movements, using anti-inflammatory drugs, both in
form of steroidal and non-steroidal and regional
injection. If these treatments are not effective, the
patient will undergo surgery (open surgery or
endoscopic procedure7.
Although recent studies have been observed that
using splints and steroids is useful as primary
treatments to improve the symptoms of patients, the
effects of these methods are usually temporary and
transient8. In addition, each of these methods also has
its own side effects, for example gastrointestinal,
renal and hepatic complications in using oral
steroidal and non-steroidal anti-inflammatory drugs
and tendon rupture and increased the probability of
nerve injury following localized corticosteroid
injection9,10.
In some of the studies, the effects of acupuncture and
massage therapy as well as stretching exercise were
studied on patients which have different results on
improving symptoms and function1,11,12. Today,
among multiple interventions for pain management,
special attention has been paid to acupuncture. The
acupuncture is the most well-known complementary
and alternative treatment, however, limited studies
have been conducted on the efficacy of acupuncture in
the treatment of mild to moderate CTS13, 14. Although
National Institutes of Health (NIH) has approved
acupuncture for the treatment of mild and moderate
CTS, still there is disagreement about its
effectiveness15. Moreover, according to many
guidelines wrist splinting is recommended as the
primary treatment option for CTS patients despite no
promise in its effectiveness16-18. Using acupuncture
and exercise therapy is increasing for CTS treatment,
but there is no specific recommendation about using
them19-21. Also, there is limited evidence in regard to
acupuncture and exercise therapy effectiveness and the
previous studies of CTS have not dealt with
Comparison of acupuncture and exercise therapy
effectiveness on ones22-26. The specific controversy
which drives the research in which to compare and
determine the effectiveness of between the
conservative treatments, acupuncture and exercise
therapy.
We have limited studies on the effectiveness of
acupuncture and therapeutic exercise in treatment of
CTS, so the present study is performed to determine
the effectiveness of two methods of acupuncture and
exercise therapy in reducing pain and improving the
quality of life of CTS patients.
Methods
Study Design: The present study is a randomized,
controlled clinical trial which is performed on 60 CTS
patients referring to the Sports Medicine Clinic of
Imam Hossein Hospital in Tehran in 2017 (Figure 1).
The neurologist based on the history and physical
examination and using EMG/NCV explained in
following at the Patient evaluation subsection made
the definitive diagnosis of patients and disease
severity. Patients enrolled in the study after receiving
explanations by researchers regarding the purpose of
the study and by obtaining informed consent.
Participants: The inclusion criteria for the study were
mild and moderate CTS, the lack of limitation in upper
The Assessment of Acupuncture and Exercise Therapy in Patients with Carpal Tunnel … Salehi et al.
NBM 203 Novelty in Biomedicine 2019, 4, 201-9
extremities that inhibit the desired exercise from the
patient (such as wrist fracture, severe scarring, burn,
presence of cyst or tumors in the area of wrists, and
history of wrist surgery), no symptoms of atrophy or
muscle weakness, absence of autoimmune or
inflammatory diseases, no previous taking steroidal
drugs, using splint and any treatment regarding CTS.
Also, exclusion criteria were as follows: severe stage
of the illness during the study, non-performing of the
exercises requested, no referring at the requested
time for acupuncture, using acetaminophen for more
than 7 days because of severe pain, pregnancy,
diabetes mellitus, any contraindication for needling
such as bleeding tendency, local infection, or a
history of needling shock.
Data Collection: At first, all patients were under full
clinical examination. The demographic and history
profiles were also completed for all patients. This
form includes demographic characteristics (age,
gender, place of living, marriage status), medical
history and clinical information including smoking
and alcohol consumption, underlying diseases,
weight, height, drugs used and characteristics of CTS
including pain severity, affected hand, and duration
of CTS.
Intervention: Block randomization which used by
Random Allocation Software random was applied to
allocate patients to groups after eligibility
confirmation27, 28. Patients were randomly divided
into three equal groups (20 patients in each group)
with an adjusted age of 10 years. In the first group,
the patients received only night splint with neutral
positioning for a period of 6 weeks (control). In the
second group, the splint and exercise therapy were
used. Exercise therapy included tendon gliding and
median nerve gliding, two times a day for 6 weeks
(Figure 2). In the third group, splint and 12 sessions
of 40 minutes electroacupuncture was performed (2
times a week) in two points of PC-7 (Daling) and
PC-6 (Neiguan) using the thin sterile needle
(0.25×25mm size gauge) with the frequency of 60-
100 Hz up to pain threshold (Figure 3). The needles
were inserted vertically into specific points in the
depth of 2-5 mm. Acetaminophen was used in all
three groups if needed.
To find acupoints the examiner asks patients to press
the thumb and little finger together for the better
presentation of the tendon of the flexor carpi radialis
and tendon of the palmaris longous. After appearing of
the tendons, the needle located at between the tendons
on the flexor aspect of the forearm, which are between
the two tendons. The distance between PC-7 and PC-6
is two thumbs wide. PC-6 (Neiguan) is located at 2
cun above the transverse crease of the wrist PC-7,
between palmaris longus and flexor carpi radialis
tendons, on the line connecting PC-3 and PC-7. PC-7
(Daling) is located in the middle of the transverse
crease of the wrist between palmaris longus and flexor
carpi radialis tendons (Figure 3)29. These acupoints
chose because of their efficiency which is reported in
previous studies30.
Patients Evaluation: To evaluate the response to
treatment, quality of life (symptoms and functional
status) and pain intensity of patients were evaluated at
baseline and after treatment. The parameters were
compared in three groups before and after treatment.
The Boston carpet tunnel questionnaire (BCTQ) was
used to assess the severity of symptoms and patients'
performance. The questionnaire included 11 questions
about the severity of the symptoms (BCTQ SYMPT)
and 8 questions about functional status (BCTQ
FUNCT). The items of each scale were scored from 1
(mildest) to 5 (most severe). The BCTQ SYMPT and
scores were calculated as the mean±standard deviation
for each item. In the present study, the Persian version
of BCTQ was used which its reliability and sensitivity
were confirmed in previous studies31.
Patients' pain intensity was assessed based on a visual
analogue scale (VAS). The patient evaluated their pain
intensity from zero (complete analgesia) to 10 (the
most experienced patient's pain).
Entrance and evaluation of information after the end of
treatment carried out by a researcher who did not
know about grouping the patients. In other words,
neither the patient nor the therapist and study
investigator was aware of which groups is treatments
or a control (triple-blind, randomized clinical trial).
However, the sports medicine specialist and student
were aware of the procedure and groups in order to
prevent the inadvertent intra and post-intervention
events.
Statistical Analysis: Version 22 of SPSS software was
used to statistical analysis. Normality for variables was
assessed using the Kolmogorov–Smirnov test.
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NBM 204 Novelty in Biomedicine 2019, 4, 201-9
Obtained data were analyzed by descriptive statistics
including frequency, mean, standard deviation,
frequency percentage and inferential statistics
including paired sample t-test, Chi-square, and
analysis of variance (ANOVA). A p-value < 0.05
was considered statistically significant.
Ethical approval of this study was obtained from
Shahid Beheshti University of Medical Sciences,
Tehran, Iran whit ethic code:
IR.SBMU.MSP.REC.1395.152. In addition, with
RCT code IRCT20180212038693N1.
Results
In the present study, 55 women and 5 men with a
mean age of 49.23±8.96 (29-70 years) participated
(Table 1). In this study, there was no statistically
significant difference between age, gender, height,
weight, job, presence of systemic disease, affected
hand, and illness severity in three groups (P>0.05).
In this study, the results of pain severity assessment
and Boston questionnaire in CTS patients was shown
that at the end of the sixth week, symptom severity
was decreased and capacity of patients’ performance
was increased in all three groups (P<0.05). However,
the improvement rate was higher in the acupuncture
group (Table 2).
The results of ANOVA showed that there was no
statistical difference in pain (P=0.302), symptoms
(P=0.524), performance (P=0.336) and quality of life
(P=0.281) in three groups, before treatment.
Discussion
The aim of the current study was to determine the
effectiveness of two methods of acupuncture and
exercise therapy in reducing pain and improving the
quality of life of CTS patients.
Regarding CTS treatment, limited studies have been
conducted using exercise and acupuncture, and on the
other hand, there is no controlled study to compare the
effectiveness of these two therapies. Therefore, the
present study is performed to compare the short-term
effects of 6 weeks acupuncture and nerve and tendon
gliding exercise on reducing pain and improvement of
symptoms and patient performance in patients with
mild to moderate CTS.
In the present study, there was no significant statistical
difference between age, gender, height, weight, and
job, presence of systemic disease, affected hand, and
illness severity in three groups, which show that these
factors do not affect our study results. There was no
statistical difference in pain, symptoms and functional
status and the quality of life in three groups, before
treatment. These results indicated the complete
randomization of samples and the absence of bias in
sample selection.
In this study, the results of pain severity and Boston
Table 1: Participant characteristics at baseline*.
Variable
Brace+ acupuncture
(n=20)
Brace+ Exercise therapy
(n=20)
Control (n=20)
P-value**
Age (year)
50.75±9.59
49.55±8.41
47.4±8.96
0.495
Gender
Female: 18 (90)
Male: 2 (10)
Female: 19 (95)
Male: 1 (5)
Female: 19 (95)
Male: 1 (5)
0.804
Weight (kg)
77.5±12.85
78.78±10.8
77.9±9.4
0.933
Height (cm)
159.35±5.3
160.2±5.8
163.5±7.8
0.098
Job
Employed: 18 (90)
Housewife: 2 (10)
Employed: 15 (75)
Housewife: 5 (25)
Employed: 12 (60)
Housewife: 8 (40)
0.077
systemic disease
(yes)
9 (11)
5 (25)
6 (30)
0.377
Affected hand
Right: 9 (45)
Left: 11 (52)
Right: 8 (40)
Left: 12 (60)
Right: 12 (60)
Left: 8 (40)
0.420
Disease severity
Mild: 13 (65)
Moderate: 7 (35)
Mild: 12 (60)
Moderate: 8 (40)
Mild: 13 (65)
Moderate: 7 (35)
0.931
*Data are presented as mean±SD or frequency (%)
**Significance at p≤0.05.
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NBM 205 Novelty in Biomedicine 2019, 4, 201-9
questionnaire in evaluating CTS patients was shown
that at the end of the sixth week, symptom severity
was decreased and patients’ performance was
increased in all three groups. In addition, the severity
of pain was decreased in all three groups. However,
the improvement of symptoms and performance and
the rate of decreasing pain was higher in the
acupuncture treatment group. The least improvement
rate was seen in the splint group.
Highly effectiveness of acupuncture in improving
symptoms and performance of CTS patients is
reported in different studies. For example, Khosrawi
et al, (2012) have shown better effectiveness of
acupuncture + night splint compared to splint alone
on improving clinical symptoms of CTS patients1.
Ho et al. also have shown that acupuncture results in
improvement of clinical symptoms in patients with
CTS30. These findings are consistent with the
findings of this study. As a result, treatment with an
acupuncture + night splint in comparison with splint
alone has a better effect on the improvement of
subjective symptoms.
The results of Chung et al. (2016) study have shown
that splinting only is not sufficient to improve
symptoms and performance of CTS patients; but
when acupuncture and night splint are used
simultaneously for treatment of mild to moderate
CTS, result in significant improvement in symptoms
severity and patient’s performance and decreasing
pain20. These findings are consistent with the
findings of this study. Although in this study splint
alone was, also effective in improving symptoms and
performance of patients, this effect was less than the
splint + electroacupuncture.
In another study, Imami Razavi and colleagues (2010)
showed that at the end of treatment with splint +
acupuncture, clinical signs and electrodiagnostic
findings were improved21. Zavela et al, (2010) also
reported the effectiveness of acupuncture in decreasing
pain and symptoms in CTS patients32. Furthermore,
Rezvain (2008) found that the application of
acupuncture with splinting is more effective in the
treatment of CTS compared to splint alone (regarding
symptoms and performance improvement)33. These
findings are consistent with the findings of this study.
At the other hand, some evidence also did not show
any improvement in CTS symptoms when intervening
with acupuncture compared to control or placebo. For
example, Yao et al, (2012) compared acupuncture with
placebo (without treatment) in the treatment of CTS
patients. Comparison of symptom scores and patient
performance (CTSAQ) before and after treatment
showed that the rate of symptom improvement and
patient performance was significant in both groups,
but there was no significant statistical difference
between two groups34. Another randomized control
study also showed no significant difference between
laser acupuncture and placebo (in 3 weeks follow up)
regarding night pain35. In another randomized control
study comparing acupuncture (10 sessions)
effectiveness with night splint (for 5 weeks), the result
showed that electroacupuncture is as effective as night
Table 2: Mean scores of pain severity, symptoms, performance and quality of life in CTS patients according to
BCTQ questionnaire.
Variable
Group
Baseline (mean±SD)
After treatment
(mean±SD)
difference
P-value**
VAS
Control
5.9 ± 0.97
4.8 ± 1.06
1.1 ± 0.85
<0.001
Brace+ Exercise therapy
6.5 ± 1.39
4.35 ± 1.9
2.15 ± 1.56
<0.001
Brace+ acupuncture
6.5 ± 1.73
2.85 ± 2
3.65 ± 1.84
<0.001
Functional
Status
Control
24.7 ± 3.28
20.45 ± 3.25
4.25 ± 2.36
<0.001
Brace+ Exercise therapy
24.6 ± 7.03
15.6 ± 7.42
9 ± 8.78
<0.001
Brace+ acupuncture
23.8 ± 5.34
8.55 ± 4.99
15.25 ± 7.1
<0.001
Symptoms
Control
18.75 ± 3.06
16.1 ± 3.81
2.65 ± 2.78
0.002
Brace+ Exercise therapy
19.85 ± 8.36
16.35 ± 9.48
3.5 ± 4.3
<0.001
Brace+ acupuncture
21.65 ± 4.07
13.85 ± 3.5
7.8 ± 4.9
<0.001
quality of life
Control
43.45 ± 6.02
36.55 ± 6.58
6.9 ± 4.44
<0.001
Brace+ Exercise therapy
44.45 ± 11.63
31.95 ± 14.63
12.5 ± 11.71
<0.001
Brace+ acupuncture
45.45 ± 8.07
22.4 ± 7.83
23.05 ± 10.86
<0.001
VAS = visual analog scale; BCTQ = Boston Carpal Tunnel Questionnaire; SD = standard deviation.
**Significance at p≤0.05.
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splint in managing symptoms and performance of
patients with mild to moderate CTS. But acupuncture
is more effective than splint in decreasing pain
(VAS)36. The reason for the difference in the results is
related to the individual characteristics of the patients,
the difference in sample size and the population
studied the difference in the criteria for evaluating the
results as well as the difference in the number of
sessions and method of the acupuncture and the
Figure 1. The study flowchart.
Figure 2. Tendon gliding (Right) and median nerve gliding exercise (middle and left). The patients were asked to do each position for 5
seconds, and repeat each position 10 times for at least two times a day.
Figure 3. Acupuncture points.
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NBM 207 Novelty in Biomedicine 2019, 4, 201-9
duration of the treatment.
On the other hand, the effectiveness of exercises
therapy in reducing pain and improving symptoms
and performance of CTS patients is reported in
different studies. For example, Madenci et al, (2012)
showed in a study that tendon and nerve gliding
exercises along with night splinting for treating CTS
result in a significant decrease of pain in CTS
patients37. The results of a study by Peñas et al
(2017) in Spain also showed that exercises therapy is
effective to improve the severity of symptoms and
performance of CTS patients38. In a study by Akalin
et al., patients with CTS were evaluated in two
treatment groups of splint alone and splint along with
tendon and nerve gliding exercises and significant
improvement in all parameters (the score of severity
of symptoms and function and neurophysiologic
findings) were observed in both groups. In this study,
though, the results in the exercise group were better
than splint, but the difference between the two
groups was not significant39. These results are to
somewhat consistent with the results of this study.
However, further controlled studies are needed in
relation to the application of mobilization techniques
in the treatment of CTS.
Moghaddasi et al. (2014) showed that performing
stretching exercises and mobilization in 8 weeks
have a significant effect on decreasing pain in CTS
patients9. The results of a study by Tal Akabi (2000)
also showed that mobilization exercises of the wrist
for 3 weeks results in significant improvement in
CTS symptoms, decreasing pain and improvement of
wrist range of motion40.
In a systematic review by Kim et al, (2015)
effectiveness of tendon and nerve gliding exercises in
the treatment of CTS patient were evaluated and they
found that these exercises result in significant
improvement of symptoms severity and patient
performance. However, the effectiveness of tendon
and nerve gliding exercises alone was not
determined, because in the above clinical studies
were used a combination of sports exercises and
standard conservative treatments including a splint,
paraffin therapy, and other exercises. So more
randomized controlled clinical studies are needed to
assess the impact of these exercises in the
management of CTS patients19.
Finally, it should be noted that the present study is for
the first time comparing the effectiveness of two
methods of therapeutic exercises and acupuncture in
the treatment of mild to moderate CTS and this study
gained valuable information, but there were also some
limitations. The relatively small sample size and the
lack of mid-term and long term monitoring of patients
are major limitations of our study. The limited number
of therapeutic sessions in the acupuncture group was
another limitation. If treatment sessions are added,
better treatment outcomes may be achieved. Since
there has not been a study comparing the effectiveness
of acupuncture with exercises in the treatment of CTS,
it is not possible to compare the findings of this study
with the results of other studies. Therefore, our results
need to be confirmed in future studies with a larger
sample and long-term monitoring.
Conclusion
The results of this study showed that all three
treatments can improve the subjective symptoms of
patients with carpal tunnel syndrome, but the
effectiveness of both methods of acupuncture and
exercise therapy was greater than the control group.
When exercises or acupuncture with night splinting
was used, the rate of improvement in the quality of life
and the reduction of pain in the patient was more than
the splint was used alone. In addition, the effectiveness
of acupuncture was greater than exercise therapy.
Therefore, acupuncture with night splint is an
effective, inexpensive and safe treatment option
available and can be applied to the treatment of mild to
moderate CTS patients.
Acknowledgment
The present study is a part of the thesis written by Dr.
Amir Rashed, with the registration number of 121 in
Faculty of Medicine, Shahid Beheshti University of
Medical Sciences, Tehran, Iran.
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