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Original Article Egyptian Journal of Health Care, 2023 EJHC Vol. 14. No.1
1030
Effect of Nursing Instructional Program on Neurophysiologic Parameters of Carpal Tunnel
Syndrome among Pregnant Women
Lawahez M. Dwedar,(1) Samah N. A. ElShora,(2) Amany M. Ahmed (3) El- Shaimaa El-Ansary (4)
(1) Lecturer of Woman’s Health and Midwifery Nursing, Faculty of Nursing, Kafrelsheikh University, Egypt.
(2,4) Lecturer of Woman's Health and Midwifery Nursing, Faculty of Nursing, Mansoura University, Egypt.
(3) Assistant Professor of Woman’s Health and Midwifery Nursing, Faculty of Nursing, Kafrelsheikh University, Egypt.
Corresponding Author: lawahez_mabrouk@nur.kfs.eg.ed
Abstract
Background: Carpal tunnel syndrome has a great impact on the pregnant woman’s daily life. Several non-
pharmacological techniques have been used to alleviate these symptoms. Aim: The present study aimed to examine the effect
of nursing instructional program on neurophysiologic parameters of carpal tunnel syndrome among pregnant women.
Methods: A quasi-experimental research design was adopted. A convenient sample of 100 pregnant women with carpal tunnel
syndrome was enrolled. This study was carried out at the obstetric and gynecological outpatient clinic of Kafrelsheikh general
hospital, Kafrelsheikh governorate, Egypt. Three tools were used to collect data: A structured interviewing Questionnaire,
Numeric Pain Rating Scale, and Boston Carpal Tunnel Syndrome Questionnaire. Results: The mean wrist pain scores at
baseline assessment didn't show a significant difference between the control and intervention groups (p>0.05). However, post-
intervention, the difference in mean wrist pain scores between the two groups was highly statistically significant (p<0.001).
When comparing the symptom severity scale and functional status scale between the two groups, the differences weren't
statistically significant at baseline assessment (p>0.05). Post-intervention, the difference in symptom severity scale was highly
statistically significant (p<0.001) between both groups while the functional status scale did not show a significant difference
(p>0.05). Conclusion: The nursing instructional program was successful in improving the neurophysiologic parameters of
carpal tunnel syndrome among pregnant women. Recommendation: Applying such nursing instructional program should be
enforced to decrease suffering among pregnant women with carpal tunnel syndrome.
Keywords: Nursing instructional program, neurophysiologic parameters, carpal tunnel syndrome, pregnant women.
Introduction
Carpal tunnel syndrome (CTS) is the most common
peripheral nerve entrapment, caused by compression
neuropathy of the median nerve at the level of the carpal
tunnel (Obuchowicz, Kruszyńska, & Strzelecki, 2021). The
median nerve permits sensory innervation to the fingers as
well as innervation to the tiny muscles of the hand, which
essentially control the grip of the hand (Urits et al., 2019).
The estimated prevalence of CTS in adults is 2.7-5.8%; it is
more frequent in the age range between 25 and 64 years
(Radiopaedia, 2023). Women are 3.6 times more likely to
have the condition than men (Hamid et al., 2020). Every
year, the high incidence rate increases the pathology-related
factors that drive up healthcare and socioeconomic expenses
(Erickson et al., 2022; Subandi et al., 2020; Zhuang et al.,
2020).
The symptoms of CTS are recognized by nocturnal
pain, a gradual loss of sensation accompanied by weakening
and numbness, weaker muscles due to severe axonal
degeneration, and tingling in the hand's median nerve
division (Genova et al., 2020). Symptoms can extend from
mild to extremely upsetting affecting one or two hands
(Setyawan, 2017). Diagnosis of CTS depends on taking
history, clinical assessments, and tests such as diagnostic
electrophysiological techniques, primarily median nerve
conduction velocity (Dabbagh et al., 2020).
Carpal tunnel syndrome is determined by sex, age,
genetics, pregnancy, diabetes mellitus, hormonal changes,
obesity, amyloidosis, autoimmune diseases such as
rheumatoid arthritis, renal illness, trauma, and thyroid illness
(Hernández-Secorún et al., 2021; Lampainen et al., 2022).
It can occur also due to chronic frequent forceful jobs
including vibration and/or excessive postures of the wrist,
typing, or repetitive wrist motion (Moradi et al., 2020;
Schmid et al., 2020).
Pregnancy can result in complications including
carpal tunnel syndrome, with a reported 62% increase in
occurrence. It can occur during the first trimester but is most
frequently seen during the third trimester (Kamel et al.,
2017). The body goes through many physical and hormonal
changes that might cause swelling during pregnancy. The
median nerve is compressed when extra fluid in the wrist
bulges, causing tingling and a lack of sensation in the hands
and fingers (Afshar & Tabrizi, 2021). Sixty out of every
one hundred pregnant women may suffer CTS symptoms.
The pain also related to CTS may be more likely to impact
the woman’s daily life routines (Cazares-Manríquez et al.,
2020; Padua et al., 2016).
Early treatment of CTS is important to avoid
permanent damage to the median nerve. There are many
Original Article Egyptian Journal of Health Care, 2023 EJHC Vol. 14. No.1
1031
management choices including conservative and surgical
treatment. Conservative includes stopping daily activities
which aggravate the condition, taking frequent rests between
tasks, resting the hand, and applying cool packs as well as
Nonsteroidal anti-inflammatory drugs (NSAIDs) such as
aspirin, ibuprofen, and other nonprescription pain relievers
may provide some short-term relief from discomfort but
haven’t been shown to treat CTS (Karjalanen, Raatikainen,
Jaatinen, & Lusa, 2022). Moreover, surgical treatment is
inappropriate during pregnancy and is exceedingly expensive
compared to conservative care (Klokkari & Mamais, 2018).
Nurses play an important role in providing
interventions that decrease CTS symptoms and increase
functional status. The nurse should instruct the women on
practicing hand exercises that can minimize CTS symptoms
and apply mild heat on the hands before practicing them. The
nurse also should advise them with the night wrist splint to
support and immobilize the wrist at night (Abdel Maksoud
& Ramadan, 2021). Earlier studies assessed the impact of
the educational intervention on CTS and concluded that the
intervention was effective in decreasing symptoms severity
and improving functional status (Abd Elmoniem et al.,
2018; Hamzeh et al., 2021). This stimulates the current
study to examine the effect of nursing instructional program
on neurophysiologic parameters of carpal tunnel syndrome
among pregnant women.
Significance of the study
The pregnancy period is characterized by a
morphophysiological variation that directly affects the
musculoskeletal system in pregnant women (Lewis et al.,
2020). The dynamic normal variation associated with
pregnancy can cause musculoskeletal system growth
disorders. Carpal tunnel syndrome is one of the most
frequent complaints during pregnancy (Oliveira et al.,
2019). Untreated CTS has a negative impact on pregnant
women’s quality of life. It can cause persistent pain,
disturbed sleep, difficulties with daily activities, and
ineffective work because of damage to the median nerve
(Wolska et al., 2018).
Women's health and midwifery nurses should at
least be able to recognize, inform, and provide conservative
measures to pregnant women with CTS to improve their
quality of life. Minimal research has been done on CTS using
wrist splints and hand exercises during pregnancy. Therefore,
more nursing research is required to confirm whether wrist
splints and hand exercises are more effective management
options. In addition to the standard treatment for carpal
tunnel syndrome, this study was conducted to examine the
effect of nursing instructional program on neurophysiologic
parameters of carpal tunnel syndrome among pregnant
women. As a result, this study will be useful in the
management of mild to moderate carpal tunnel syndrome.
Aim of the study
The present study aimed to examine the effect of
nursing instructional program on neurophysiologic
parameters of carpal tunnel syndrome among pregnant
women.
Operational definitions
Neurophysiologic parameters of carpal tunnel
syndrome: refer to symptom severity, functional status
(measured by Boston Carpal Tunnel Syndrome
Questionnaire), and wrist pain intensity (measured by
Numeric Pain Rating Scale).
Nursing instructional program includes the
educational session containing practicing hand exercises
(such as wrist flexor stretches, wrist extensor stretches,
medial nerve glide, and tendon gliding exercises) and night
splint application.
Research hypotheses
H.1. Pregnant women with carpal tunnel syndrome who
receive the nursing instructional program have a lower
level of pain than controls.
H.2. Pregnant women with carpal tunnel syndrome who
receive the nursing instructional program have a lower
mean score of symptom severity than controls.
H.3. Pregnant women with carpal tunnel syndrome who
receive the nursing instructional program have a higher
mean score of functional status than controls.
Subjects and method
Research design
The hypotheses were tested using a quasi-experimental
approach with a non-equivalent control group pre-and post-
test. Women were divided into an intervention group and a
control group. All women underwent the baseline
assessments of the dependent variables. Only women in the
intervention group attended the instructional program. Then,
all women underwent a post-test to evaluate the difference in
the dependent variables (LoBiondo-Wood & Haber, 2018).
Setting
This study was carried out at the obstetric and
gynecological outpatient clinic of Kafrelsheikh general
hospital, Kafrelsheikh governorate, Egypt. It is located on the
first floor and has three sub-clinics. The first one is intended
for history taking and diagnosis. The second is equipped with
ultrasound for obstetrical and gynecological examination
while the third clinic is dedicated to gynecological
examination and surgical dressing. The official working
hours begin at 9 am and end at 1 pm. The outpatient clinic
receives about 2000 pregnant women every year.
Original Article Egyptian Journal of Health Care, 2023 EJHC Vol. 14. No.1
1032
Sample
A convenient sample of 100 pregnant women with
carpal tunnel syndrome between the ages of 18 and 35 years
was enrolled.
Sample size calculation
Based on data from the literature (Abd Elmoniem et al.,
2018), considering a level of significance of 5%, and power
of study of 80%, the sample size can be calculated using the
following formula:
n=
where, SD = standard deviation obtained from the previous
study; Zα/2, for 5% this is 1.96; Zβ, for 80% this is 0.84 and d,
for the expected difference. Therefore,
n= =49.7
Based on the above formula, the sample size required is 50 in
each group.
Data collection tools:
The data was collected using three tools:
Tool 1: A structured interviewing questionnaire
It was developed by the researchers after reviewing
the related literatures (Abd Elmoniem et al., 2018; Afshar&
Tabrizi, 2021; Oliveira et al., 2019). It included three parts:
Part I: Socio-demographic data of the studied pregnant
women
:
such as age, education, residence, occupation, and
telephone number; Part II: Obstetric
history: such as
gravida, para, mode of the previous deliveries, and
gestational age. Part III: Wrist pain characteristics: this part
included questions related to the presence and the site of
wrist pain (Right, left, or bilateral).
Tool 2: Numeric Pain Rating Scale (NPRS)
It is a self-report pain scale, that was used to
determine the severity of wrist pain (McCaffery & Beebe,
1989). It is a horizontal line with a number from zero to ten
that represents the respondents' level of pain. On a scale from
0, "no pain," to 10, "severe pain," women were asked to
choose a whole number that best describes the level of pain
they experience. A scoring system: The NPRS has 3 main
sections: the first section reflects mild pain and is listed from
1-3 cm, the second section is listed from 4-7 cm for moderate
pain, and the third one is listed from 8-10 cm for severe pain.
Higher scores indicate the worst pain.
Tool 3: Boston Carpal Tunnel Syndrome Questionnaire
(BCTQ)
It is a self-administered questionnaire adopted from
Beaton et al., (2000) to measure the symptom severity and
functional status of CTS. It consisted of 2 scales: the
symptom severity scale includes 11 items to evaluate various
symptoms like pain, weakness, paresthesia, nocturnal
symptoms, and difficulties grasping and the functional status
scale includes 8 items to measure functional deficiencies:
writing, holding a book, gripping a telephone, opening jars,
carrying grocery bags, buttoning clothing, conducting
household tasks, bathing, and dressing. A scoring system:
Each item of the symptom severity scale is graded on a
Likert scale with 5 possible points, ranging from 1 (no
symptoms) to 5 (the worst symptoms). Each response to the
functional status scale is graded on a 5-point Likert scale,
with 1 (easiest) and 5 (most difficult) performing the activity.
Validity and reliability of the tools
The content validity of the tools was tested and confirmed by
three specialists in the field of maternity nursing. The tools
were validated for the accuracy, applicability, and
completeness of their contents. Accordingly, no
modifications were made. The Cronbach's alpha coefficient
test was used to assess the reliability of the suggested
instruments. Cronbach's alpha of 0.89 for the structured
interview questionnaire indicated a good positive correlation
between the tool's elements, reliability for Numeric Pain
Rating Scale was 0.96 whereas the BCTQ's test-retest
reliability was 0.95.
Ethical consideration
Ethical approval to conduct the study was attained
from the Faculty of Medicine ethical committee of
Kafrelsheikh University (MKSU 23-3-7). Official permission
to carry out the study was attained from the director of the
previously mentioned setting. The researcher explained to
pregnant women the aim and advantages of the study. The
researcher told them that their participation is completely
voluntary, and they have the right to quit at any time, for any
reason, without having an impact on their care. The pregnant
women were also told that there were no health risks or
dangers from this study. Women were given the assurance
that the data would only be utilized for the purposes of the
study, and precautions were taken to ensure anonymity in
data coding. Each pregnant woman who accepted to
participate in the study and met the eligibility requirements
was asked for her signed agreement.
Pilot study
It was conducted on 10 pregnant women who
fulfilled the selection criteria to evaluate the clarity,
application, and relevance of the study tools. Based on its
Original Article Egyptian Journal of Health Care, 2023 EJHC Vol. 14. No.1
1033
findings, no modifications were made to the tools and no
issues that might hinder the data collection were found. The
pilot study sample was included in the study.
Research procedure
Data were collected within nine months from April
2022 to December 2022. The researcher attended the
predetermined setting two days a week from 9:00 am to 1:00
pm. This study was carried out through preparation,
interview and assessment, implementation, and evaluation.
Preparation for the study: To develop data-
gathering tools and apply the instructional program, a
thorough evaluation of the related literature has been carried
out.
Interview and assessment: Following recruitment,
the researcher conducted a one-on-one interview with each
pregnant woman to collect her socio-demographic data and
obstetrical history using a predefined interviewing
questionnaire. The researcher recorded the responses after
asking the questions in Arabic. To get a baseline evaluation,
the pregnant women were also asked to rate the intensity of
their symptoms, their functional status, and their wrist pain
using the BCTQ and NPRS, respectively. All pregnant
women in the intervention and control groups underwent an
interview and evaluation. Each pregnant woman's assessment
took approximately 20 to 30 minutes to complete.
Implementation: Routine care was provided to
pregnant women in the control group in accordance with the
hospital's standard of care. Whereas the pregnant women in
the intervention group attended one session of the nursing
instructional program in addition to receiving routine care.
The session lasted nearly 30 to 45 minutes. Its goal was
addressed using a variety of instructional techniques,
including discussion, demonstration, and re-demonstration. A
computerized PowerPoint presentation was displayed to
present the provided information. Arabic pamphlets with
summaries of the session content and additional colored
images were provided following the conclusion of the
session.
Educational session: It was designed to inform
pregnant women about the meaning, danger signs,
symptoms, and treatment of CTS. Wrist splints were
distributed among pregnant women (Figure 1). Women were
advised to wear it at night to support the wrist while holding
it firm and still immobilizing it. It also showed them how to
perform wrist flexor and wrist extensor stretches. Stretching
the wrist flexors involves straightening the arm, palm down,
and bending the wrist so that the fingers point downward.
Use the other hand to gently bring the hand towards the body
until feeling a stretch on the outside of the forearm (Figure
2). By straightening the arm and bending the wrist back, one
can do a wrist extensor stretch. Then, using the other hand,
gently press across the palm and bring it back until feeling a
stretch on the inside of the forearm (Figure 3). The pregnant
women were told to hold each stretch for 15 seconds during
the two exercises.
Figure 1. Wrist splint
Adopted from: Healthwise Staff. (2022). Wrist
splint. Available at:
https://www.northshore.org/healthresources/encyclopedia/en
cyclopedia.aspx?DocumentHwid=zm6001
Figure 2. Wrist flexor stretch
Figure 3. Wrist extensor
stretch
Adopted from: Healthwise Staff. (2022). Carpal Tunnel
Syndrome: Exercises. Available at:
https://myhealth.alberta.ca/Health/aftercareinformation/pages/co
nditions.aspx?hwid=ad1506&
The researcher also trained pregnant women on
performing medial nerve glide and tendon gliding exercises.
Each pregnant woman was instructed to apply mild heat to
her hand for 15 minutes prior to practicing the exercises and
maintain the neck and shoulder in a neutral position during
the exercises. For three to seven seconds, maintain each
position. Use a bag of crushed ice for 20 minutes after the
workouts are finished to reduce inflammation. The workouts
are done for 5–10 repetitions each, 5–10 times daily.
Six alternative hand and wrist positions are used in
the medial nerve glide technique to mobilize the medial
nerve: 1) A fist is formed by placing the thumb outside the
fingers, 2) extending the fingers, and keeping the thumb
close to the side of the hand; 3) Moreover, the wrist is
extended and the fingers are kept straight.4) Hold fingers and
wrist in place while extending thumb; 5) Keep fingers
extended while turning forearm palm up; and 6) Keep fingers
extended while using the other hand to gently stretch thumb
(Figure 4).
Original Article Egyptian Journal of Health Care, 2023 EJHC Vol. 14. No.1
1034
Figure 4. Totten and Hunter nerve gliding exercises
(11) (A-F): "(A) wrist in neutral, fingers and thumb in
flexion; (B) wrist in neutral, fingers and thumb extended; (C)
wrist and fingers extended, thumb in neutral; (D) wrist,
fingers, and thumbs extended; (E) as in (D) with the forearm
in supination; (F) as in (E) with a gentle stretch of thumb".
Adopted from: Nazarieh et al. (2020). Non-surgical
management and post-surgical rehabilitation of carpal tunnel
syndrome: An algorithmic approach and practical guideline.
Asian Journal of Sports Medicine, 11(3).
Tendon gliding exercise is a mobilization technique
in which the fingers should be moved through the following
five distinct postures to slide the hand's flexor tendons: 1)
Hand, wrist, and finger straight; 2) Tips of fingers bent into
the “hook” position; 3) Making a tight fist with the thumb
over the fingers, 4) Bend the fingers at the bottom knuckle
while maintaining them straight, and 5) Touch the palm with
the middle joint of the fingers (Figure 5).
Figure 5. (1-5) Tendon gliding exercises. (1)
straight; (2) straight fist; (3) table top; (4) fist; (5) hook.
Adopted from: Nazarieh et al. (2020). Non-surgical
management and post-surgical rehabilitation of carpal tunnel
syndrome: An algorithmic approach and practical guideline.
Asian Journal of Sports Medicine, 11(3).
Evaluation: One month after implementing the
suggested intervention, results were evaluated to determine
the intensity of symptoms and functional status using the
NPRS, as well as wrist discomfort using BCTQ. This
evaluation was performed for both intervention and control
groups through an interview during the follow-up visit.
Statistical analysis
The collected data were arranged, coded, and
statistically analyzed using the statistical package for social
science version 26.0 (SPSS, Chicago, IL). For quantitative
variables, the arithmetic mean and standard deviation were
employed to define the central tendency of observations and
quantify the dispersion of results around the mean. The one-
way analysis of variance (ANOVA) test was used for
comparison among more than two variables with continuous
quantitative data, whereas the student's t-test was used for
comparison between two variables with continuous
quantitative data. To compare the variables with categorical
data, the Chi-square [X2] test was applied. The cutoff for
statistical significance was p<0.05.
Results
The current study's findings are organized into four
primary sections: socio-demographic data, obstetrical
history, wrist pain characteristics, and neurophysiologic
parameters of carpal tunnel syndrome.
a. Socio-demographic data
While there were no statistically significant
differences between the two groups in terms of age,
educational level, residence, and occupation (p>0.05), the
results of the current study demonstrated homogeneity of the
pregnant women and matching between the control and
intervention groups. According to Table (1), 44.0% of the
intervention group and 40.0% of the control group were both
under the age of 25. In terms of education, 34.0% of the
intervention group and 38.0% of the control group had
finished their preparatory education. In terms of residence,
72.0% of the intervention group and 76.0% of the control
group both came from urban areas. In terms of occupation,
housewives made up the majority of women in both groups.
b. Obstetrical history
It was revealed that the pregnant women in both groups
were homogeneous with regard to prior obstetrical history
because there were no statistically significant differences
between the two groups in terms of gravidity, parity, mode of
prior delivery, or complications from prior pregnancies
(p>0.05). In terms of gestation, the control and intervention
groups' respective gravidity rates were 72.0% and 74.0%. In
Original Article Egyptian Journal of Health Care, 2023 EJHC Vol. 14. No.1
1035
terms of parity, 70.0% of the intervention group and 72.0%
of the control group were both primiparas. In terms of prior
delivery mode, 67.5% of the intervention group and 70.7% of
the control group both underwent cesarean sections. The
findings showed that difficulties during their prior
pregnancies occurred in 24.4% of the control group and
12.5% of the intervention group (Table 2). In terms of
gestational age, the findings showed that 86.0% of the
intervention group and 90.0% of the control group were in
the third trimester of pregnancy (Figure 6).
c. Wrist pain characteristics
As shown in Table (3), all the control and
intervention groups suffered from hand pain pre-intervention.
While post-intervention, 84.0% of the control group and
50.0% of the intervention group suffered from hand pain.
The difference between the two groups was statistically
significant (p<0.001). Pain severity showed that pre-
intervention, 40.0% of the control group had severe pain as
compared to 30.0% of the intervention group with no
statistically significant difference between the levels of pain
among the two groups (p=0.574). When comparing levels of
pain post-intervention, Table (4) showed that 47.6% of the
control group had severe pain in comparison to no one in the
intervention group. This difference was highly statistically
significant (p<0.001).
d. Neurophysiologic parameters of carpal tunnel syndrome
It was found that there was no statistically
significant difference between the mean scores of the control
group and the intervention group prior to the intervention for
the symptom severity scale (p=0.494). There was a
statistically significant difference in the mean scores post-
intervention (p=0.013). The functional status scale results
showed that neither pre-intervention (p=0.758) nor post-
intervention (p=0.118) differences in mean scores were
found. There was no statistically significant difference in the
overall mean BCTQ scores between the control group and
the intervention group prior to the intervention (p=0.802).
After the intervention, there was a statistically significant
difference (p=0.032) in the overall mean scores of both
groups.
Table 1. Socio-demographic characteristics of the studied pregnant women
Variables
Control group
(N=50)
Intervention group
(N=50)
Chi-Square
Freq.
%
Freq.
%
X2
P
Age (Years)
< 25
20
40.0
22
44.0
25 – 30
14
28.0
18
36.0
> 30
16
32.0
10
20.0
1.980
0.372
Mean ±SD
27.1 ±4.5
25.9 ±3.9
1.378
0.171
Level of education
Read and write
4
8.0
3
6.0
Primary education
5
10.0
4
8.0
Preparatory education
19
38.0
17
34.0
Secondary education
14
28.0
19
38.0
Higher education
8
16.0
7
14.0
1.189
0.880
Residence
Rural
12
24.0
14
28.0
Urban
38
76.0
36
72.0
0.208
0.648
Occupation
Housewife
39
78.0
32
64.0
Working
11
22.0
18
36.0
2.380
0.123
Original Article Egyptian Journal of Health Care, 2023 EJHC Vol. 14. No.1
1036
Table 2. Obstetric history of the studied pregnant women
Items
Control group (N=50)
Intervention group (N=50)
Chi-Square
Freq.
%
Freq.
%
X2
P
Gravidity
1
7
14.0
7
14.0
2
36
72.0
37
74.0
3 or more
7
14.0
6
12.0
0.091
0.956
Parity
Nullipara
9
18.0
10
20.0
1
36
72.0
35
70.0
2
5
10.0
5
10.0
0.067
0.967
Mode of prior delivery
(n=41)
(n=40)
VD
12
29.3
13
32.5
CS
29
70.7
27
67.5
0.099
0.753
Prior pregnancy complications
(n=41)
(n=40)
Yes
10
24.4
5
12.5
No
31
75.6
35
87.5
1.897
0.168
If yes, what were they?
(n=10)
(n=5)
Abortion
6
60.0
0
0.0
PROM
1
10.0
2
40.0
Placenta Previa
2
20.0
2
40.0
Polyhydramnios
1
10.0
1
20.0
5.250
0.263
Figure 6. Gestational age of the studied pregnant women
Original Article Egyptian Journal of Health Care, 2023 EJHC Vol. 14. No.1
1037
Table 3. Comparison of wrist pain characteristics among both groups pre-intervention
Variables
Control group
(N=50)
Intervention group
(N=50)
Chi-Square
Freq.
%
Freq.
%
X2
P
Presence of wrist pain
Absent
0
0.0
0
0.0
Present
50
100.0
50
100.0
0.000
1.000
Site of wrist pain
Bilateral
11
22.0
10
20.0
Right
22
44.0
24
48.0
Left
17
34.0
16
32.0
0.165
0.921
Intensity of wrist pain
Mild
4
8.0
5
10.0
Moderate
26
52.0
30
60.0
Severe
20
40.0
15
30.0
1.111
0.574
Table 4. Comparison of wrist pain characteristics among both groups post-intervention
Control group
(N=50)
Intervention group
(N=50)
Chi-Square
Freq.
%
Freq.
%
X2
P
Presence of wrist pain
Absent
8
16.0
25
50.0
Present
42
84.0
25
50.0
13.071
<0.001**
Site of wrist pain
(n=42)
(n=25)
Bilateral
3
7.1
3
12.0
Right
22
52.4
9
36.0
Left
17
40.5
13
52.0
1.787
0.409
Intensity of wrist pain
(n=42)
(n=25)
Mild
3
7.1
19
76.0
Moderate
19
45.2
6
24.0
Severe
20
47.6
0
0.0
36.428
<0.001**
Table 5. Comparison of the Boston Carpal Tunnel Syndrome mean score among both groups pre-intervention
Control group
Intervention group
Student’s T-Test
Mean ±SD
Mean ±SD
T
P
Symptom severity scale
2.9 ±0.4
2.8 ±0.4
0.687
0.494
Functional status scale
3.2 ±0.5
3.2 ±0.5
0.308
0.758
Total BCTQ Score
3.0 ±0.4
3.0 ±0.3
0.251
0.802
Table 6. Comparison of the Boston Carpal Tunnel Syndrome mean score among both groups post-intervention
Control group
Intervention group
Student’s T-Test
Mean ±SD
Mean ±SD
T
P
Symptom severity scale
2.3 ±1.0
1.9 ±0.3
2.520
0.013*
Functional status scale
2.3 ±1.2
2.1 ±0.3
1.579
0.118
Total BCTQ Score
2.3 ±1.0
2.0 ±0.2
2.180
0.032*
Original Article Egyptian Journal of Health Care, 2023 EJHC Vol. 14. No.1
1038
Discussion
This study aimed at examining the effect of nursing
instructional program on neurophysiologic parameters of
carpal tunnel syndrome among pregnant women. It was
found that most pregnant women with CTS were in their
third trimester of pregnancy. This is similar to an
epidemiological study done by Ajroud et al. (2020) who
studied carpal tunnel syndrome among pregnant women at
Al-Wahda hospital Derna and observed that the majority of
the women were in their 3rd trimester. It is vindicated by the
actuality that there is raise in water retention which leads to
edema, and most pregnant women are present in the last
trimester.
The study aim was attained through the study
findings which revealed that there was no statistically
significant difference between the intervention and control
groups concerning pain severity at baseline assessment while
after the intervention, there is a significant decline in pain
severity among both groups. These findings supported the
first study hypothesis " Pregnant women with carpal tunnel
syndrome who receive nursing instructional program have a
lower level of pain than controls".
Similarly, Naeiji et al. (2021) analyzed the effect of
the Persian manual on patients with mild and moderate
carpal tunnel syndrome. They showed that pain improved in
the experimental group significantly than in the monitoring
group. This finding is also supported by a study done by
Wolny & Line, (2019) titled: Is the treatment of carpal
tunnel syndrome with manual therapy based on
neurodynamic approaches effective? a controlled, random
experiment. They declared that there is a significant change
in hand pain severity in the intervention group compared to
the monitoring group.
In the same line, Ahmed & Khatab (2020)
conducted a study designed to find out if hand exercises and
night splinting had any influence on CTS patients' symptoms.
They reported that after the intervention, there was a
significant reduction in hand pain severity among the studied
group compared to the control group. This finding
announced that hand exercises and night splints are effective
methods of relieving hand pain. The effectiveness may
improve symptoms of CTS by prohibiting or extending the
cohesions through the median nerve and tendons, lowering
tenosynovial edema, recovering venous return, and
decreasing the median nerve strain. As a result, the hands’
blood circulation improved.
In addition, the night splint helped the joint in a
balanced posture. When women slept at night, the symptoms
became worse because the hands are more probable to bend.
The night splint blocks these from occurring. It's also
significant; on the day pregnant women should normally
move their hands to save the muscles from weakness and
stiffness.
The results of the current study showed that there
was no statistically significant difference in the mean scores
among the control and intervention groups pre-intervention
for any of the items on the symptom severity scale of the
Boston Carpal Tunnel Syndrome Questionnaire. While there
was a statistically significant difference in the mean scores
post-intervention. Thus, the second study hypothesis:
"Pregnant women with carpal tunnel syndrome who receive
nursing instructional program have a lower mean score of
symptom severity than controls" was also validated.
These findings are appropriate with the findings of a
study done by Naeiji et al. (2021) stated that there was a
significant refinement in the study group regarding the
BCTQ symptom severity scale compared to the monitoring
group after the intervention. Similarly, Keskin et al. (2020)
examined effectiveness of home exercise in pregnant women
with carpal tunnel syndrome. They assessed BCTQ symptom
severity scale items pre-and post-intervention. Pre-intervention,
there was no statistically significant difference between the
mean scores among the control and study groups while post-
intervention, there was a statistically significant difference
between the mean scores. This result is identical to Wolny &
Line (2019) who mentioned significant changes in pain and
symptom severity in the experimental group after the
intervention.
Concerning the functional status scale, it was shown
that there was no statistically significant difference between
the mean scores among the control and intervention groups
either pre-intervention or post-intervention. Thus, the third
study hypothesis: "Pregnant women with carpal tunnel
syndrome who receive nursing instructional program have a
higher mean score of functional status than controls" was
unsupported. This finding is inappropriate with the finding of
a study done by Naeiji et al. (2021) stated that there was a
significant perfection in the experimental group with regard
to the BCTQ functional status scale compared to the
monitoring group. A randomized controlled Turkish study
conducted by Keskin et al. (2020) partially agreed with the
present study’s findings; it revealed no statistically
significant difference between the mean scores among the
control and intervention groups regarding BCTQ functional
status scale pre-intervention while post-intervention, there
was a statistically significant difference between the mean
scores.
In contrast with the current study, the results of
Ahmed & Khatab, (2020) reported that the highest
proportion of the study group had moderate difficulty with
their activities on the functional status scale pre-intervention.
Post-intervention, it improved and significantly correlated
with Boston carpal tunnel syndrome. This result conflict with
Wolny & Line (2019) who found statistically significant
changes in the functional status in the intervention group
after the intervention. Perhaps, the reported differences in the
functional status scale between this study and other studies
might be due to the sample of study being pregnant women
and most of them were in 3rd trimester which led to an
increase in the severity of CTS.
Regarding the total BCTQ mean score, there was no
statistically significant difference between the total mean
scores of the control and intervention groups pre-intervention
while post-intervention, the difference between the total
Original Article Egyptian Journal of Health Care, 2023 EJHC Vol. 14. No.1
1039
mean scores of both groups was statistically significant.
Similarly, Ajroud, et al. (2020) concluded that home
physiotherapy can be used as a conservative treatment during
pregnancy to improve CTS symptoms. In the same line,
Atroshi et al. (2019) in a randomized placebo-controlled
trial study examined the treatment of CTS with wrist
splinting and found that splint treatment can be used as
conservative management which revealed evidence
concerning the efficacy of hand splinting in patients had
CTS.
As well likeness with Unver & Akyolcu (2018) in
their research to decrease the CTS symptoms in patients
under hemodialysis using hand exercise, they mentioned that
most of the studied group with mild CTS symptoms
improved by the ball exercise, so this exercise had a lot of
advantages such as effective, handy and faint cost to use as
an alternative treatment in CTS. This finding is appropriate
to the findings of a study done by Abd Elmoniem et al.
(2018) examined how an educational program regarding
carpal tunnel syndrome affected pregnant women's
knowledge, the intensity of their symptoms, and their
functional status came to the conclusion that using a night
splint and exercising during pregnancy helped the women's
symptoms become less severe.
From the present study findings, the nursing
instructional program is an effective intervention that
improves the neurophysiologic parameters of carpal tunnel
syndrome among pregnant women. It should be provided by
nurses at antenatal care units.
Conclusion
It can be concluded that the nursing instructional
program was successful in the improvement of the
neurophysiologic parameters of carpal tunnel syndrome
among pregnant women, according to the study's findings.
Recommendations
According to the study's conclusion, the following are
suggested:
• Apply such nursing instructional program could be
imposed to decrease suffering among pregnant
women with CTS.
• Design an educational program to increase
maternity nurses' knowledge regarding hand
exercises and splinting for CTS.
• Provide pregnant women with adequate evidence-
based knowledge about strategies that improve the
neurophysiologic parameters of CTS.
• Include hand exercises and splinting for CTS among
pregnant women in the nursing curriculum.
• Replicate the current work on a bigger probability
sample in various settings as a future study.
Acknowledgment
The researchers appreciate the participation of women
in the study.
Conflicts of interest
The researchers declare no conflict of interest.
References
Abd Elmoniem, S.O., Abd-Elhakm, A.M., Ibrahim, H.A
(2018). The Effect of an Educational Intervention about
Carpal Tunnel Syndrome on Pregnant Womens' Knowledge,
Symptoms Severity, and Function Status. IOSR Journal of
Nursing and Health Science, 7(6): 19-28.
Abdel Maksoud, M & Ramadan, S, (2021). The Effect of
Nursing Rehabilitation Program on Symptoms Severity and
Functional Status in Patients with Carpal Tunnel Syndrome
Undergoing Surgery. Egyptian Journal of Health Care, 12(3),
1028-1046.
Afshar, A., & Tabrizi, A. (2021). Pregnancy-related hand
and wrist problems. Archives of Bone and Joint
Surgery, 9(3), 345.
Ahmed, H., & Khatab, H. (2020). The Effect of Night
Splinting and Hand Exercise on Reducing the Symptoms in
Patients with Carpal Tunnel Syndrome. Egyptian Journal of
Health Care.11(4):615-633.
Ajroud, S., Younis, M., & Elzahaf, R. A. (2020). An
epidemiological study of carpal tunnel syndrome among
pregnant women at Al-Wahda hospital Derna. Engineer, 1, 1-
35.
Atroshi, I., Tadjerbashi, K., McCabe, S. J., & Ranstam,
J. (2019). Treatment of carpal tunnel syndrome with wrist
splinting: study protocol for a randomized placebo-controlled
trial. Trials, 20, 1-11.
Beaton, D. E., Bombardier, C., Guillemin, F., & Ferraz,
M. B. (2000). Guidelines for the process of cross-cultural
adaptation of self-report measures. Spine, 25(24), 3186-3191.
Cazares-Manríquez, M. A., Wilson, C. C., Vardasca, R.,
García-Alcaraz, J. L., Olguín-Tiznado, J. E., López-
Barreras, J. A., & García-Rivera, B. R. (2020). A review
of carpal tunnel syndrome and its association with age, body
mass index, cardiovascular risk factors, hand dominance, and
sex. Applied Sciences, 10(10): 3488.
Dabbagh, A., MacDermid, J. C., Yong, J., Macedo, L. G.,
& Packham, T. L. (2020). Diagnosing carpal tunnel
syndrome: diagnostic test accuracy of scales, questionnaires,
and hand symptom diagrams—a systematic review. Journal
of Orthopedic & Sports Physical Therapy, 50(11): 622-631.
Erickson, M., Lawrence, M., & Lucado, A. (2022). The
role of diagnostic ultrasound in the examination of carpal
tunnel syndrome: an update and systematic review. Journal
of Hand Therapy, 35(2), 215-225.
Original Article Egyptian Journal of Health Care, 2023 EJHC Vol. 14. No.1
1040
Genova, A., Dix, O., Saefan, A., Thakur, M., & Hassan,
A. (2020). Carpal tunnel syndrome: a review of
literature. Cureus, 12(3).
Hamid, A., Rahman, Z. F., Suherdin, S., Widati, S., &
Wahyudiono, Y. D. A. (2020). Factors Related to Carpal
Tunnel Syndrome (CTS) Complaints on Employees in the
Bank BNI Branch of Palu. Jurnal Ilmu Kesehatan
Masyarakat, 11(01), 63-74.
Hamzeh, H., Madi, M., Alghwiri, A. A., & Hawamdeh, Z.
(2021). The long-term effect of neurodynamics vs exercise
therapy on pain and function in people with carpal tunnel
syndrome: A randomized parallel-group clinical trial. Journal
of Hand Therapy, 34(4), 521-530.
Healthwise Staff. (2022). Carpal Tunnel Syndrome:
Exercises. Available at:
https://myhealth.alberta.ca/Health/aftercareinformation/pages
/conditions.aspx?hwid=ad1506&
Healthwise Staff. (2022). Wrist splint. Available at:
https://www.northshore.org/healthresources/encyclopedia/en
cyclopedia.aspx?DocumentHwid=zm6001
Hernández-Secorún, M., Montaña-Cortés, R., Hidalgo-
García, C., Rodríguez-Sanz, J., Corral-de-Toro, J.,
Monti-Ballano, S., ... & Lucha-López, M. O. (2021).
Effectiveness of conservative treatment according to severity
and systemic disease in carpal tunnel syndrome: a systematic
review. International Journal of Environmental Research and
Public Health, 18(5): 2365.
Kamel, D. M., Hamed, N. S., Raoof, N. A. A., & Tantawy,
S. A. (2017). Pulsed magnetic field versus ultrasound in the
treatment of postnatal carpal tunnel syndrome: A randomized
controlled trial in the women of an Egyptian
population. Journal of advanced research, 8(1), 45-53.
Karjalanen, T., Raatikainen, S., Jaatinen, K., & Lusa, V.
(2022). Update on the efficacy of conservative treatments for
carpal tunnel syndrome. Journal of clinical medicine, 11(4),
950.
Keskin Y, Kilic G, Taspinar O, Posul SO, Halac G, Eren
F, Erol E, Urkmez B, Aydin T (2020). Effectiveness of
home exercise in pregnant women with carpal tunnel
syndrome: Randomized Control Trial. Journal of Pakistan
Medical Association .70(2):202-207.
Klokkari, D., & Mamais, I. (2018). Effectiveness of
surgical versus conservative treatment for carpal tunnel
syndrome: A systematic review, meta-analysis, and
qualitative analysis. Hong Kong Physiotherapy
Journal, 38(02), 91-114.
Lampainen, K., Shiri, R., Auvinen, J., Karppinen, J.,
Ryhänen, J., & Hulkkonen, S. (2022). Weight-Related and
Personal Risk Factors of Carpal Tunnel Syndrome in the
Northern Finland Birth Cohort 1966. Journal of clinical
medicine, 11(6), 1510.
Lewis, K. J., Coppieters, M. W., Ross, L., Hughes, I.,
Vicenzino, B., & Schmid, A. B. (2020). Group education,
night splinting, and home exercises reduce conversion to
surgery for carpal tunnel syndrome: a multicenter
randomized trial. Journal of Physiotherapy, 66(2), 97-104.
LoBiondo-Wood, G. & Haber, J. (2018). Nursing research:
methods and critical appraisal for evidence-based practice
(9th ed.) Elsevier:171-179.
McCaffery, M., & Beebe, A. (1989). The numeric pain
rating scale instructions. Pain: Clinic manual for nursing
practice. St. Louis, MO: Mosby.
Moradi, A., Sadr, A., Ebrahimzadeh, M. H.,
Hassankhani, G. G., & Mehrad-Majd, H. (2020). Does
diabetes mellitus change the carpal tunnel release outcomes?
Evidence from a systematic review and meta-analysis.
Journal of Hand Therapy, 33(3):394-401.
Naeiji, H., Mokaberinejad, R., Raeissadat, S. A., Nouri,
F., Fallah, Y., Haj Manouchehri, R., Abbassian, A., &
Riahi, S. M. (2021). Effect of Persian manual therapy (Fateh
technique) on patients with mild and moderate carpal tunnel
syndrome: a clinical trial. Journal of Contemporary Medical
Sciences, 7(4), 227–234.
Nazarieh, M., Hakakzadeh, A., Ghannadi, S., Maleklou,
F., Tavakol, Z., & Alizadeh, Z. (2020). Non-surgical
management and post-surgical rehabilitation of carpal tunnel
syndrome: An algorithmic approach and practical guideline.
Asian Journal of Sports Medicine, 11(3).
Obuchowicz, R., Kruszyńska, J., & Strzelecki, M. (2021).
Classifying median nerves in carpal tunnel syndrome:
Ultrasound image analysis. Biocybernetics and Biomedical
Engineering, 41(2):335-351.
Oliveira, G. A. D. D., Bernardes, J. M., Santos, E. D. S.,
& Dias, A. (2019). Carpal tunnel syndrome during the third
trimester of pregnancy: prevalence and risk factors. Archives
of gynecology and obstetrics, 300, 623-631.
Padua, L., Coraci, D., Erra, C., Pazzaglia, C., Paolasso, I.,
Loreti, C., ... & Hobson-Webb, L. D. (2016). Carpal tunnel
syndrome: clinical features, diagnosis, and management. The
Lancet Neurology, 15(12):1273-1284.
Radiopaedia (2023). Carpal tunnel syndrome. Available
at: https://radiopaedia.org/?lang=us.
Schmid, A. B., Fundaun, J., & Tampin, B. (2020).
Entrapment neuropathies: a contemporary approach to
pathophysiology, clinical assessment, and management. Pain
reports, 5(4).
Setyawan, H. (2017). Risk factors of carpal tunnel syndrome
in food-packing workers Karanganyar. Kesmas: Jurnal
Kesehatan Masyarakat Nasional (National Public Health
Journal), 11(3), 123-126.
Subandi, S., Mirawati, D. K., Putra, S. E., Hafizhan, M.,
Susilo, W. A., & Danuaji, R. (2020). The relationship
Original Article Egyptian Journal of Health Care, 2023 EJHC Vol. 14. No.1
1041
between working period of batik craftsmen and incident of
carpal tunnel syndrome. Malang Neurology Journal, 6(2):73-
76.
Unver, S., & Akyolcu, N. (2018). The effect of hand
exercise on reducing the symptoms in hemodialysis patients
with carpal tunnel syndrome. Asian journal of
neurosurgery, 13(01), 31-36.
Urits, I., Gress, K., Charipova, K., Orhurhu, V., Kaye, A.
D., & Viswanath, O. (2019). Recent advances in the
understanding and management of carpal tunnel syndrome: a
comprehensive review. Current pain and headache reports,
23(10):1-8.
Wolny, T., & Linek, P. (2019). Is manual therapy based on
neurodynamic techniques effective in the treatment of carpal
tunnel syndrome? A randomized controlled trial. Clinical
Rehabilitation, 33(3), 408-417.
Wolska, J. M., Wolski, D., Bieńko, M., & Radzki, R. P.
(2018). Life quality of patients with carpal tunnel
syndrome. European Journal of Clinical and Experimental
Medicine, (3), 217-223.
Zhuang, T., Kortlever, J. T., Shapiro, L. M., Baker, L.,
Harris, A. H., & Kamal, R. N. (2020). The influence of cost
information on treatment choice: a mixed-methods study.
The Journal of hand surgery, 45(10):899-908.
