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Manipulative treatment of carpal tunnel syndrome: Biomechanical and osteopathic intervention to increase the length of the transverse carpal ligament: Part 2. Effect of sex differences and manipulative "priming"

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As a theoretical basis for treatment of carpal tunnel syndrome (CTS) and expanding upon part 1 of this study, the authors investigated the effects of static loading (weights) and dynamic loading (osteopathic manipulation [OM]) on 20 cadaver limbs (10 male, 10 female). This larger study group allowed for comparative analysis of results by sex and reversal of sequencing for testing protocols. In static loading, 10-newton loads were applied to metal pins inserted into carpal bones. In dynamic loading, the OM maneuvers used were those currently used in clinical settings to treat patients with CTS. Transverse carpal ligament (TCL) response was observed by measuring changes in the width of the transverse carpal arch (TCA) with three-dimensional video analysis and precision calipers. Results demonstrated maximal TCL elongation of 13% (3.7 mm) with a residual elongation after recovery of 9% (2.6 mm) from weight loads in the female cadaver limbs, compared to less than 1 mm as noted in part 1, which used lower weight loads and combined results from both sexes. Favorable responses to all interventions were more significant among female cadaver limbs. Higher weight loads also caused more linear translatory motion through the metal pins, resulting in TCA widening equal to 63% of the increases occurring at skin level, compared to only 38% with lower loads. When OM was performed first, it led to greater widening of the TCA and lengthening of the TCL during the weight loading that followed. Both methods hold promise to favorably impact the course of management of CTS, particularly in women.
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JAOA • Vol 105 • No 3 • March 2005 • 135Sucher et al • Original Contribution
As a theoretical basis for treatment of carpal tunnel syn-
drome (CTS) and expanding upon part 1 of this study, the
authors investigated the effects of static loading (weights)
and dynamic loading (osteopathic manipulation [OM])
on 20 cadaver limbs (10 male, 10 female). This larger study
group allowed for comparative analysis of results by sex
and reversal of sequencing for testing protocols. In static
loading, 10-newton loads were applied to metal pins
inserted into carpal bones. In dynamic loading, the
OM maneuvers used were those currently used in clinical
settings to treat patients with CTS. Transverse carpal lig-
ament (TCL) response was observed by measuring changes
in the width of the transverse carpal arch (TCA) with three-
dimensional video analysis and precision calipers. Results
demonstrated maximal TCL elongation of 13% (3.7 mm)
with a residual elongation after recovery of 9% (2.6 mm)
from weight loads in the female cadaver limbs, compared
to less than 1 mm as noted in part 1, which used lower
weight loads and combined results from both sexes. Favor-
able responses to all interventions were more significant
among female cadaver limbs. Higher weight loads also
caused more linear translatory motion through the metal
pins, resulting in TCA widening equal to 63% of the
increases occurring at skin level, compared to only 38%
with lower loads. When OM was performed first, it led to
greater widening of the TCA and lengthening of the TCL
during the weight loading that followed. Both methods
hold promise to favorably impact the course of manage-
ment of CTS, particularly in women.
C
linical management of carpal tunnel syndrome (CTS)
continues to be a challenge to physicians and their
patients, both of whom are often left to struggle with a choice
between pursuing limited conservative treatment or surgical
intervention in the form of surgical release of the transverse
carpal ligament (TCL).1However, osteopathic manipulative
treatment (OMT) and stretching exercises have shown
promising results when used in combination therapy as a
potential treatment modality for CTS, demonstrating an
increase in the width of the transverse carpal arch (TCA) as
confirmed with nerve conduction improvements and findings
from magnetic resonance imaging.2–6
In the first part of this study,7we measured actual TCL
elongation under direct clinical observation during sustained
static loading (weights). The width of the TCA was also mea-
sured before and after osteopathic manipulation (OM).7Both
methods confirmed the potential benefit of these non-sur-
gical approaches to enlarge the carpal tunnel and alleviate
symptoms of CTS. In addition, these conservative treatment
methods produced changes in the TCA that approached
those seen after surgical release of the TCL.8,9
In part 1,7we used lighter weight loads than were used
in the present study. Additionally, part 1 was conducted
with a smaller subject group (ie, seven cadaver limbs), min-
imizing any inherent difference in results by sex. Observations
from the use of varying weight loads in the original study also
led us to anticipate that higher weight loading could further
increase the TCL elongation effect. Observations from part 1
also indicated that our methods and results could easily be
duplicated in a clinical setting without damaging the skin
and subcutaneous tissues from increased pressure.
Therefore, in the present study, we opted to use higher
applied loads and identified equal numbers of male and
female cadaver limbs so that we might assess results for any
differences by sex. In addition, the sequencing of static versus
dynamic weight loading was varied (weights first or OM first)
to observe for any alterations in outcome.
Finally, because two OM maneuvers used on cadaver
limbs in part 1 of the study appeared to have minimal effect,
Manipulative Treatment of Carpal Tunnel Syndrome: Biomechanical and
Osteopathic Intervention to Increase the Length of the Transverse Carpal Ligament:
Part 2. Effect of Sex Differences and Manipulative “Priming”
Benjamin M. Sucher, DO; Richard N. Hinrichs, PhD; Robert L. Welcher, MS; Luis-Diego Quiroz, BS;
Bryan F. St. Laurent, MS; and Bryan J. Morrison, MS
From the Center for Carpal Tunnel Studies in Paradise Valley, Ariz (Sucher),
Arizona State University’s Department of Kinesiology in Tempe (Hinrichs,
Welcher, Quiroz, St Laurent, and Morrison), and the University of Wisconsin
at Eau Claire’s Department of Kinesiology and Athletics (Welcher).
Address correspondence to Benjamin M. Sucher, DO, Center for
Carpal Tunnel Studies, 10585 N Tatum Blvd, Ste D135, Paradise Valley, AZ
85253-1073.
E-mail: drsucher@centerforcarpaltunnel.com
ORIGINAL CONTRIBUTION
136 • JAOA • Vol 105 • No 3 • March 2005
we chose to eliminate them from the protocol for the present
study to simplify the procedures.
Methods
Preparation and Static Loading (Weights)
Twenty human cadaver limbs (10 male, 10 female), sectioned
at the midhumerus level, were used in the evaluation. The
mean age at death in our study population was 65 years
(63 years for males and 67 years for females), and there was no
known injury or disease involving the upper extremities. No
other information was available on the premorbid condition
of the cadavers.
Of the 20 limbs evaluated, 11 were right and 9 were left.
All arrived frozen and were maintained in that condition until
the day of testing, at which time they were warmed to room
temperature. Freezing has been shown to have no significant
effect on the biomechanical properties of ligaments.10,11
Prior to testing, investigators used a drill to place sur-
gical pins (1.6 mm in diameter, approximately 50 mm in length)
into each of the four carpal bones that would serve as attach-
ment sites for the TCL: the scaphoid and pisiform on the prox-
imal end of the carpal tunnel, and the trapezium and hamate
on the distal end (Figure 1 and Figure 2). The pins were defini-
tive markers above the surface of the skin, allowing investi-
gators to measure the width of the TCA accurately, also pro-
viding data regarding the TCL length. Pin placement was
verified by fluoroscopy. Additionally, three 4-mm diameter
white balls were placed at precisely measured locations on
each pin to delineate its long axis above skin level (Figure 3).
Two 60 Hz video cameras were mounted to the ceiling of
the testing lab looking diagonally down on the limb from the
left and right. The camera-to-limb distances were approxi-
Sucher et al • Original Contribution
ORIGINAL CONTRIBUTION
Figure 1. Radiographic image of a male cadaver
limb showing placement of surgical pins in the
scaphoid and pisiform on the proximal end of the
carpal tunnel and in the trapezium and hamate on
the distal end of the carpal tunnel (saggital view).
Figure 2. Radiographic image of a male cadaver
limb showing placement of surgical pins in the
scaphoid and pisiform on the proximal end of the
carpal tunnel and in the trapezium and hamate on
the distal end of the carpal tunnel (anteroposte-
rior view).
Figure 3. Experimental set-up demonstrates cadaver limb mounted
and secured on plywood boards with pins in place and wires attached,
as detailed in part 1 of this study.
7
Figure 4. Primary investigator (B.M.S.) performing manipulation
maneuver 4: Guy-wire and distal row transverse extension combined
(ie, manipulation maneuver 1 and manipulation maneuver 2).
JAOA • Vol 105 • No 3 • March 2005 • 137
5. Thenar extension/abduction and lateral axial rotation (not
used in the present study), and
6. Guy-wire and thenar extension/abduction and lateral axial
rotation combined (ie, manipulation maneuver 1 and manip-
ulation maneuver 5).7
Transverse carpal extension maneuvers have been
described previously2and involve a 3-point bending by the
osteopathic physician who hooks his thumbs on the inner
ventral edge of the carpal bones (trapezium and hamate dis-
tally, scaphoid and pisiform proximally) while his fingers
wrap around dorsally to converge on the center of the wrist to
provide a counterforce. This manipulation maneuver allows
a powerful leverage for the osteopathic physician’s thumbs to
apply distraction forces transversely across the carpal canal and
separate or widen the TCA as the TCL is stretched.
The guy-wire maneuver, described in part 1,7requires
the osteopathic physician to apply maximal abduction with
extension to the thumb and little finger. This position vigor-
ously stretches the tendons of the flexor pollicis longus and
flexor digitorum profundus of the fifth digit, both of which
deviate around the inside edge of the distal carpal bones
(trapezium and hamate, respectively), and create a fulcrum
effect with force vectors at the deflection contact points of
those bones which tend to pull the TCA apart.
Finally, in the extension/abduction and lateral axial rota-
tion, also previously described,2,4 the osteopathic physician
uses the thumb as a lever to apply direct traction forces on the
TCL. This OM maneuver has been shown to be highly effec-
tive clinically4because the abductor pollicis brevis and oppo-
nens pollicis muscles are directly attached to the TCL, so that
securing the medial aspect of the wrist and hand provides an
“anchor” that allows for effective traction by applying vig-
orous counterforce with extension/abduction of the thumb. At
the same time, the osteopathic physician can move the thumb
in the reverse direction of opposition (lateral axial rotation) to
further stretch and elongate the TCL.
Experimental Groups and Loading Sequence
Half of the cadaver limbs of each sex (ie, 5) received static
loading (weights) first followed by dynamic loading (OM) on
subsequent days. The other half of cadaver limbs of each sex
underwent OM first followed by weights on subsequent days.
This protocol created four separate study groups: (1)
males, weights first; (2) females, weights first; (3) males,
OM first; and (4) females, OM first. The total experiment lasted
approximately 36 hours for each cadaver limb. Overnight
between testing days, each limb was returned to the refriger-
ator but not refrozen.
Data Collection and Analysis
Although pin-to-pin distances were recorded at skin level
using precision calipers, as in part 1 of this study,7we also
used 3D video analysis in the present study to compute actual
TCL elongations from the 3D motion of the white balls placed
mately 2 m. Coordinates of the markers, as documented in
the two-dimensional images captured on these cameras, were
used to calculate the three-dimensional (3D) positions of the
markers on each pin during application of, and recovery from,
tensile loading using the direct linear transformation method.12
Three-dimensional positions were calculated at set intervals
throughout the two testing sequences. Details of the 3D
methodology are forthcoming (R.N.H., B.M.S., R.L.W., et al,
unpublished data, 2005).
Wires were attached to each pin with weights suspended
over pulleys to provide horizontal distraction forces across
the TCL, as previously described.7In part 1,7we used weight
loads of 2 newtons (N), 4 N, and 8 N in static loading proce-
dures. In response to results from part 1, however, we chose
to increase all static loads in the present study to 10 N per pin.
Precision calipers were used to measure pin-to-pin dis-
tances just above skin level at certain elapsed-time intervals
(measured in minutes) after the loads were applied: 0.5, 1, 3,
7, 15, 30, 60, 120, and 180. Caliper measurements were used to
determine the time at which no further lengthening was
achieved and equilibrium was assumed. For this reason, it
was also sometimes necessary to measure pin-to-pin distances
at 240 minutes. Typically, static loads were applied for 3 hours
with maximal widening of the TCA obtained after 2 hours
(ie, the measurement at 3 hours was the same as at 2 hours).
Once maximal elongation was achieved, static loads were
removed and similar caliper measurements were taken during
the recovery period. A typical recovery period lasted 2 hours.
Following the recovery period, static loads were reapplied
and then once again removed when equilibrium was reached
using the aforementioned criteria. Equilibrium required
approximately 2 hours to achieve in all cases with verifica-
tion taking place at 3 hours.
The duration of the entire static loading sequence (ie,
2 cycles of static loading and unloading) was approximately
6 hours for each human cadaver limb.
Dynamic Loading (Osteopathic Manipulation)
Dynamic loads were applied by the primary investigator
(B.M.S.) using OM . The four manipulations used in this study
are a subset of the six used in part 1 (ie, 2, 3, 4, and 6 applied in
sequence).6Osteopathic manipulations were repeated after a 15-
minute recovery period. The two least effective manipulations
from part 1 (ie, 1 and 5) were not used in the present study.
However, for continuity between the two parts of this
study, all six manipulation maneuvers performed in part 1
are listed here:
1. Guy wire indirect transverse extension (not used in the
present study),
2. Distal row transverse extension,
3. Proximal row transverse extension,
4. Guy-wire and distal row transverse extension combined
(ie, manipulation maneuver 1 and manipulation maneuver 2)
(Figure 4),
Sucher et al • Original Contribution
ORIGINAL CONTRIBUTION
138 • JAOA • Vol 105 • No 3 • March 2005
on the bone pins. The details of this method are forthcoming
(R.N.H., B.M.S., R.L.W., et al, unpublished data, 2005) and are
summarized below.
By knowing the 3D coordinates of the three balls on each
pin, the 3D coordinates of the point where each pin inter-
sected the TCL could be calculated by extrapolating along
each pin below the skin a certain distance. Once testing was
complete, investigators dissected down to the TCL and mea-
sured below-skin distances using precision calipers.
Calculating changes in the 3D coordinates of ligament-pin
intersection points during loading and unloading allowed us
to calculate TCL elongations. This method was acceptably
accurate with a mean error of 0.41 mm 0.25 mm. When nor-
malized to the mean starting TCL length of 32.9 mm, the error
was 1.25% (R.N.H., B.M.S., R.L.W., et al, unpublished data,
2005).
As in part 1,7the primary area of interest in the TCL was
the distal (“thick”) portion spanning between the trapezium
and hamate bones. Data analysis for the present study required
that we obtain data by: (1) plotting the data derived from
caliper measurements of pin movement above skin level, and
(2) plotting the data derived from 3D videography of points on
the pins to predict actual TCL length changes. Elongations
were normalized by dividing the change in length by the orig-
inal length, and are expressed as a percentage of strain.
This new analytical model is in contrast with that pre-
sented in part 1,7where all elongation measurements were
noted in millimeters only. Normalizing elongation data makes
it easier to combine results from limbs with different initial
(pretest) TCL lengths. However, we took the mean strain
Sucher et al • Original Contribution
ORIGINAL CONTRIBUTION
Figure 5. Manipulation set 1: dynamic loading. Results of dynamic
loading (osteopathic manipulation) alone on the transverse carpal lig-
ament in males (n=5) vs females (n=5) on the first day of testing.
Static loading was performed after the manipulation sequence was
completed. Manipulation maneuver 2 (distal row transverse extension),
manipulation maneuver 4 (guy-wire and distal row transverse exten-
sion combined), and manipulation maneuver 6 (guy-wire and thenar
extension/abduction and lateral axial rotation combined)
7
were used.
The results of manipulation maneuver 3 (proximal row transverse
extension) are not presented here because this manipulation
maneuver is intended to stretch the proximal portion of the TCL and
has little effect on the distal portion of the TCL.
Figure 6. Manipulation set 1: 15-minute recovery period after
dynamic loading. Results of dynamic loading (osteopathic manipu-
lation) alone on the transverse carpal ligament in males (n=5) vs
females (n=5).
JAOA • Vol 105 • No 3 • March 2005 • 139
was performed using SAS software (version 8.2 for Windows,
SAS Institute Inc, Cary, NC). The dependent variable was
residual TCL elongation at the end of the recovery period.
Independent variables were sex (male vs female) and
order of loading sequence (static [weights] followed by
dynamic [OM] or vice versa). When appropriate, pairwise
planned contrasts were performed to investigate simple effects.
The level of significance was set to .05 for all tests.
Results
The dynamic loading results demonstrate that OM alone was
able to elongate the TCL more significantly in females than in
males (P=.006), with substantially greater peak TCL elongation
and less recoil during recovery (manipulation set 1: Figure 5 and
Figure 6; manipulation set 2: Figure 7 and Figure 8).
values, as measured in percentages, and multiplied that
number by the mean initial TCL length for each sex (28.7 mm
for females and 36.6 mm for males) to provide an equivalent
elongation in millimeters that could then be compared with the
results of other studies.
In order to determine significant differences between
means, a two-way repeated-measures analysis of variance
Sucher et al • Original Contribution
ORIGINAL CONTRIBUTION
Figure 7. Manipulation set 2: dynamic loading (procedure repeated).
Results of dynamic loading (osteopathic manipulation) alone on the
transverse carpal ligament in males (n=5) vs females (n=5) on the
first day of testing. Static loading was performed after the manipu-
lation sequence was completed. Manipulation maneuver 2 (distal
row transverse extension), manipulation maneuver 4 (guy-wire and
distal row transverse extension combined), and manipulation
maneuver 6 (guy-wire and thenar extension/abduction and lateral axial
rotation combined)
7
were used. The results of manipulation
maneuver 3 (proximal row transverse extension) are not presented
here because this manipulation maneuver is intended to stretch the
proximal portion of the TCL and has little effect on the distal portion
of the TCL.
Figure 8. Manipulation set 2: 15-minute recovery period after
dynamic loading (procedure repeated). Results of dynamic loading
(osteopathic manipulation) alone on the transverse carpal ligament
in males (n=5) vs females (n=5).
140 • JAOA • Vol 105 • No 3 • March 2005
The results of manipulation maneuver 3 (proximal row
transverse extension) are not included in Figure 5 and Figure 7
because this manipulation is intended to stretch the proximal
portion of the TCL and we found it to have little effect on the
distal portion of the TCL. As discussed in part 1,7we consider
the distal portion of the TCL to be the “limiting factor” in TCL
stretches and the site where most of the pathology/compres-
sion in CTS occurs.
Male TCLs recoiled almost back to baseline following
OM, whereas female TCLs maintained some (approximately
5%) residual elongation (Figure 8). Peak elongations in the
distal band of the TCL occurred with manipulation maneu-
vers 2 and 4. There was a slightly higher peak strain by adding
the guy-wire technique to the transverse extension (manipu-
lation maneuver 4), similar to the results observed in part 1.7
In both manipulation sets, the thenar and guy-wire technique
(manipulation maneuver 6) was not effective in stretching the
TCL (Figure 5 and Figure 7).
Static loading results (weights) demonstrate a typical
“creep” response, with the distal portion of the TCL elon-
gating between 5% and 7% (1.6 mm to 2.3 mm) over a 2-hour
period, then returning close to baseline measures when the
weights were removed (Figure 6). The second application of
weights generally stretched the TCL more than the initial
application of weights did, and the final resting position reflects
an overall increase in TCL length of approximately 2% (0.6 mm)
for most of the cadaver limbs (Figure 8).
The one group that differed from the other three was the
female group that received OM first (Figure 9 and Figure 10).
In this group, dynamic loading (OM) allowed the static loading
(weights) to stretch the TCL significantly further than in males
(9% [2.6 mm] vs 2% [0.7 mm], P=.0006). The reverse was not
found to be true, however; that is, OM was not significantly
more effective when preceded by weights for either sex
(P=.213).
The overall mean change (standard deviation [SD]) in
TCL length (determined by 3D video analysis) was found to be
63% 36% SD of the change in pin separation at skin level
(as measured using precision calipers). The relatively large
standard deviation reflects differences between limbs as well as
differences between the loaded and unloaded states of TCLs.
Generally, the values were smaller during the loading of the
TCLs and larger during the recovery periods after elongations.
Comment
After analyzing results of the present study, several key points
are apparent in relation to the results from part 1,7especially
when comparing male to female TCL responses at higher
weight loads and in alternate loading sequences.
The TCL elongation produced in the present study was
substantially greater than estimated in part 1.7Further, the
ratio of TCL lengthening relative to the separation of the pins
Sucher et al • Original Contribution
ORIGINAL CONTRIBUTION
Figure 9. Results of static loading (weights) first and dynamic loading
(osteopathic manipulation) first trials for male cadaver limbs. Loading
sequence had little effect on the results for male cadaver limbs. Elon-
gations were normalized by dividing the change in length by the orig-
inal length, and are expressed as a percentage of strain.
JAOA • Vol 105 • No 3 • March 2005 • 141
We have now also demonstrated that the actual changes
in TCL length (measured by video) were approximately 63%
of the changes in pin separation (measured by precision
calipers). In other words, for every millimeter that the pins
moved further apart above the skin, the TCL actually elongated
0.63 mm. This new result contrasts sharply with the results of
part 1 in which we estimated this value to be only 38%.7
In part 1,7we used caliper measurements for both above-
skin and at-ligament–level measures in two cadaver limbs
dissected prior to applying static loads. In those two limbs, we
dissected down to the TCL first, applied loads to the pins,
and took direct measurements at both sites as the pins moved
apart from each other. We directly observed (in the dissected
state) that the measurements at ligament level were only about
38% of those taken above the skin. Based upon these obser-
vations in part 1,7mean residual TCL elongation was calculated
to be less than 1 mm, compared to 2.6 mm for the female
TCLs in the present study.
It now appears to have been inaccurate to apply the 38%
value to the other five cadaver limbs that were tested intact in
part 1,7when the loads were applied to the pins prior to dis-
section. In the present study, it has become obvious that the
TCL elongates in a different fashion when loaded after dis-
section compared to when it is loaded before dissection. Evi-
dently, the surrounding tissue affects the manner in which
the pins (and hence the bones and TCL) move during loading.
There is more of a side-to-side parallel translation of the pins
during loading when the surrounding tissue is left intact
(Figure 11).
In contrast, when this tissue is removed, there is increased
at skin level was also greater. All interventions produced
greater effects on female TCLs, and performing OM prior to
weight loading produced an enhanced effect that was not
observed when reversing the sequence of the two testing pro-
cedures.
Finally, the most effective manipulative maneuver was
shown to be the same one as was used in the initial study that
added the guy-wire maneuver to the distal row transverse
extension (manipulation maneuver 4, Figure 4).7
In part 1 of this study,7we used lighter weight loads (2 N,
4 N, and 8 N) for longer periods of time (8-12 hours) and did
not produce the degree of TCL elongation achieved in the
present study with 10 N applied for 2 to 3 hours.
In addition, part 1 focused on maximal TCL elongations
that occurred during the application of loads, whereas the
present study focused on residual TCL elongations once loads
were removed, because this effect would be the more clinically
significant and desirable result from any intervention used to
treat patients with CTS.
Sucher et al • Original Contribution
ORIGINAL CONTRIBUTION
Figure 10. Results of static loading (weights) first and dynamic
loading (osteopathic manipulation [OM]) first trials for female cadaver
limbs. Prior application of dynamic loading (OM) had a large and sig-
nificant effect for female cadaver limbs. In particular, note the shift
in baseline for the trial using OM first, indicating residual elongation
carried over from OM maneuvers used on the previous day. Elon-
gations were normalized by dividing the change in length by the orig-
inal length, and are expressed as a percentage of strain.
142 • JAOA • Vol 105 • No 3 • March 2005
rotation of the pins that results in greater movement above the
skin level (Figure 12), but relatively less widening of the TCA,
with less bone separation and less TCL elongation. In any
event, residual TCA widening obtained in part 1 was sub-
stantially less than that achieved in the present study among
the female cadaver limbs.
Another significant finding in the present study were sex
differences in static and dynamic loading results. The differ-
ence in response by sex suggests a need for osteopathic
researchers to quantify the elastic properties of ligaments in
males and females so that we might establish reference ranges
for the purposes of comparison.
The primary investigator (B.M.S.) observed that male
cadaver wrists were more resistant to OM. In general, the
male wrists were noted to be larger, making it cumbersome and
more difficult technically to apply OM optimally while working
around the surgical pins. This technical challenge inherent to
the study was particularly problematic when the primary
investigator attempted to apply manipulation maneuver 4 to
male wrists (Figure 4).
In fact, we believe this difficulty partially explains the
greater TCL strain (elongation) with OM in females. Because
male TCLs were observed to be “thicker” in comparison to that
of the females,7and were less extensible according to the strain
data, it is reasonable to presume that a 10 N load would have
less effect on lengthening male TCLs than it could on a thinner
and more extensible female TCL, thereby explaining the dif-
ference in response to static loading.
Perhaps an even more significant finding that was exclu-
sive to females was that the effect of applying OM on day 1 of
testing was apparent in day 2 when static loading was applied.
When OM was applied first, it appears to have enhanced the
effect of subsequent static loading, an effect which we call
“priming.” Interestingly, when the sequence was reversed, there
was no evidence of any priming effect from applying weights
before OM. This effect logically suggests that in a clinical situ-
ation, the “preferred” sequence of therapy would be osteo-
pathic manipulative treatment (OMT) first, followed by static
stretching (ie, a regimen of stretching exercises for the patient to
follow at home after a physician provides OMT in the office).
Previous clinical trials2–6 demonstrated successful treat-
ment of CTS using combinations of various treatment modal-
ities, with OMT and vigorous stretching exercises as the main-
stay. However, no controlled study was undertaken regarding
the most effective sequencing of a combined OMT and exer-
cise treatment protocol. These two approaches were often ran-
domly applied because patient compliance and accessibility to
physician’s offices varied. It now appears that a recommended
protocol beginning with OMT is justified.
It is noteworthy that female TCLs responded significantly
better to OM and static loading than male TCLs. Because sub-
stantially more women suffer from CTS than men,13 it is con-
Sucher et al • Original Contribution
ORIGINAL CONTRIBUTION
Figure 11. Above-skin vs below-skin transverse carpal ligament
measurements (TCL): pure translation of pins (an unlikely outcome).
Above-skin measurements reflect TCL elongation directly.
Figure 12. Above-skin vs below-skin transverse carpal ligament
measurements (TCL): combined translation and rotation of pins (a
more likely outcome). The distance pins separate above the skin is
greater than actual TCL elongation.
JAOA • Vol 105 • No 3 • March 2005 • 143
This finding has the potential to impact and dramatically alter
clinical outcomes. Knowledge and application of this pre-
ferred sequence of OMT followed by stretching should be
used to increase patient motivation and compliance.
Finally, this study adds further objective evidence that
the OM technique which adds the guy-wire maneuver to the
distal carpal row transverse extension7is the most effective
osteopathic approach in the management of CTS.
Acknowledgment
This work was funded by a grant from the American Osteopathic
Association (No. #98-28-460).
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venient that women could more readily benefit from treat-
ment with OMT for this condition than men.
However, it is likely that male TCL elongation would
approach levels observed in the females by applying greater
static loads—or by using more vigorous OM techniques in
combination with more vigorous stretching exercises in this
patient population.
It is encouraging that residual TCL elongation in female
limbs was greater than estimated in part 1.7This result further
supports the greater potential of OMT to alleviate symptoms
of CTS because the resulting increase in TCA dimensions
more closely approaches changes observed postoperatively,
after transection of the TCL.8,9
Future studies will investigate additional OM techniques,
such as two-person manipulations that could be more effective
on the larger and more challenging male subjects. Such an
approach might facilitate manipulation maneuver 4, the use of
which was limited in the present study, as noted elsewhere.
In live subjects (actual patients), the primary investigator
(B.M.S.) has noted anecdotally that OMT is clinically very
effective in men when more vigorous (higher force) techniques
are used and when a second osteopathic physician is available
to assist (oral communication, June 2004). The observed thicker
TCLs on male cadaver limbs, which were more resistant to
elongation using static weight loading compared with TCLs in
female cadaver limbs, supports the requirement for the use of
higher forces in males.
The results of the present study are being used as param-
eters to design a dynamic orthotic device that would apply low
static loads to patient’s TCLs over several hours. Clinical trials
will be required to assess the efficacy of this type of treatment
for patients with CTS, however. As noted, we expect to observe
in clinical trials that the findings on cadaver studies will com-
pare with living tissue because, as noted, it has been previously
demonstrated that postmortem storage has little or no effect on
the biomechanical properties of ligaments.10,11
Conclusion
Elongation of the TCL was underestimated in part 1 of this
study.7Widening of the TCA provides a much greater per-
centage of pin separation at skin level than prior calculations
predicted. Thus, intervention with OMT, stretching exercises,
and the use of dynamic orthosis should be more effective than
previously concluded7based upon the results of the present
study. These interventions may prove to have greater effects
on women than men. Technical limitations inherent in the
study protocol may have reduced the clinical efficacy of pro-
posed treatment effects on male wrists. However, these specific
limitations would not exist in the clinical setting.
Because OM appears to prime the TCL, potentially making
it more responsive to subsequent stretching or exercise, it
appears that there is a preferred sequence for these combined
treatment protocols when used to treat patients with CTS.
Sucher et al • Original Contribution
ORIGINAL CONTRIBUTION
... Since the incidence of CTS is greater in women than in men, and less studies examined the differences between genders and TCL (thickness and stiffness). Our study showed that gender was not significantly related to TCL thickness and stiffness in the patient and control groups, which is consistent with previous studies (32,33). However, female TCLs are more prone to strain (32,33). ...
... Our study showed that gender was not significantly related to TCL thickness and stiffness in the patient and control groups, which is consistent with previous studies (32,33). However, female TCLs are more prone to strain (32,33). ...
Article
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Objectives The goal of this work is to determine the clinical value of the transverse carpal ligament (TCL) in carpal tunnel syndrome (CTS) for guiding subsequent treatment. Methods This study analyzed patients who underwent median nerve (MN) ultrasound (US) examination of the wrist from April 2020 to April 2021. The cross-sectional area and anteroposterior diameter of the MN, as well as the TCL thickness and stiffness, were measured from images. The intra-group and intra-patient subgroup differences were compared using a t- test and a rank test. We also utilized receiver operating characteristic (ROC) curves to diagnose CTS and evaluate the severity. Results The final cohort consisted of 120 wrists (bilateral) from 60 samples, evenly balanced across the patient and control groups according to their CTS diagnosis. In the unilateral positive patient subgroup, the MN and TCL of the positive hand were significantly thicker and stiffer than the negative counterparts (both, p < 0.05). The values from the right were also thicker and stiffer than the left (both, p < 0.05) in patients with bilateral CTS. The MN and TCL of the patient group were also significantly thicker and stiffer than those of the control group (both, p < 0.001). For diagnosing CTS, the area under the curve (AUC) of TCL thickness and stiffness at the distal carpal tunnel (DCT) ranged between 0.925 and 0.967. For evaluating CTS severity, we found that the optimal TCL stiffness is sufficient for diagnosing mild and non-mild patient cases (AUC: Emean = 0.757, Emax = 0.779). Conclusions Shear wave elastography is therefore an effective method for CTS diagnosis and management.
... This CAW change is attributable to the mobility of carpal bones which is guided by bone/cartilage configuration and inter-carpal ligaments (Gabra et al., 2012;Xiu et al., 2010). Attempts to widen (Sucher et al., 2005) or narrow Marquardt et al., 2016;Marquardt et al., 2015) the CAW have been made to alter the carpal tunnel morphological structure as a means to increase the carpal tunnel crosssectional area (CSA) for median nerve decompression. Widening the CAW can be limited due to the mechanical constraint imposed by the thick band of the transverse carpal ligament. ...
... The maximal CAW increase (from 25.1 to 25.9 mm) occurred with a force application at 310°. This change was similar to those reported in the previous biomechanical studies (Sucher et al., 2005;Xiu et al., 2010). The largest decrease of 22.1 mm 2 (8%) in the total CSA was found at the force direction of 310° (dorsally directed). ...
Article
Background: Manipulating the carpal arch width (i.e. distance between hamate and trapezium bones) has been suggested as a means to increase carpal tunnel cross-sectional area and alleviate median nerve compression. The purpose of this study was to develop a finite element model of the carpal tunnel and to determine an optimal force direction to maximize area. Methods: A planar geometric model of carpal bones at hamate level was reconstructed from MRI with inter-carpal joint spaces filled with a linear elastic surrogate tissue. Experimental data with discrete carpal tunnel pressures (50, 100, 150, and 200mmHg) and corresponding carpal bone movements were used to obtain material property of surrogate tissue by inverse finite element analysis. The resulting model was used to simulate changes of carpal arch widths and areas with directional variations of a unit force applied at the hook of hamate. Findings: Inverse finite element model predicted the experimental area data within 1.5% error. Simulation of force applications showed that carpal arch width and area were dependent on the direction of force application, and minimal arch width and maximal area occurred at 138° (i.e. volar-radial direction) with respect to the hamate-to-trapezium axis. At this force direction, the width changed to 24.4mm from its initial 25.1mm (3% decrease), and the area changed to 301.6mm(2) from 290.3mm(2) (4% increase). Interpretation: The findings of the current study guide biomechanical manipulation to gain tunnel area increase, potentially helping reduce carpal tunnel pressure and relieve symptoms of compression median neuropathy.
... Myofacial releasing of retinaculum musculorum flexorum which is used for osteopathic manipulative treatment and stretching exercises, is a very effective method. As a result of this method, a potential treatment creates an increase in the width of the ligamentum carpi transversum and allows the nerve functions to be performed (6). ...
Article
Full-text available
Aim: We aimed to investigate the efficiency of the kinesio taping technique and to compare efficacy of this technique with a treatment programme using all three types of myofacial releasing of flexor retinaculum, mobilization of the median nerve, and tendon gliding exercises in the Carpal Tunnel Sendrome (CTS). Material and Methods: Forty female patients with CTS, randomly divided into exercise and kinesio taping groups consisted twenty patients in each group and received treatment for 4 weeks. In Group 1 applied mobilization of the median nerve, myofascial releasing of flexor retinaculum, and tendon gliding exercises therapy for 5 days per week, while in Group 2 applied the kinesio taping technique two times per week on Mondays and Thursdays. Patients were evaluated according to Boston Symptom Severity Scale and Boston Functional Capacity Scale before and after treatment. Intragroup and intergroup treatment efficacy were compared. Results: The Boston Symptom Severity Scale and the Boston Functional Capacity Scale scores were significantly reduced in both groups between before and after treatment in intragroup comparison (p<0.005). There was no significant difference between before and after treatment according to the Boston Symptom Severity Scale scores in intergroup comparison (p<0.005). However, the Boston Functional Capacity Scale scores showed a statistically significant decrease in the exercise group between before and after treatment (p<0.005). Conclusion: Positive effects on CTS symptoms were observed in both groups, but statistically significant difference was not observed between groups. Excercise group was superior to taping group when we compare two groups in terms of CTS hand function capacity improvement. Oz Amaç: Karpal tünel sendromu (KTS) tedavisinde, kinezyo bantlama tekniğinin ne kadar etkin olduğunu araştırmak ve bu teknik ile retinaculum musculorum flexorum'un miyofasyal gevşetilmesi, n. medianus mobilizasyonu ve tendon kaydırma egzersizlerinin üçünün birlikte yapıldığı tedavi programının etkinliğini karşılaştırmaktır. Materyal ve Metod: KTS'li 40 bayan hasta, rastgele yöntemle egzersiz (n=20) ve bantlama (n=20) olmak iki gruba ayrıldı ve 4 hafta tedaviye alındı. Grup 1'e haftada 5 gün retinaculum musculorum flexorum'un miyofasyal olarak gevşetilmesi, n. medianus mobilizasyonu ve tendon kaydırma egzersizleri; Grup 2'ye pazartesi ve perşembe olmak üzere haftada 2 kez kinezyo bantlama tekniği uygulandı. Hastalar tedavi öncesi ve tedavi sonrasında Boston Semptom Şiddeti Skalası ve Boston Fonksiyonel Kapasite Skalası'na Araştırma Makalesi / Research Article 42 Med Records 2019;1(2):41-7
... This is first study to explore an effect of this device on carpal tunnel. Sucher et al, 2005 26 observed increase in the length of the transverse carpal ligament after doing manipulative treatment and along with dynamic orthosis should be more effective. This study is the first to explore the effect of this nonsurgical intervention in Indians. ...
Article
Full-text available
Background: The present study was conducted with an aim to compare the efficacy and safety of CarpaStretch® relative to wrist splinting in patients with CTS. Objective: To examine the effect of using CarpaStretch®, a novel dynamic splint for the treatment of Carpal Tunnel Syndrome. Methods: The efficacy and safety of CarpaStretch® was compared with conventional splints in a prospective 6-month trial with a follow-up at 12 months. 30 subjects with confirmed Carpal Tunnel Syndrome were enrolled in each group. Nerve conduction tests, wrist MRI, provocation tests and patient satisfaction questionnaires were assessed in the study. Results: At the end of 6 months, there were significant increases in sensory nerve conduction velocity in both intervention and control groups, and the difference between groups were not significant. A higher proportion of subjects using CarpaStretch® showed improvement in severity grade relative to control at 6 months. Small but clinically meaningful increases were seen in carpal tunnel dimensions in the CarpaStretch® group. There was a greater reduction in the incidence of paraesthesia and increase in the time of paraesthesia in the CarpaStretch® group. No adverse effects were reported in either group, but 4 subjects in the control group opted for surgery. Conclusion: CarpaStretch® can be used for effective non-surgical management of Carpal Tunnel Syndrome.
... This stretching may lead to a relaxation of tension and increased flexibility of the TCL. This would reduce the pressure inside the CT, also decreasing the compression on the median nerve, which is ultimately responsible for the clinical profile of sensory and motor impairment in these patients (Chammas et al., 2014;Sucher et al., 2005). ...
Article
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Carpal tunnel syndrome was studied by use of supplemental palpatory diagnosis in 20 abnormal wrists. Restriction in motion at the carpal tunnel was quantified with a rating system. All wrists with carpal tunnel syndrome revealed at least moderate restriction to motion, as compared with only mild or no restriction in 20 wrists in normal, symptom-free subjects. Several participants (16 abnormal wrists) underwent osteopathic manipulative treatment, including a new "opponens roll" maneuver, and self-stretching, or a similar treatment accomplished by use of a self-treatment accomplished by use of a self-treatment appliance. In those treated, palpatory restriction decreased into the normal range, often before symptoms decreased. Improvement in nerve conduction studies usually followed within 1 to 3 months. Palpatory diagnosis is a useful adjunctive method of assessing patient status in carpal tunnel syndrome and helpful in prognosticating outcome. The modified manipulative technique described for the treatment of mild to moderate carpal tunnel syndrome may be effective in more severe cases.