The aim of this study is to investigate whether the addition of Graded Motor Imagery (GMI) to progressive neurodynamic exercises is more effective than progressive neurodynamic exercises alone in individuals with carpal tunnel syndrome (CTS). The objectives are to reduce pain and symptom severity, improve pain, sensorimotor function, physical performance, and grip strength through the addition of GMI.
46 voluntary patients with CTS, aged between 30-60 years will be randomly divided into two groups: GMI and progressive neurodynamic exercise group. Interventions will be applied for 6 weeks, 2 times a week (12 sessions). Both groups will receive progressive neurodynamic exercises and a nighttime resting splint. The GMI group will additionally receive Graded Motor Imagery, while the control group will receive no additional intervention. The patients will be assessed before, and after treatment. Upper extremity function and disability will be assessed using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, cognitive status will be screened using the Mini-Mental State Examination (MMSE), and symptom severity and functional status related to CTS will be evaluated using the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ). Sensory function will be assessed using the Semmes-Weinstein Monofilament Test and the Two-Point Discrimination Test, fine manual dexterity will be evaluated using the Purdue Pegboard Test, and hand grip strength will be measured using a Jamar hand dynamometer.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
SINGLE
Enrollment
46
GMI includes three stages. GMI program will span over 6 weeks. The first 2 weeks will focus on lateralization, followed by 2 weeks of motor imagery, and the final 2 weeks will involve mirror therapy. Lateralization: Patients will be asked to differentiate whether the hands shown in the Recognise™ Hand application belongs to the right or left side of their body. Motor Imagery: Patients will be instructed to imagine slowly and smoothly moving their affected extremities to the posture depicted in the photos in the Recognise™ Hand application and then returning to the starting position. Mirror Therapy: Using a mirror measuring 300 x 300 x 300 mm³ placed between the upper extremities, patients will be instructed to progressively move only their unaffected extremity, then their affected extremity, and finally both extremities.
The progressive neurodynamic exercises involved holding each position for 5 seconds. Each session included two sets of 10 repetitions (2×10). The treatment lasted for 30-minute sessions, conducted twice weekly over a total of 6 weeks.
Disabilities of the Arm, Shoulder, and Hand (DASH)
DASH is a 30-item self-report tool assessing upper-extremity disability and symptoms, including daily activities, pain, numbness, joint stiffness, weakness, sleep issues, and psychological effects. Examples include turning a doorknob, changing a light bulb, and cutting food. Scores range from 0 to 100; higher scores indicate more severe symptoms and impairment.
Time frame: Baseline
Disabilities of the Arm, Shoulder, and Hand (DASH)
DASH is a 30-item self-report tool assessing upper-extremity disability and symptoms, including daily activities, pain, numbness, joint stiffness, weakness, sleep issues, and psychological effects. Examples include turning a doorknob, changing a light bulb, and cutting food. Scores range from 0 to 100; higher scores indicate more severe symptoms and impairment.
Time frame: After the 6-week intervention
Mini Mental State Examination
The Mini-Mental State Examination (MMSE) will be used to assess the cognitive status of patients. It consists of 11 questions and is evaluated on a scale of 30 points. A score between 24-30 is considered normal, 18-23 indicates mild cognitive impairment, and a score of 17 or below is indicative of severe dementia. The MMSE assesses orientation, memory, attention, calculation, recall, language, motor function, perception, and visuospatial abilities.
Time frame: Baseline
Mini Mental State Examination
The Mini-Mental State Examination (MMSE) will be used to assess the cognitive status of patients. It consists of 11 questions and is evaluated on a scale of 30 points. A score between 24-30 is considered normal, 18-23 indicates mild cognitive impairment, and a score of 17 or below is indicative of severe dementia. The MMSE assesses orientation, memory, attention, calculation, recall, language, motor function, perception, and visuospatial abilities.
Time frame: After the 6-week intervention
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The night splint was fitted with a wrist splint that keeps the wrist in a neutral position, permits finger flexion, maintains the wrist within a 0°-5° extension range, and ends just distal to the distal palmar crease.
Boston Carpal Tunnel Syndrome Questionnaire (BCTQ)
A patient-reported assessment uses a 5-point Likert scale with two subscales: the 11-item Symptom Severity Scale (CTSQ-S) for symptom intensity like numbness and pain, and the 8-item Functional Status Scale (CTSQ-F) for ADL ability such as writing and dressing. Higher scores mean more severe symptoms and impairment. The BCTQ shows high reliability, validity, and sensitivity to clinical changes.
Time frame: Baseline
Boston Carpal Tunnel Syndrome Questionnaire (BCTQ)
A patient-reported assessment uses a 5-point Likert scale with two subscales: the 11-item Symptom Severity Scale (CTSQ-S) for symptom intensity like numbness and pain, and the 8-item Functional Status Scale (CTSQ-F) for ADL ability such as writing and dressing. Higher scores mean more severe symptoms and impairment. The BCTQ shows high reliability, validity, and sensitivity to clinical changes.
Time frame: After the 6-week intervention
The Semmes-Weinstein Monofilament Test
The assessment used a monofilament test (0.49-0.96), known for high sensitivity in diagnosing CTS. Sensory thresholds were checked at the radial tips of the thumbs, index, middle, and ring fingers. The monofilament was applied perpendicularly to the dorsal finger pads with eyes closed and the wrist in a neutral position. Pressure was applied for 1 to 1.5 seconds until slight bending of the filament. Lower readings indicate better sensory function; higher readings suggest worse light touch perception. A gauge of 2.83 grams is the normal threshold, while 3.22 grams or higher indicates moderate-to-severe sensory impairment in CTS.
Time frame: Baseline
The Semmes-Weinstein Monofilament Test
The assessment used a monofilament test (0.49-0.96), known for high sensitivity in diagnosing CTS. Sensory thresholds were checked at the radial tips of the thumbs, index, middle, and ring fingers. The monofilament was applied perpendicularly to the dorsal finger pads with eyes closed and the wrist in a neutral position. Pressure was applied for 1 to 1.5 seconds until slight bending of the filament. Lower readings indicate better sensory function; higher readings suggest worse light touch perception. A gauge of 2.83 grams is the normal threshold, while 3.22 grams or higher indicates moderate-to-severe sensory impairment in CTS.
Time frame: After the 6-week intervention
Purdue Pegboard Test
The Purdue Pegboard consists of 50 holes in two columns, with pins, washers, and sleeves in four recesses at the top. Patients sat in front of the apparatus and performed four tests: the dominant hand, non-dominant hand, two-hand, and assembly test. For the hand tests, they inserted pins into holes with their hands for 30 seconds each; the two-hand test used both hands. In the assembly test, they placed materials in order: pin → washer → collars → washer within 60 seconds. Each test was repeated three times, and scores were averaged. This test assesses fine motor skills, coordination, finger dexterity, hand-eye coordination, and small object manipulation; lower scores indicate poorer hand skills.
Time frame: Baseline
Purdue Pegboard Test
The Purdue Pegboard consists of 50 holes in two columns, with pins, washers, and sleeves in four recesses at the top. Patients sat in front of the apparatus and performed four tests: the dominant hand, non-dominant hand, two-hand, and assembly test. For the hand tests, they inserted pins into holes with their hands for 30 seconds each; the two-hand test used both hands. In the assembly test, they placed materials in order: pin → washer → collars → washer within 60 seconds. Each test was repeated three times, and scores were averaged. This test assesses fine motor skills, coordination, finger dexterity, hand-eye coordination, and small object manipulation; lower scores indicate poorer hand skills.
Time frame: After the 6-week intervention
The Two-Point Discrimination Test
The two-point discrimination threshold was evaluated using an esthesiometer applied to the pulp of the thumb, index, and middle fingers. During the evaluation, participants' eyes remained closed, and light stimuli, consisting of either one or two points, were randomly presented along the longitudinal axis of the fingers. The procedure began at a distance of 5 mm, with 10 trials conducted at each specified interval. If the participant failed to achieve at least seven correct responses, the distance was increased by 1 mm, and the test was repeated. The discrimination threshold was defined as the smallest distance at which at least seven out of ten responses were correct. Testing was discontinued at a maximum distance of 15 mm, with values below 6 mm considered within normal limits.
Time frame: Baseline
The Two-Point Discrimination Test
The two-point discrimination threshold was evaluated using an esthesiometer applied to the pulp of the thumb, index, and middle fingers. During the evaluation, participants' eyes remained closed, and light stimuli, consisting of either one or two points, were randomly presented along the longitudinal axis of the fingers. The procedure began at a distance of 5 mm, with 10 trials conducted at each specified interval. If the participant failed to achieve at least seven correct responses, the distance was increased by 1 mm, and the test was repeated. The discrimination threshold was defined as the smallest distance at which at least seven out of ten responses were correct. Testing was discontinued at a maximum distance of 15 mm, with values below 6 mm considered within normal limits.
Time frame: After the 6-week intervention
Grip Strength
Grip strength was measured using a hand dynamometer. The participant sat comfortably with shoulder abducted, elbow at 90°, and forearm neutral. The wrist was between 0° and 30° extension. Each hand was tested three times with one-minute rests, and the average was recorded.
Time frame: Baseline
Grip Strength
Grip strength was measured using a hand dynamometer. The participant sat comfortably with shoulder abducted, elbow at 90°, and forearm neutral. The wrist was between 0° and 30° extension. Each hand was tested three times with one-minute rests, and the average was recorded.
Time frame: After the 6-week intervention