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| Name | Class |
|---|---|
| Wellcome Trust | OTHER |
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INTRODUCTION: Carpal tunnel syndrome (CTS) is a relatively common condition caused by compression of one of the main nerves at the wrist, the median nerve. Non-surgical treatments, like steroid injections and physiotherapy, are the first line of treatment for patients with carpal tunnel syndrome. The investigators have previously shown that specific physiotherapeutic exercises (neurodynamic exercises) can reduce the need for carpal tunnel surgery in some patients. Experimental studies in animal models demonstrate that these exercises have an anti-inflammatory effect and can help the nerve to regenerate. However, the exact mechanisms of action of these exercises are not well understood in patients. A better understanding of the mechanisms of action of physiotherapeutic exercises would help clinicians to better target these treatments to those patients who may benefit from them.
AIM: To investigate the mechanisms of action of 6 weeks' neurodynamic treatments on nerve function and structure as well as patient-reported outcome measures in patients with CTS compared to a positive control intervention (routine care steroid injection) and a negative control intervention (advice).
METHODS AND ANALYSIS: In this single-blind randomised mechanistic trial, patients with confirmed mild to moderate CTS (n=78) and age and gender-matched healthy controls (n=30) will be included. Patients will be randomly allocated to a 6-week neurodynamic exercise group, steroid injection, or advice group. Outcome measures will be explored at baseline (patients and controls), post-intervention (patients), and 6-month follow-up (patients). Outcomes include diffusion-weighted and anatomical MRI of the median nerve at the wrist, quantitative sensory testing, nerve conduction studies, inflammatory markers in blood and skin biopsies, and validated questionnaires for pain, function, and psychological factors. Two-way repeated measures ANCOVAs (factors time and intervention, adjusted for baseline measurements as a continuous covariate) will be performed to identify differences in MRI parameters, clinical assessment, and inflammatory markers between patients in different groups and healthy controls.
Follow-up at 6 months will only include outcome measures from questionnaires.
Details on enrollment:
Pilot testing of healthy participants who consented to our ethics but will not be included in the study was on 13-April-2023.
Details on amendment:
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Neurodynamic exercises | Experimental | 6-weeks home exercise programme of nerve and tendon gliding exercises |
|
| Steroid injection Steroid injection (Depomedrone 40mg) | Active Comparator | Single steroid injection into Carpal Tunnel (positive control group) |
|
| Advice | Other | The advice group will receive advice but no additional intervention during the 6 week intervention period (negative control group) |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Neurodynamic exercises | Other | The neurodynamic exercises will consist of a home-based exercise programme performed over a period of 6 weeks. Patients will attend a single session with an investigator who will instruct them the home exercise programme consisting of nerve and tendon gliding exercises which will be adjusted with pre-specified progressions over the 6 weeks intervention period. Patients will receive a leaflet and a video link detailing these exercises. |
| Measure | Description | Time Frame |
|---|---|---|
| Median nerve fractional anisotropy as determined on diffusion weighted imaging | Fractional anisotropy will be extracted from regions-of-interest in the median nerve and compared to healthy control group | Baseline |
| Change in median nerve fractional anisotropy as determined on diffusion weighted imaging | Change in fractional anisotropy extracted from regions-of-interest in the median nerve at post-intervention (after 6-weeks) compared to baseline | From baseline to post-intervention (after 6-weeks) |
| Measure | Description | Time Frame |
|---|---|---|
| Nerve markers on diffusion weighted imaging: water diffusivity (mm2/s) | Measured at the median nerve and cervical dorsal root ganglia. mm2/s; continuous data | Baseline |
| Change to nerve markers on diffusion weighted imaging: water diffusivity (mm2/s) |
| Measure | Description | Time Frame |
|---|---|---|
| Blood samples - DNA | Blood samples coupled with detailed phenotype data will investigate potential gene associations in CTS and recovery | Baseline |
| Change in blood samples - DNA | Change in blood samples coupled with detailed phenotype data will investigate potential gene associations in CTS and recovery |
Inclusion Criteria
Patients:
Healthy participants:
Exclusion Criteria
Patients:
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| Name | Affiliation | Role |
|---|---|---|
| Eva Sierra-Silvestre, PhD | University of Oxford | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Nuffield Department of Clinical Neurosciences, University of Oxford | Oxford | Oxfordshire | OX3 9DU | United Kingdom |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 39068435 | Derived | E SS, M T, Ac T, M S, G B, Ab S. Mechanisms of neurodynamic treatments (MONET): a protocol for a mechanistic, randomised, single-blind controlled trial in patients with carpal tunnel syndrome. BMC Musculoskelet Disord. 2024 Jul 27;25(1):590. doi: 10.1186/s12891-024-07713-6. |
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All IPDs that underlie results in a publication.
IPD that underlie results of a publication will be shared upon the final publication of the main manuscripts of this study.
IPD will be shared upon reasonable request and in line with ethical approval with authors contacting the study investigators.
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| ID | Term |
|---|---|
| D002349 | Carpal Tunnel Syndrome |
| ID | Term |
|---|---|
| D020423 | Median Neuropathy |
| D020422 | Mononeuropathies |
| D010523 | Peripheral Nervous System Diseases |
| D009468 | Neuromuscular Diseases |
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| ID | Term |
|---|---|
| D013256 | Steroids |
| D003376 | Counseling |
| ID | Term |
|---|---|
| D000072473 | Fused-Ring Compounds |
| D011083 | Polycyclic Compounds |
| D008605 | Mental Health Services |
| D004191 | Behavioral Disciplines and Activities |
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The outcomes assessor and the person responsible for the statistical analysis will be blinded to the participants' allocation.
|
| Steroid injection (Depomedrone 40mg) | Drug | Steroid injection (Depomedrone 40mg) into the carpal tunnel as per standard practice in patients with carpal tunnel syndrome |
|
| Advice | Other | Group receiving advice but no additional treatment |
|
Measured at the median nerve and cervical dorsal root ganglia. mm2/s; continuous data
| From baseline to post-intervention (after 6-weeks) |
| Nerve markers on anatomical MRI | Measured at the median nerve and cervical dorsal root ganglia. ratio/mm2; continuous data | Baseline |
| Change in nerve markers on anatomical MRI | Measured at the median nerve and cervical dorsal root ganglia. ratio/mm2; continuous data | From baseline to post-intervention (after 6-weeks) |
| Median nerve MRI T2 mapping | ms; continuous data | Baseline |
| Changes in median nerve MRI T2 mapping | ms; continuous data | From baseline to post-intervention (after 6-weeks) |
| Median nerve MRI magnetisation transfer ratio (MTR) | ratio; continuous data | Baseline |
| Changes in median nerve MRI magnetisation transfer ratio (MTR) | ratio; continuous data | From baseline to post-intervention (after 6-weeks) |
| Changes in median nerve conduction velocities from electrodiagnostic studies (m/s) | m/s; continuous data | From baseline to post-intervention (after 6-weeks) |
| Changes in median sensory nerve action potentials (SNAPs) and compound muscle action potentials (CMAPs): amplitudes (mV) | mV; continuous data | From baseline to post-intervention (after 6-weeks) |
| Thermal detection thresholds as assessed in Quantitative Sensory testing - warm and cold detection threshold; thermal sensory limen | Thermal detection thresholds will be assessed using a thermode over the index finger (e.g., ventral aspect of the proximal phalanx of the index finger). Data is measured in degrees celsius (point at which cold or warm is detected) | Baseline |
| Change in thermal detection thresholds as assessed in Quantitative Sensory testing- warm and cold detection threshold; thermal sensory limen | Thermal detection thresholds will be assessed using a thermode over the index finger (e.g., ventral aspect of the proximal phalanx of the index finger). Data is measured in degrees celsius (point at which cold or warm is detected) | From baseline to post-intervention (after 6-weeks) |
| Thermal pain thresholds as assessed in Quantitative Sensory testing- warm and cold painful threshold | Pain thermal thresholds will be assessed using a thermode over the index finger (e.g., ventral aspect of the proximal phalanx of the index finger) and over the contralateral lower limb (tibial anterior). Data is measured in degrees celsius (point at which cold or warm is initially detected as painful) | Baseline |
| Change in thermal pain thresholds as assessed in Quantitative Sensory testing- warm and cold painful threshold | Pain thermal thresholds will be assessed using a thermode over the index finger (e.g., ventral aspect of the proximal phalanx of the index finger) and over the contralateral lower limb (tibial anterior). Data is measured in degrees celsius (point at which cold or warm is initially detected as painful) | From baseline to post-intervention (after 6-weeks) |
| Mechanical detection thresholds as assessed in Quantitative sensory testing | Mechanical detection thresholds will be assessed using a standardised set of von Frey filaments (mN) over the index finger. Geometric mean will be calculated | Baseline |
| Change in mechanical detection thresholds as assessed in Quantitative sensory testing | Mechanical detection thresholds will be assessed using a standardised set of von Frey filaments (mN) over the index finger. Geometric mean wil be calculated | From baseline to post-intervention (after 6-weeks) |
| Mechanical pain thresholds as assessed in Quantitative sensory testing | Mechanical pain thresholds will be assessed using a series of weighted pin prick stimulators (mN). They will be assessed over the index finger and over the contralateral lower limb (tibial anterior). | Baseline |
| Change in mechanical pain thresholds as assessed in Quantitative sensory testing | Mechanical pain thresholds will be assessed using a series of weighted pin prick stimulators (mN). They will be assessed over the index finger and over the contralateral lower limb (tibial anterior). | From baseline to post-intervention (after 6-weeks) |
| Mechanical pain sensitivity as assessed in Quantitative sensory testing | Mechanical pain sensitivity will be assessed using a series of weighted pin prick stimulators (mN) over the index finger. Pain rating for each stimulus on a 0-100 numerical rating scale ('0' indicating "no pain", and '100' indicating "most intense pain imaginable"). Geometric mean of all numerical ratings for pinprick stimuli will be calculated | Baseline |
| Change in mechanical pain sensitivity as assessed in Quantitative sensory testing | Mechanical pain sensitivity will be assessed using a series of weighted pin prick stimulators (mN) over the index finger. Pain rating for each stimulus on a 0-100 numerical rating scale ('0' indicating "no pain", and '100' indicating "most intense pain imaginable"). Geometric mean of all numerical ratings for pinprick stimuli will be calculated | From baseline to post-intervention (after 6-weeks) |
| Dynamic mechanical allodynia as assessed in Quantitative sensory testing | Pain rating for each stimulus on a 0-100 numerical rating scale ('0' indicating "no pain", and '100' indicating "most intense pain imaginable"). Geometric mean (compound measure) of all numerical ratings across light touch stimulators over the index finger | Baseline |
| Change in dynamic mechanical allodynia as assessed in Quantitative sensory testing | Pain rating for each stimulus on a 0-100 numerical rating scale ('0' indicating "no pain", and '100' indicating "most intense pain imaginable"). Geometric mean (compound measure) of all numerical ratings across light touch stimulators over the index finger | From baseline to post-intervention (after 6-weeks) |
| Wind-up ratio as assessed in Quantitative sensory testing | Wind-up ration will be assessed using a pin prick (mN) over the index finger (e.g., ventral aspect of the proximal phalanx of the index finger). Ratio, continous data | Baseline |
| Change in wind-up ratio as assessed in Quantitative sensory testing | Change in wind-up ration will be assessed using a pin prick (mN) over the index finger (e.g., ventral aspect of the proximal phalanx of the index finger). Ratio, continuous data | From baseline to post-intervention (after 6-weeks) |
| Vibration detection thresholds as assessed in Quantitative sensory testing | Vibration detection thresholds will be assessed using a tuning fork (64 Hz, 8/8 scale) over a bony prominence over (e.g., palmar side of the distal end of the second metacarpal) | Baseline |
| Change in vibration detection thresholds as assessed in Quantitative sensory testing | Change in vibration detection thresholds will be assessed using a tuning fork (64 Hz, 8/8 scale) over a bony prominence over (e.g., palmar side of the distal end of the second metacarpal) | From baseline to post-intervention (after 6-weeks) |
| Pressure pain thresholds as assessed in Quantitative sensory testing | Pressure pain thresholds will be assessed using an algometer (kg) on the thenar eminence and over the contralateral lower limb (tibialis anterior) | Baseline |
| Change in pressure pain thresholds as assessed in Quantitative sensory testing | Change in pressure pain thresholds will be assessed using an algometer (kg) on the thenar eminence and over the contralateral lower limb (tibialis anterior) | From baseline to post-intervention (after 6-weeks) |
| Pinch strength test - maximum isometric strength | Pinch grip dynamometry. Continuous data, kg | Baseline |
| Change in pinch strength test - maximum isometric strength | Pinch grip dynamometry. Continuous data, kg | From baseline to post-intervention (after 6-weeks) |
| Nerve mechanosensitivity- upper limb neurodynamic test (median nerve) | Evaluation of nerve mechanosensitivity in response to mechanical load (increased tension) applied to the nerve. Range of elbow extension at point of symptoms (degrees) | Baseline |
| Change in nerve mechanosensitivity- upper limb neurodynamic test (median nerve) | Change in nerve mechanosensitivity in response to mechanical load (increased tension) applied to the nerve. Range of elbow extension at point of symptoms (degrees) | From baseline to post-intervention (after 6-weeks) |
| Nerve mechanosensitivity - positive upper limb neurodynamic tests | Upper limb neurodynamic tests will be assessed to determine the presence of increased mechanosensitivity. The neurodynamic test will be graded as 'positive', when there is at least partial reproduction of symptoms plus when symptoms can be modified with structural differentiation. Otherwise, the neurodynamic test will be graded as 'negative' | Baseline |
| Change in nerve mechanosensitivity - positive upper limb neurodynamic tests | Upper limb neurodynamic tests will be assessed to determine the presence of increased mechanosensitivity. The neurodynamic test will be graded as 'positive', when there is at least partial reproduction of symptoms and when symptoms can be modified with structural differentiation. Otherwise, the neurodynamic test will be graded as 'negative' | From baseline to post-intervention (after 6-weeks) |
| Symptom severity and limitations in hand function as assessed by the Boston carpal tunnel syndrome questionnaire | Patient reported symptoms and limitations on the Boston carpal tunnel syndrome questionnaire | Baseline, post-intervention (after 6 weeks), 6-months follow up |
| Symptom intensity levels on a Visual Analogue Scale (VAS) | Patient reported average intensity of pain, paraesthesia and numbness on 10cm visual analogue scales, ranging from no symptoms to worst symptoms ever | Baseline, post-intervention (after 6 weeks), 6-months follow up |
| Location of symptoms in a body and a hand diagram | Patient reported location of symptoms in a body diagram and a hand diagram. | Baseline, post-intervention (after 6 weeks) |
| Presence of central sensitisation as assessed with the Central Sensitisation Inventory | Patient reported central sensitisation on the Central Sensitisation Inventory | Baseline, post-intervention (after 6 weeks), 6-months follow up |
| Functional deficits- Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire | Participant reported outcomes on ability to perform activities as per quick DASH questionnaire | Baseline, post-intervention (after 6 weeks), 6-months follow up |
| Functional deficits- Patient specific functional scale (PSFS) | Participant reported outcomes on the patient specific functional scale | Baseline, post-intervention (after 6 weeks), 6-months follow up |
| Presence of neuropathic pain - DN4 | Patient screened for neuropathic pain using DN4 | Baseline, post-intervention (after 6 weeks), 6-months follow up |
| Presence of neuropathic pain - pain DETECT | Patient screened for neuropathic pain using pain DETECT | Baseline, post-intervention (after 6 weeks), 6-months follow up |
| Neuropathic pain symptoms - Neuropathic Pain Symptom Inventory | Patient reported outcomes on neuropathic pain symptoms as assessed on Neuropathic Pain Symptom Inventory. | Baseline, post-intervention (after 6 weeks), 6-months follow up |
| Presence of psychological co-morbidities - The Depression, Anxiety, and Positive Outlook Scale (DAPOS) | Participant reported outcomes on depression and anxiety as per DAPOS | Baseline, post-intervention (after 6 weeks), 6-months follow up |
| Presence of psychological co-morbidities - short-form Pain Anxiety Symptoms Scale (PASS-20) | Participant reported outcomes on depression and anxiety as per short-form Pain Anxiety Symptoms Scale (PASS-20) | Baseline, post-intervention (after 6 weeks), 6-months follow up |
| Presence of psychological co-morbidities - pain catastrophizing scale (PCS) | Participant reported outcomes on depression and anxiety as per pain catastrophising scale (PCS) | Baseline, post-intervention (after 6 weeks), 6-months follow up |
| Assessment of quality of life - EQ-5D-5L | Participant reported outcomes on quality of life as per EQ-5D-5L questionnaire | Baseline, post-intervention (after 6 weeks), 6-months follow up |
| Assessment of sleep interference - Insomnia Severity Index | Participant reported outcomes on sleep interference with the Insomnia Severity Index. | Baseline, post-intervention (after 6 weeks), 6-months follow up |
| Adverse and serious adverse events | Patient self-reported adverse events | From start of intervention until end of intervention (6 weeks) |
| Exercise adherence to the neurodynamic home-based intervention - number of sessions | Patient self-reported number of sessions per day throughout the intervention in an exercise diary | From start of intervention until end of intervention (6 weeks) |
| From baseline to post-intervention (after 6-weeks) |
| Concentration of serum inflammatory markers - metabolomics | Concentrations of inflammatory markers in serum | Baseline |
| Change in the concentration of serum inflammatory markers - metabolomics | Change in the concentrations of inflammatory markers in serum | From baseline to post-intervention (after 6-weeks) |
| Pro-inflammatory cytokine levels | Proinflammatory cytokine assay (pg/ml); continuous data | Baseline |
| Change in pro-inflammatory cytokine levels | Change in proinflammatory cytokine assay (pg/ml); continuous data | From baseline to post-intervention (after 6-weeks) |
| Concentration of inflammatory markers in serial skin biopsies | Concentration of inflammatory markers in skin biopsies. Baseline biopsy will be performed in the most distal part of the ventrolateral side of the proximal phalanx of the index finger. The 6-weeks biopsy will be performed proximally, avoiding the primary biopsy site | Baseline |
| Change in concentration of inflammatory markers in serial skin biopsies | Change in concentration of inflammatory markers in skin biopsies. Baseline biopsy will be performed in the most distal part of the ventrolateral side of the proximal phalanx of the index finger. The 6-weeks biopsy will be performed proximally, avoiding the primary biopsy site | From baseline to post-intervention (after 6-weeks) |
| D009422 | Nervous System Diseases |
| D009408 | Nerve Compression Syndromes |
| D012090 | Cumulative Trauma Disorders |
| D013180 | Sprains and Strains |
| D014947 | Wounds and Injuries |
| D003153 | Community Health Services |
| D006296 | Health Services |
| D005159 | Health Care Facilities Workforce and Services |