Critically Appraised Paper
Activity Analysis
Adeline Pierre
OTR 625: Advanced Clinical Reasoning
Barry University
Dr. Beckley
August 22, 2010

CRITICALLY APPRAISED PAPER (CAP) WORKSHEET
CITATION:
Moraska, A., Chandler, C., Edmiston-Schaetzel, A., Franklin, G., Calenda, E., & Enebo, B. (2008). Comparison of a targeted and general massage protocol on strength, function, and symptoms Associated with carpal tunnel syndrome: a randomized pilot study. Journal Of Alternative And Complementary Medicine (New York, N.Y.), 14 (3), 259-267. Retrieved from MEDLINE database. |

FOCUSED QUESTION: Can massage therapy be an effective conservative intervention method for the treatment of carpal tunnel syndrome? |

PROBLEM STATEMENT (JUSTIFICATION OF THE NEED FOR THE STUDY): Carpal tunnel syndrome is the most reported nerve compression syndrome. The cause of this syndrome is due to fibrotic tissue build up along with compression in the carpal tunnel. Conservative care is recommended before surgery is recommended. In doing so, this author is investigating the effectiveness of massage therapy for relief of nerve compression to reduce connective tissue fibrosis, edema, or musculoskeletal disturbance. |

RESEARCH OBJECTIVE(S):
List study objectives. The aim of this study was to evaluate the effectiveness of two distinct massage therapy protocols on strength, function, and symptoms associated with carpal tunnel syndrome (CTS). |

Describe how the research objectives address the focused question. The research objectives address the focus question by the authors conducting a study to evaluate the effectiveness of two distinct massage protocols in reducing nerve compression. |

DESIGN TYPE: The study was a randomized pilot study design with double pre-tests and subjects blinded to treatment group assignment. |

Level of Evidence Level I |

Limitations (appropriateness of study design):
Was the study design type appropriate for the knowledge level about this topic? If no, explain. Yes, the design type was appropriate for this level. |

SAMPLE SELECTION:
How were subjects selected to participate? Please describe.
Inclusion Criteria: * All participants provided written documentation of clinical diagnosis of CTS by a medical practitioner (MD, DO, or DC) * Positive CTS diagnosis in one or both upper extremities for at least six months prior to enrollment in the study. |

Exclusion Criteria: * Persons who had surgery for CTS. * Individuals who were pregnant. * Individuals who smoked. * Individuals who had diabetes mellitus. * Participants had to refrain from receiving concurrent manual therapies or acupuncture. |

Sample Selection Biases: If yes, explain
Volunteers/Referrals
Yes, they were volunteers that were recruited through flyers, posters distribution throughout the community, and advertisements in a local newspaper. |

Attention: No |

Other (list and explain): NR |

SAMPLE CHARACTERISTICS:
N=28
% Dropouts: 0.964 (one person dropped out) GM Group: #/(%) Male: 1 #/ (%) Female: 12 Ethnicity: NR TM Group: #/(%) Male: 4 #/ (%) Female: 10 Ethnicity: NR Disease/disability diagnosis Patients diagnosed with carpal tunnel syndrome. |

Check appropriate group: <20/study group | 20-50/study groupX | 51-100/study group | 101-149/study group | 150-200/study group |

Sample Characteristics Bias: If no, explain.
If there is more than one study group, was there a similarity between the groups? Yes, there was a similarity between the groups. |

Were the reasons for the dropout reported? Yes, the reason for the dropout was reported. The participant was removed from the study owing to an illness unrelated to CTS or massage. |

INTERVENTION(S) –include only those intervention relevant to answering the evidence-based question. Group 1 (GM protocol) Brief Description | Applied bilaterally and consisted of: 1) 15 minutes of effleurage, petrissage, friction, passive motion, and cross-fiber friction all directed at the back and neck with the participant in a prone position. | Setting | A wellness clinic at a teaching institution in the United States | Who Delivered? | Degreed massage therapist (certified massage therapist, licensed massage therapist, or licensed massage practitioner) | Frequency? | Each session was for 30 minutes | Duration? | Six weeks of twice weekly massage |

Group 2 (TM protocol) Brief Description | Aim at probable sites of nerve entrapment along the afflicted upper extremity. Participants remained in a supine position for the entire treatment with a cylindrical bolster under the knees. The protocol consists of: 1) 3 minutes of lymphatic drainage of the thorax and axillary regions, 2) 8 minutes of mobilization, soft-tissue manipulation, myofascial release, traction, and friction directed at the neck and shoulder region, 3) 9 minutes of myofascial release, soft-tissue manipulation, and mobilization directed at the chest and upper arm, and 4) 10 minutes of pin and stretch, cross-fiber friction, stretching, and flushing techniques were performed on the forearm and hand. | Setting | A wellness clinic at a teaching institution in the United States | Who Delivered? | Degreed massage therapist (certified massage therapist, licensed massage therapist, or licensed massage practitioner) | Frequency? | Each session was for 30 minutes | Duration? | Six weeks of twice weekly massage |

Intervention Biases: Explain, if needed.
Contamination
No, participants were asked to refrain from receiving concurrent manual therapies or acupuncture during the study. Medication intake for CTS was limited to the use of nonprescription pain relievers on an as needed basis. |

Co-intervention None reported. |

Timing All participants completed the study as recommended for the study, for 6 weeks, twice weekly massage. Evaluations were conducted twice during baseline, 2 days after the 7th and 11th massage and at a follow-up visit 4 weeks after the 12th massage treatment. |

Site Yes, same site throughout the study session. |

Use of different therapists to provide intervention? No, Only degreed massage therapist (certified massage therapist, licensed massage therapist, or licensed massage practitioner) was used. |
MEASURES AND OUTCOMES
Complete for each relevant measure when answering the evidence-based question:
Name of measure: Strength, symptom, functional and statistical measures |

Outcome(s) measured (what was measured?): There were several measures used to determine the dependent variables. Those measures where hand grip and key pinch dynamometers, Levine Symptom and Function evaluation. The evaluation was conducted on a baseline of two days on the 7th and 11th visit with a follow-up visit on the 4th week after the 12th massage treatment. |

Is the measure reliable (as reported in article)? Yes |

Is the measure valid (as reported in article)? Yes |

How frequently was the measure used for each group in the study? Each group received a 30 minute massage however massage varied with each group. GM protocol focused on reducing muscular tension and improving blood circulation in the back, neck, and upper extremities. TM protocol focused on the lymphatic system to reduce fluid in the carpal tunnel region, connective tissue restriction, and hypertonicity. This treatment method was performed when the treatment protocol was administered at each session. |

Measurement Biases
Were the evaluators blinded the treatment status: If no, explain. Yes, the evaluators blinded the treatment. |

Recall or memory bias. If yes, explain. No, there was no recall or memory bias in this study. |

Limitations (appropriateness of outcomes and measures) if no, explain.
Did the measures adequately measure the outcome(s) Yes |

RESULTS:
List results of outcomes relevant to answering the focused question Include statistical significance where appropriate (p<0.05) Include effect if report: This study indicated that grip strength improved over the course of the study (p<0.001); the interaction indicated that the TM group experienced a significantly greater strength increase compared to TM group with an increase from 25.1 to 29.5 kg (p<0.001; 95% CI 27.7-31.3 kg) noted over the course of the study. For the participants in the GM study, a statistically nonsignificant increase from 25.1 to 26.3 kg (a 4.8% increase) in grip strength was observed (p=0.21). In the TM group, improvement was first detected after the 7th massage session and was maintained following the 11th massage and at least 4 weeks after the last treatment (p<0.01. for all time points). |

Was this study adequately powered (large enough to show a difference)? If no, explain. Yes |

Were appropriate analytic methods used? If no, explain. Yes |

Were statistics appropriately reported (in written or table format)? If no, explain. Yes, there were written and table format. |

CONCLUSION:
State the authors’ conclusions that are applicable to answering the evidence-based question. The author concluded that both the GM and TM treatment protocols resulted in an improvement of subjective measures associated with CTS, but improvement in grip strength was only detected with the TM protocol. Massage therapy can be a practical conservative intervention when treating compression neuropathies, such as CTS. Additional research is needed. |

Were the conclusions appropriate for the Study Design (Level of Evidence)? If no, explain. Yes, the conclusions were appropriate. |

Were the conclusions appropriate given the study limitation and biases? If no, explain. Yes |

IMPLICATIONS FOR OCCUPATIONAL THERAPY: The study demonstrated that massage therapy is an effective conservative treatment regimen that is useful in reducing the symptoms of CTS. Occupational therapy is able to use these guidelines stated in the study and incorporate it in the intervention process to achieve similar results. |