COMPARATIVE EFFECTIVENESS OF DEXAMETHASONE VERSUS KETOPROFEN PHONOPHORESIS IN MANAGEMENT OF CARPAL TUNNEL SYNDROME

COMPARATIVE EFFECTIVENESS OF
DEXAMETHASONE VERSUS KETOPROFEN
PHONOPHORESIS IN MANAGEMENT OF CARPAL
TUNNEL SYNDROME
Akram A. Ahmed1 ; Amal H.M. Ibrahim2 ; Tamer M. Belal3
and Ghada Esmaeil4
1.Department of Physiotherapy, Talkha Central Hospital, Dakahlia,
2.prof. of Physical Therapy for Basic Science,Faculty of Physical Therapy, Cairo
University, Egypt.
3.prof of Neurology, Faculty of Medicine, Mansoura University. Egypt.
4.Assisst.prof. of Physical Therapy for Basic Science,Faculty of Physical Therapy,
Cairo University, Egypt
Key Words: Carpal Tunnel Syndrome, Semmes Weinstein
Monofilaments, Phonophoresis, and Nerve gliding.
ABSTRACT
Aim: to compare between the effect of dexamethasone phonophoresis
with nerve gliding, ketoprofen phonophoresis with nerve gliding and
nerve gliding in management of mild to moderate carpal tunnel
syndrome (CTS).Subjects.Sixty patients suffering from mild to moderate
carpal tunnel syndrome were selected from Department of Neurology,
Mansoura University. Their age ranged between 20 and 30 years old.
They were divided randomly into three equal groups. Group A (study
group); 20 patients receive dexamethasone phonophoresis and nerve
gliding, group B (study group); 20 patients receive
ketoprofen phonophoresis and nerve gliding, and Group (C- control
group); 20 patients receive nerve gliding. All groups were assessed
before and after treatment using visual analogue scale (VAS) for pain,
Semmes Weinstein Monofilaments (SWM) for skin sensation, and
handheld dynamometer (HHD) for hand grip strength.The treatment
program was given 3 times/ week for 6 weeks for the three groups.
Results: There were significant decrease in VAS after-treatment, mean
difference for VAS after-treatment show significance between group A
versus group C (P=0.0001; P<0.05) and group B versus group C
(P=0.0001; P<0.05), but no significant difference between group A
versus group B (P=1.000; P>0.05). Mean differences between groups
showed that the dexamethasone phonophoresis plus nerve gliding group
(Group A) give the highest VAS value. The repeated measure ANOVA
revealed that a significant difference among HHD in group A (P=0.0001;
P<0.05), but no significant differences within group B and group C
Egypt. J. of Appl. Sci., 36 (7-8) 2021 94-101
(P=0.118; P>0.05). Mean differences among groups show siginificant
improvent in SWM. Conclusion: it could be concluded that
dexamethasone phonophoresis and ketoprofen phonophoresis combined
with nerve gliding are effective in the treatment of carpal tunnel
syndrome than nerve glid alone.
INTRODUCTION
Carpal tunnel syndrome (CTS) is a common medical entrapment
neuropathy of the upper extremity, which causes pain and paresthesia’s
in the distribution of the median nerve, numbness, and tingling in the
hand and arm occurs when the median nerve is squeezed or compressed
as it travels through the wrist (Wipperman, & Goerl. 2016). These
sensations may be felt in the thumb, index finger, middle finger, and the
radial side of the ring finger (Burton et al., 2014).
Obesity, forceful use of the hand, position of the hand, vibration,
monotonous wrist activity, pregnancy, genetic heredity, and rheumatoid
inflammation are risk factors for CTS. (Yeh et al., (2020) Rhode &
Rhode, (2016)
It is important to diagnose and treat CTS, because delay may
result in irreversible median nerve damage with persistent symptoms and
permanent disability (Keith et al., 2009).Various possibilities or
treatment including surgical and conservative treatments have been used
for CTS (Karatay et al., 2009).Conservative treatment of CTS would
seem to be preferable as the initial treatment choice, particularly for mild
to moderate cases (Gerritsen et al., 2002).Conservative treatments
include rest and avoidance of extreme activity with the hand, ultrasound
and laser therapy, splinting the wrist in a neutral position, non steroidal
anti-inflammatory drugs, oral steroids, local corticosteroid injections, and
surgery to decompress the median nerve segment.Iontophoresis and
phonophoresis methods were also used to introduce locally antiinflammatory
steroid drugs for CTS treatment (Karatay et al., 2009).
However, there are some controversies about the reported results
by these studies. Banta (1994), suggested that iontophoresis may
become an alternative to steroid injections to the carpal tunnel region.
Later, Dakowicz and Latosiewicz. 2005, showed that using a
combination of hydrocortisone iontophoresis and ultrasound therapy may
diminish the symptoms of patients with mild to moderate
CTS. Gokoglu et al., 2005, also reported a successful treatment by
iontophoresis of dexamethasone sodium phosphate (Dex-P) in patients
with CTS. In other study, (Amirjani et al., 2009) were reported
superiority between iontophoresis and phonophoresis methods to deliver
betamethasone or corticosteroid drugs for CTS treatment
95 Egypt. J. of Appl. Sci., 36 (7-8) 2021
MATERIALS AND METHODS
The study was designed as a prospective, randomized controlled
trial.
Participants
Sixty patients were selected from departments of neurology,
Mansoura University Hospitals by neurology physician.Patient’s
age ranged from 20 to 30 years with mild to moderate CTS diagnosed by
clinical examination, electrophysiological study, and ultrasound.
Patients will be divided randomly into three equal groups;
Group (A); 20 patients receive dexamethasone phonophoresis and nerve
gliding.
Group (B); 20 patients receive ketoprofen phonophoresis and nerve
gliding.
Group (C); 20 patients receive nerve gliding.
All groups were assessed before and after 6 weeks of treatment
using visual analogue scale (VAS) for pain, Semmes Weinstein
Monofilaments (SWM) for skin sensation, and handheld dynamometer
(HHD) for hand grip strength.
Intervention:
Participants in group (A), received
phonophoresis of local dexamethasone gel on the palm of their
wrist crease using ultrasound continuous mode, 1.5 W/cm2 intensity, and
1MHz frequency for 5 minutes with nerve gliding. Participants in group
(B) received phonophoresis of local ketoprofen gel on the palm of their
wrist crease using ultrasound continuous mode, 1.5 W/cm2 intensity, and
1MHz frequency for 5 minutes with nerve gliding.Participants in group
(C) control group, received nerve gliding only.
Statistical Analysis:
Shapiro-Wilk test was used, to examine normalitydistribution of
all data (P>0.05) after removal outliers that detected by box and whiskers
plots. Additionally, Levene's test for testing the homogeneity of variance
revealed that there was no significant difference (P>0.05). The data is
normally distributed and parametric analysis is done. The statistical
analysis was conducted by using statistical SPSS Package program
version 25 for Windows (SPSS, Inc., Chicago, IL). Quantitative
descriptive statistics data including the mean and standard deviation for
VAS,score variables.Qualitative descriptive statistics data including the
number and percentage for filaments variables. Chi-square test used to
compare between before- and after-treatment of filaments within each
group. Also, to compare among groups A, B, and C at before-treatment
and after-treatment.
Egypt. J. of Appl. Sci., 36 (7-8) 2021 96
RESULTS AND DISCUSSION
The results revealed that there were significant differences in VAS
after-treatment between group A and group C (P=0.0001; P<0.05) and
group B versus group C (P=0.0001; P<0.05), but no significant difference
between group A versus group B (P=1.000; P>0.05), Mean differences
between groups showed that the dexamethasone phonophoresis plus nerve
gliding group (Group A) give the highest VAS value (Table 1). In HHD,
the statistical analysis by repeated measure ANOVA revealed that a
significant difference group A (P=0.0001; P<0.05), but no significant
differences within group B (P=0.174; P>0.05) and group C (P=0.118;
P>0.05). Mean differences between groups showed that the dexamethasone
phonophoresis plus nerve gliding group (Group A) give the highest HHD
value (Figure 1). In Semmes Weinstein monofilaments among groups A, B,
and C. The statistical analysis byChi-square test revealed that there was a
significant difference (P=0.0001; P<0.05) in filaments at after treatment
among groups A, B, and C (Table 2).
Table (1): Mean values before- and after-treatment VAS within each
group.
VAS (Mean ±SD)
Items Group A Group B Group C
Before treatment 6.76 ±1.11 6.31 ±0.76 7.50 ±0.88
After treatment 0.00 ±0.00 0.00 ±0.00 3.90 ±1.02
Mixed MANOVA (Overall effect)
MANOVA-test F-value P-value Significance
Group effect 130.366 0.0001* S
Time effect 152.806 0.0001* S
Interaction effect 48.258 0.0001* S
Figure (1): Mean values of HHD at before- and after-treatment among groups.
97 Egypt. J. of Appl. Sci., 36 (7-8) 2021
Table (2): Distribution and comparative of filaments among groups
Items
Filaments
χ2-
value
P-value
Significanc
e
Groups
Group A Group B Group C
Before
treatment
Diminished
sensation
10 (50%)
20
(100%)
13 (65%)
37.674 0.0001* S
Normal sensation 10 (50%) 0 (0%) 0 (0%)
No sensation 0 (0%) 0 (0%) 7 (35%)
After
treatment
Total recover 10 (50%)
20
(100%)
0 (0%)
No recover 0 (0%) 0 (0%) 8 (40%) 80.000 0.0001* S
Normal sensation 10 (50%) 0 (0%) 0 (0%)
Mild recover 0 (0%) 0 (0%) 12 (60%)
Group A: receives dexamethasone phonophoresis plus nerve gliding
Group B: receives ketoprofen phonophoresis plus nerve gliding
Group C: receives nerve gliding only (control group)
Data are expressed as number and percentage χ2-square value: Chisquare
value P-value: probability value S: significant
* Significant (P<0.05) NS: non-significant
Hoshang et al., 2011, designed a study to compare the effect of
iontophoresis and phonophoresis of dexamethasone (DXA) on 51hands
with mild or moderate CTS. They concluded that using phonophoresis of
DXA is more effective for CTS treatment than iontophoresis.
Hong et al., 1988, has been usedUS therapy as a treatment for
various conditions including CTS. It converts electrical energy into a
sound wave. The wave transmits through the skin into the deeper tissue
and increases tissue temperature. The biophysical effects of US on CTS
include (1) stimulation of nerve regeneration; (2) increasing the
conductivity of nerve; and (3) reducing the inflammatory process.
Phonophoresis is a modified method that uses US to enhance
cutaneous absorption of topical anti-inflammatory drugs from the skin
into the deeper target tissues. It is a noninvasive and low- risk technique.
It combines the treatment of US and anti-inflammatory drugs; therefore,
increased beneficial effects are expected. There are many reports about
its effects on musculoskeletal conditions. Recently, the reports of
phonophoresis treatment in CTS patients have shown positive results
using a variety of drugs and study designs.
Yildiz et al., 2011, conducted a study ona randomized, doubleblind,
controlled trial compared the efficacy of US and ketoprofen PH in
mild to moderate CTS. The results showed that the ketoprofen PH group
had a significantly decreased Visual Analogue Scale (VAS) of pain
compared to the US group. Another study by Soyupek et al., 2012,
conducted a single-blind study to compare the efficacy of conservative
treatments between four groups of CTS patients: (1) PH of corticosteroid
(PH-CS); (2) PH of NSAIDs (PH-NSAIDs-diclofenac gel); (3) local
corticosteroid injection (LCSI); and (4) volar wrist splint. The results
Egypt. J. of Appl. Sci., 36 (7-8) 2021 98
showed that PH-CS group was markedly improved in
electrophysiological studies, grip strength, and functional status. There
were significant improvements in grip strength, pegboard test, and pain
intensity in the PH- NSAIDs group. However, the patients who received
US were not included in this study. The superiority of PH over US
treatment was inconclusive.
Bakhtiary et al., 2013, conducted a randomized clinical study
compared the effects of PH with iontophoresis technique in CTS
patients. Both treatments used the same dose of 0.4% dexamethasone
sodium phosphate. The results revealed that the PH method was more
effective than iontophoresis in improving hand functions and
electrophysiological parameters.
Although many studies have reported the benefits of PH treatment
in CTS, the determination of whether PH is better than standard US is
still inconclusive as well as whether NSAIDs or dexamethasone sodium
phosphate is better for PH.
Jariya Boonhong 2019 has conducted a study on effectiveness of
phonophoresis treatment in carpal tunnel syndrome that comparing between
three randomized groups .All three groups received 10 sessions of 1-MHz
frequency, 1.0 w/cm2 intensity ultrasound wave with stroking technique,
continuous mode, at the palm side of the hand over the carpal tunnel area—10
minutes per session, two to three times per week for 4 weeks, for a total of 10
sessions. During each session, the patients received 15 cm3 of study gel
according to the study groups. The PH-P group received 0.5% piroxicam gel
mixture (equivalence of 20 mg of piroxicam). The PH-Dex group received
0.4% dexamethasone sodium phosphate gel mixture (equivalence 60 mg of
dexamethasone). The US group received nondrug gel. This study revealed that
US, PH-P, and PH-Dex (using 1 MHz frequency and 1.0 w/cm2 intensity) were
not effective in improving electrodiagnostic parameters (DSL and DML) in
mild to moderate CTS but did improve clinical symptoms and functional status
without the between-group statistical differences. PH is not superior to standard
US in management of CTS.
CONCLUSION
The results obtained from the current study showed that: Both
dexamethasone and ketoprofen phonophoresis combined with nerve
gliding were more effective in treatment of mild to moderate carpal
tunnel syndrome than nerve gliding alone.
Source of Funding: This study received no financial support.
Conflict of Interest: The authors have no conflict of interest to declare.
ACKNOWLEDGMENTS
The authors would like to thank all patients who participated in
the study
99 Egypt. J. of Appl. Sci., 36 (7-8) 2021
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الفعالية المقارنة لمديکساميثازون مقابل الکيتوبروفين في
علاج متلازمة النفق الرسغي
أکرم عبدالمنعم أحمد 1 ، أمل حسن محمد إب ا رهيم 2 ، تامر محمد بلال 3 ، غادة إسماعيل
1. قسم العلاج الطبيعي بمستشفى طمخا المرکزي بالدقهمية
2. أستاذ, قسم العلاج الطبيعي لمعموم الأساسية , کمية العلاج الطبيعي , جامعة القاهرة , مصر.
-3 أستاذ, قسم الأم ا رض العصبية , کمية الطب , جامعة المنصورة, مصر.
4. أستاذ مساعد, قسم العلاج الطبيعى لمعموم الأساسية , کمية العلاج الطبيعي , جامعة القاهرة , مصر
الهدف: المقارنة بين تأثي ا ردخال الديکساميثازون عن طريق الموجات فوق الصوتية مع تمارين انزلاق
العصب , و تأثي ا ردخال الکيتوبروفين عن طريق الموجات فوق الصوتية مع تمارين انزلاق العصب
وتمارين انزلاق العصاب في علاج متلازمة النفق الرسغي الخفيفة إلى المتوسطة. المشارکين: 06
مريض يعانون من أع ا رض متلازمة النفق الرسغى خفيفة الى متوسطة تم اختيارهم من قسم المخ
والأعصاب بجامعة المنصورة. ت ا روحت أعمارهم بين 26 و 36 سنة. تم تقسيمهم بشکل عشوائي إلى
ثلاث مجموعات متساوية. المجموعة أ )مجموعة الد ا رسة( ؛ 26 مريضا يتمقون الديکساميثازون عن
طريق الموجات فوق الصوتية مع تمارين انزلاق العصب , المجموعة ب )مجموعة الد ا رسة( ؛ 26 مريضا
يتمق ون الکيتوبروفين عن طريق الموجات فوق الصوتية مع تمارين انزلاق العصب, والمجموعة ج
)المجموعة الضابطة( ؛ 26 مريضا يتمقون تمارين انزلاق العصب. تم تقييم جميع المجموعات قبل وبعد
Semmes للألم , وخيوط أحادية من (VAS) العلاج باستخدام المقياس التناظري البصري
لقوة قبضة اليد , (HHD) لإختبار الاحساس , ومقياس الدينامومتر المحمول Weinstein (SWM)
وتم إعطاء برنامج العلاج 3 م ا رت في الأسبوع لمدة 0 أسابيع لممجموعات الثلاث. النتائج: کان هناک
انخفاض ممحوظ لمشعور بالألم بعد انتهاء الخطة العلاجية تعطى الأفضمية لممجموعة أ في التحسن طبقا
لممقارنة بين متوسط القيمة لممجموعات الثلاثة. وأظهر تحسن ممحوظ في قوة قبضة اليد بمقارنة
المجموعة أ مقابل المجموعة ج والمجموعة ب مقابل المجموعة ج ولکن لايوجد فروق ممحوظة بين
المجموعة أ والمجموعة ب في تحسن قبضة اليد ويعطى الأفضمية أيضا في التحسن بالمقارنة بين الثلاث
مجموعات لممجموعة أ. وبالنسبة لاختبار الاحساس أظهر تحسن ممحوظ في الثلاث مجموعات مع
إعطاء الأفضمية لممجموعة أ. الخلاصة: يمکن الاستنتاج أن عممية ادخال الديکساميثازون و
الکيتوبروفين عن طريق الموجات فوق الصوتية جنبًا إلى جنب مع تمارين انزلاق العصب فعالة في
علاج متلازمة النفق الرسغي أکثر من تمارين انزلاق العصب وحدها.
الکممات المفتاحية: متلازمة النفق الرسغي , الشعي ا رت الأحادية سيميس وينشتاين , الرحلان
الصوتي , انزلاق العصب .