Research ArticleEffects of Exercise and Enzyme Therapy in Early OccupationalCarpal Tunnel Syndrome A Preliminary Study

Vjra C-dkovaacute12 Marie Naklaacutedalovaacute1 and Ladislav Štjpaacutenek 1

1Department of Occupational Medicine University Hospital Olomouc and Faculty of Medicine and DentistryPalacky University Olomouc Czech Republic2General Practitioner Baska Czech Republic

Correspondence should be addressed to Ladislav Stepanek stepanekladislavgmailcom

Received 30 October 2018 Revised 10 December 2018 Accepted 30 December 2018 Published 23 January 2019

Academic Editor Luenda Charles

Copyright copy 2019 Vera Zıdkova et al This is an open access article distributed under the Creative Commons Attribution Licensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

ObjectivesOccupational carpal tunnel syndrome (CTS) due to upper extremity overuse has in recent years been themost commonlyrecognized occupational disease in the Czech Republic and its prevalence has steadily increased This pilot observation aimed toassess the effects of exercise techniques and oral enzyme therapy in automotive plant workers with early CTS Patients andMethodsThe observation comprised automotive plant assembly line workers in whom nerve conduction study revealed incipient CTS Thesubjects were divided into three groups a group practicing exercise techniques (exercising N=15) a group receiving oral enzymetherapy (N=16) and a group of controls (N=14) Subjects in the control group were only observed without any specific interventionwhich is a common procedure in incipient CTSThroughout 9-week observation the workers did their jobs Prior to and after thatperiod the workersrsquo CTS-related symptoms were ascertained through structured interviews with a physician and the followingmedian nerve parameters were measured sensory conduction velocity (SCV) and distal motor latency (DML) Results In both theexercise and enzyme therapy groups statistically significant decreases in the total score for symptoms were achieved (plt00001)unlike controls On final examination both treated groups demonstrated significantly increased SCV as compared with the initialvalues (p=000013 and plt00001 respectively) in controls the mean SCV did not significantly change Similarly a statistically sig-nificant shortening of DMLwas noted in the enzyme therapy group (p=0008)ConclusionThe results showed the efficiency of bothexercise and oral enzyme therapy in incipient CTSThesemethodsmay be recommended for preventingmore severe forms of CTS

1 Introduction

Repetitive strain injury has been recognized as an occupa-tional disease in the Czech Republic since 1975 [1] Whilethe incidence of the other occupational diseases has gen-erally decreased the trend is opposite for this group ofconditions [2] Occupational carpal tunnel syndrome (CTS)due to upper extremity overuse has been the most commonoccupational disease in the Czech Republic for more than 10years This condition has been most frequently observed inthe automotive industry in the last three years [3 4]

This is also true for the studied plant where automobileparts are assembled with CTS being the most commonhealth problem in workers exposed to upper extremityoveruse Despite the fact that several targeted technologicaland organizational preventive measures were put in place in

the plant (eg improved workplace ergonomics or directedrotation of workers between various operations) the healthproblem still persists [5]

Therefore its prevention and therapy are a hot issueCTS management is both surgical (especially in advancedconditions) and conservative including splints keeping thewrist at a neutral position especially at night topical corticos-teroids nonsteroidal anti-inflammatory drugs therapeuticultrasound job change yoga acupuncture oral enzyme ther-apy or kinesiotherapy [6ndash10] However uniform standardevidence-based guidelines for treating CTS are still lacking[11]

The study is aimed at assessing the effect of exercisetechniques and oral enzyme therapy in the incipient formsof median nerve damage at the wrist in workers exposed toupper extremity overuse in an automotive plant

HindawiBioMed Research InternationalVolume 2019 Article ID 8720493 7 pageshttpsdoiorg10115520198720493

2 BioMed Research International

Table 1 Sample composition by age gender and initial findings

group persons(N) males () females

()age extremities with

difficulties (N)

extremities with abnormalNCS (N)

ME min max total SCV DML SCV+DMLexercise 15 12 (800) 3 (200) 35 24 54 22 21 16 5 0enzymetherapy 16 10 (625) 6 (375) 31 22 59 24 26 17 17 8

controls 14 12 (857) 2 (143) 35 24 60 13 18 15 6 3ME median NCS nerve conduction study SCV sensory conduction velocity DML distal motor latency

2 Materials and Methods

21 Subjects and Study Protocol The prospective pilot obser-vation comprised automotive plant assembly line workersin whom during annual periodic preventive occupationalhealth examination nerve conduction study (NCS) revealedincipientmedian neuropathy at the wrist whowere willing toparticipate in the project and in whom the following stateswere not found out previously injected corticosteroids forCTS inflammatory joint disease a history of trauma to theaffected hand surgery for CTS pregnancy polyneuropathyand other relevant states These forms of slightly abnormalNCS findings are only a matter for increased observationwithout any targeted intervention Informed consent wasobtained fromall participants after explaining all informationregarding the project to them

All workers (N=45) were exposed to the risk factor localmuscular strain to the upper extremities [12] Their worktasks including installation of engines gearboxes super-chargers shock absorbers and other parts were performedwhile standing Workers mostly handled small parts or loadsof up to 10 kg only rarely and irregularly pneumatic torquewrenches were used

Workers were offered three possible ways of participationbased on their preferences expressed during the initial medi-cal examination in a group practicing exercising in a groupreceiving oral enzyme therapy and in a group of controlsThegroup composition by gender and age is shown in Table 1Thesubjects were gradually enrolled between mid-2014 and mid-2016 throughout the study period the workers did their jobs

Initially and after nine weeks workers were asked aboutCTS-related symptoms and underwent NCS of the mediannerve For keeping compliance the exercise and enzymetherapy groups had additional medical appointments afterthree and six weeks during which they were reeducated andmotivated to exercise and use theirmedication regularly Alsotolerability of enzyme therapy was assessed

22 Data Collection During a structured interview theworkerrsquos symptoms were recorded by a physician for eachhand separately The questions were focused on the typeintensity duration and frequency of symptoms Also notedduring the interview were difficulties performing commondaily activities caused by impaired fine hand motor skills(eg manipulating coins buttons or zippers using mobilephones and opening plastic bottles) For statistical analysissymptoms were assigned points based on their severity (see

Table 2) Provocative tests (Tinelrsquos Phalenrsquos and DelPinorsquos)were also included and assessed as a part of the point score

In our study the core objective method for assessingthe prevalence and severity of CTS was a NCS test of themedian nerve at the wrist The main studied parameterswere distal motor latency (DML) and sensory conductionvelocity (SCV) All NCS tests were carried out by a singleneurologist in accordance with standard methods That isSCV was determined to the 2nd or 3rd finger at 14 cm andDML of the median nerve at 8 cm at an angle [13]

Normal conduction parameters of themedian nerve wereSCV ge 5000 ms and at the same time DML lt 420 msIn the study moderate neuropathy was defined as SCV3810ndash4000 ms and at the same time DML 490ndash529 msThese moderate forms of neuropathy were the reason forrelocating the worker to another job because of the risk ofdeveloping occupational disease Cases neither reaching thisgrade nor showing normal values were labeled as incipientmedian neuropathy and included in the study Cases hav-ing SCV le 380 ms and at the same time DMLge 530ms together with relevant clinical findings are consideredas having an occupational disease in the Czech RepublicFor clarity purposes motor and sensory conduction wereassessed separately however there were some workers withcombined sensorimotor lesions (Table 1)

23 Exercise Techniques Individuals in the exercise groupperformed three simple techniques with neuromobilizationelements at least once daily throughout the study period [14]They were given explanation about the principle and aimof the exercise and were adequately educated about how toperform the techniques They received both a printed leafletwith pictures of the techniques and an audiovisual recordingshowing the techniques

The first preparative technique (Figure 1(a)) focuses onsoft tissue treatment fascicular mobilization of the retinacu-lum flexorumThe aim of the technique is to adjust flexibilityof this soft tissuewith a deep push and pull in order to preventits fibrosis Through the preserved flexibility of the areamore space is gained for the median nerve The technique ispushing and pulling from the carpal bones to the palm Theback of the wrist is stretchedwith the opposite thumbmovingfrom place to place leaving the thumb in each place for about3 seconds In total the technique should be performed forabout 30 seconds

The second technique (Figure 1(b)) concentrates on therelaxation of flexor muscle groups using the ldquohold-relaxrdquo

BioMed Research International 3

Table 2 Assessment of symptoms

Asking about symptoms presence of symptomsdifficulties points handright le

Type of symptoms (DAYNIGHT)intensity of symptomsno ndash unbearable (0-5)

pains 0ndash50ndash5tingling burning 0ndash50ndash5

other 0ndash50ndash5

When symptoms occur

never 0during work 1

at rest 1at night 1

How long symptoms last

never 0less than 101015840 1

10ndash601015840 2more than 601015840 3Permanently 4

DAYHow oen symptomsoccur

never 01ndash2x 13ndash5x 2

more than 5x 3permanently 4

NIGHTHow oen symptomswoke himher up

never 01ndash2x 13ndash5x 2

more than 5x 3permanently 4

Difficulties performingactivities needing finehand motor skills

yesno 10

Provocative tests PhalenTinelDelPino 111TOTAL

technique with the neurophysiological effect of postisometricrelaxation The technique requires that the person stands orsits straightThe palms are clasped in front of the chest Firstthe fingers press against each other for 5 seconds and then thepressure is released for another 5 seconds Then the palmsare placed together and moved towards the abdomen Aswith the third technique minimal and maximal numbers ofrepetitions are set and the actual number of repetitions is upto the individual tolerance This technique is repeated two orthree times

The third technique (Figure 1(c)) is a neuromobilizationtechnique using slide and strain of the median nerve Toperform the technique the person stands with their side toa wall with the arm stretched and the palm leaning againstthe wall the hand is slightly rotated The extended arm isbent at the elbow and extended againThus the elbow joint isslowly extended from the flexed position bymoving the entiretrunkThe technique is performed 6 to 8 times Additionallyif possible the head is tilted towards the opposite shoulder

which makes the technique more effective through acting onmore proximal parts of the median nerve As a result of thesetechniques the nerve adapts to the change in pressure overvarious extreme positions

24 EnzymeTherapy The second group was put on a 9-weekcourse of oral enzyme therapy with Wobenzym (MUCOSPharma GmbH amp Co KG Germany) an over-the-counterdrug in enterosolvent tablets containing in the administereddaily dose (20 pills divided into two doses) 2000 mg pan-creatin 900 mg bromelain 1200 mg papain 480 mg trypsin20 mg chymotrypsin 200 mg amylase 200 mg lipase and1000 mg rutin It has anti-inflammatory antiedematous andanalgesic effects For these properties it is used for treatmentof various types of musculoskeletal disorders [15 16] At thebeginning of the study all workers were informed about thereasons for and effects of the therapy way of administrationand potential adverse effects

4 BioMed Research International

(a) (b)

(c)

Figure 1 Three exercise techniques performed by the exercise group

Tolerability of the enzyme therapy was assessed duringeach appointment through targeted questions Five cases ofadverse effects were reported These were previously knowncommon side effects affecting the digestive system (changedstool consistency abdominal discomfort) of mild intensity intwo women and three men The difficulties lasted for 3 to20 days spontaneously resolved and were not a reason todiscontinue the medication

25 Statistical Analysis Statistical analysis was performedwith IBM SPSS Statistics Version 21 Release 21000 Nor-mality of initial values in the groups was assessed withthe KolmogorovndashSmirnov test which ruled out statisticallysignificant differences in age and gender distribution betweenthe groups SCV was evaluated using ANOVA repeatedmeasures The significance of changes in DML was analyzedwith the paired samples t-test The significance of changes inthe final score of symptoms as compared with the initial scorewas tested with the Wilcoxon signed-rank test

3 Results

In all observed groups isolated sensory or motor conduc-tion lesions in one or both extremities were detected aswell as combined sensorimotor lesions Motor conductionlesions and combined sensorimotor lesions indicate moresevere states In all extremities with symptoms abnormalNCS findings were also noted the only exception was onecase in the exercise group On the other hand there wereseveral asymptomatic cases with positiveNCS findingsTheseincluded two cases in the enzyme therapy group and five inthe control group (Table 1) The effects of interventions wereevaluated in the three following parameters

31 Symptoms The analysis included all extremities withsymptoms on initial examination namely 22 extremities inthe exercise group 24 extremities in the enzyme therapygroup and 13 extremities in the control group In both theexercise and enzyme therapy groups statistically significantdecreases in the total score were achieved (plt0001) Incontrols the total score remained practically unchanged(Table 3)

Difficulties performing aforementioned common dailyactivities were not frequent They were noticed in 7 extrem-ities of the enzyme therapy group (5 of them stated as onlyoccasionally) in 4 extremities of the exercise group (2 of themonly occasionally) and in 3 extremities of the control groupProvocative tests were positive only in 5 extremities 3 of themwere in the exercise group 2 in the control group and nonein the enzyme therapy group

32 Sensory Conduction (SCV) The statistical evaluationincluded 48 extremities with impairment of the sensoryconduction in the median nerve at the wrist There wasno statistically significant difference in initial SCV valuesbetween the three groups On final examination both theexercise and enzyme therapy groups demonstrated signif-icantly increased SCV as compared with the initial values(plt0001) In controls the mean SCV did not significantlychange compared to the initial value (p=0660) as seenfrom Table 4 There was no significant difference in theintervention effect between the exercise and enzyme therapygroups (p=04)

33 Motor Conduction (DML) The study assessed a total of28 extremities with impairment of the motor conduction inthe median nerve Most abnormal findings were observed in

BioMed Research International 5

Table 3 Development in symptoms

extremities withsymptoms in the group(N)

medicalexamination

total score of symptoms(mean) plusmn SD ME percentile statistical

significance25 75ExerciseN=22

initial 96plusmn48 7 7 98 plt0001final 20plusmn28 0 0 5

enzyme therapyN=24

initial 115plusmn76 8 7 148 plt0001final 55plusmn65 6 0 8

controlsN=13

initial 117plusmn49 9 8 145 p=0161final 109plusmn57 10 8 135

SD standard deviation ME median

Table 4 Assessment of the development in sensory conduction of the median nerve

sensory lesions in the group (N) NCS mean SCV (ms) plusmnSD

95 confidence interval for themean significance

of the changelower limit upper limit

ExerciseN=16

initial 4714plusmn153 4632 4795 plt0001final 5311plusmn757 4907 5714

enzyme therapyN=17

initial 4532plusmn303 4376 4688 plt0001final 5475plusmn844 5041 5909

controlsN=15

initial 4570plusmn264 4424 4716 p=0660final 4638plusmn194 4531 4745

NCS nerve conduction study SCV sensory conduction velocity SD standard deviation

the enzyme therapy group Distribution of DML findings inall groups and their development is shown in Table 5 Uponcompletion of oral enzyme therapy a statistically significantimprovement inDML compared to the initial valuewas noted(p=0008) In that group improvement was achieved in 10out of 17 abnormal NCS findings of those 6 cases were inthe normal range after 9 weeks Given the small number ofabnormal NCS findings of DML in the exercise and controlgroups statistical analysis was not possible

A certain minute improvement in the mean DML SCVand total scores for symptoms was also noted in the controlgroup this may be explained by the fact that unfortunatelytwo control subjects did not adhere to the study protocol andtook several days off work during the observation period

4 Discussion

In the present study a significant positive effect of spe-cific exercise techniques and oral enzyme therapy on CTSmanifestations was achieved The effectiveness of appliedprocedures was confirmed on both symptoms and NCSparameters

CTS is a major global health burden In the literaturevarious definitions for diagnosing CTS are used these arebased on the presence of various symptoms clinical signsprovocative test results and electrodiagnostic abnormalitieswhich is associated with the absence of international stan-dards for diagnosing the condition [17] Therefore thereare considerable differences in the incidence and prevalencerates stated in the literature depending on the criteriaused [18] Thus CTS therapy is a current issue recently

it has also involved kinesiotherapy and neuromobilizationtechniques that are based on a series of both active andpassivemovements aimed at restoring normal properties of the nerve[11 14]

Oskouei et al compared the efficacy of neuromobilizationtechniques in individuals with mild to moderate CTS (20persons and 32 CTS cases) The patients were divided intotwo groups Both groups underwent standard physiotherapy(a wrist splint worn night and day electrical nerve stimu-lation and therapeutic ultrasound) Additionally one groupreceived two neuromobilizationmaneuversThe study resultsshowed that in both groups symptoms such as tinglingnumbness weakness and pain were significantly reducedThere were also improvements in the median nerve tensiontest and Phalenrsquos sign (p = 0005) However NCS andhand function test results were significantly improved in theneuromobilization group The authors therefore concludedthat neuromobilization in combination with routine phys-iotherapy improved certain clinical findings more effectivelythan routine physiotherapy alone [19] In our study the ben-efit of neuromobilization was confirmed as well Althoughthe exercise techniques differ from those in our study aneuromobilization effect on themedian nervemay be similar

Kwolek and Zwolinska reported significant improve-ments in the quality of sensation range ofmotion at the wristand handmuscle strength in 61 patients not only immediatelyafter completion of rehabilitation (therapeutic ultrasoundmassage and kinesiotherapy) but also one year later [20]

De-la-Llave-Rincon et al carried out a prospective caseseries to examine the combined effect of soft tissue mobi-lization and neurodynamicmobilization of the entire median

6 BioMed Research International

Table 5 Assessment of the development in motor conduction of the median nerve

motor lesions in the group (N) NCS Mean DML (ms) plusmnSD

95 confidence interval for themean significance of

the changelower limit upper limit

ExerciseN=5

initial 424plusmn009 413 435final 414plusmn007 406 422

enzyme therapyN=17

initial 444plusmn028 43 458 p=0008final 410plusmn041 388 433

controlsN=6

initial 445plusmn021 423 467final 422plusmn028 392 451

NCS nerve conduction study DML distal motor latency SD standard deviation

nerve in 18 women suffering from chronic CTS The assess-ments were performed at baseline immediately after theintervention and 1 week after completion of the therapy Theabove techniques decreased the intensity of pain but failed toimprove pressure pain sensitivity The intensity of pain wasnoticed also in our study as a part of the symptom scorereduction Exercise techniques in this study performed witha physiotherapist are focused also on proximal parts of themedian nerve In case of our suggested exercise techniquesthe proximal parts are slid in the third technique [21]

However the effect of neuromobilization was not alwaysobserved Heebner and Roddey studied the effect of neuro-mobilization added to standard therapy Sixty CTS patientswere assigned to two groups The first group underwentstandard therapy including patient education (discussionon the definition anatomy cause and risk factors of CTSstressing healthy lifestyle choices such as posture correctionexercises changing work ergonomics to reduce repetitiveor sustained hand strain limiting repetitive overuse stressreducing prolonged wrist flexion or extension decreasingsalt intake and not smoking) wearing neutral wrist splintsat night and performing eight tendon-gliding exercisesIn addition to that individuals in the other group wereinstructed to repeat a neuromobilization exercise ten timeson three to five occasions a day (with the exercise beingsimilar to the third technique in the present study) Theoutcomes were assessed at baseline and after one and sixmonths using the Arm Shoulder and Hand Questionnairethe Brigham and Womanrsquos Hospital Carpal Tunnel SpecificQuestionnaire (CTSQ) and elbow extension range of motionduring amedian nerve tension test No significant differencesbetween the groups were noted with the only exceptionbeing improved scores on the CTSQ function scale in thefirst group after six months However the authors admit thatchronicity of symptoms poor self-reported compliance andinadequate follow-up sessions may have adversely affectedthe study outcomes The frequency of reeducation probablydid not provide sufficient compliance compared to our higherfrequency Additionally more severe forms of CTS wereincluded in the study by Heebner and Roddey than in ourobservation [22]

Studies confirming the beneficial effects of enzyme ther-apy in musculoskeletal and extremity peripheral nerve dis-orders due to overuse are difficult to find in the literature

Specific problems related to upper extremity overuse and theresulting conditions (tendinitis tenosynovitis epicondylitisentrapment neuropathy) leading to sick leave were addressedin a retrospective study by Zlamal showing that workers withthe above-mentioned occupational exposure and conditionswhounderwent oral enzyme therapy in addition to obligatorytherapy (rest oral analgesics topical analgesic and anti-inflammatory ointments) required a significantly shortertreatment time [23]

Nakladalova et al studied the effects of enzyme therapyin female electric motor winders with CTS Oral enzymetherapy was shown to have beneficial effects on both theincidence and severity ofmedian neuropathy at the wristTheassessment was performed using both a symptom question-naire and NCS tests [24]

In the present study subjects themselves could selecttheir experimental group Therefore the enzyme therapygroup was filled earlier The study showed that workersmostly preferred medication to exercise On the other handthose who learned the recommended techniques continuedperforming them even after the study was completed as theybrought them relief

The study outcomes suggest beneficial effects of bothexercise techniques with neuromobilization and oral enzymetherapy in early CTS There were improvements in bothsymptoms and NCS test results Another benefit of thestudy is that after the initial education the subjects wereable to perform the techniques on their own which savesthe patientrsquos time as well as the physiotherapistrsquos work assessions are not required Moreover patients may exercisein accordance with their needs and possibilities We planto continue the research by extending the sample size andassessing the effect of oral enzyme therapy combined withexercise techniques

41 Limitations The study has its limitations Boston CTSquestionnaire was not applied however there is significantsimilarity with the questionnaire used in our study Relativelysmall sample size is another limitation A certain limitationof the study was the fact that two control subjects did notcompletely adhere to the study protocol and took severaldays off work on the other hand the effect of resting wasnoticeable

BioMed Research International 7

5 Conclusions

The pilot observation confirmed the efficiency of both exer-cise techniques and oral enzyme therapy on early stagesof occupational median neuropathy at the wristmdashthe CTSThese methods may be recommended for improving CTSmanifestations and preventing more severe forms of CTS

Data Availability

The data used to support the findings of this study areavailable from the corresponding author upon request

Conflicts of Interest

The authors declare that there are no conflicts of interestregarding the publication of this paper

Acknowledgments

The studywas supported by theUniversityHospital OlomoucFund [RVO 619895592 RVO 00098892] and by the projectMUCOS Pharma CZ sro [MUC-0114]

References

[1] ldquoImplementing the social security actrdquo Act No 1281975 CollFederal Ministry of Labor and Social Affairs of Czechoslovakia1975 httpswwwzakonyprolidiczcs1975-128

[2] J Jarolımek and PUrban ldquoTwenty year development of occupa-tional diseases in the czech republic Medical and geographicalaspectsrdquo Central European Journal of Public Health vol 22 no4 pp 251ndash256 2014

[3] ldquoOccupational diseases in the czech republic 2017rdquoTheNationalInstitute of Public Health 2017 httpwwwszuczuploadsNZPHlaseni NzP 2017pdf

[4] J Jarolımek P Urban P Pavlınek and D Dzurova ldquoOccu-pational diseases in the automotive industry in Czechia ndashGeographic and medical contextrdquo International Journal ofOccupational Medicine and Environmental Health vol 30 no3 pp 455ndash468 2017

[5] V Zıdkova M Nakladalova J Zapletalova Z Nakladal andH Kollarova ldquoExperiences with preventing carpal tunnelsyndrome in an automotive plantrdquo International Journal ofOccupational Medicine and Environmental Health vol 30 no1 pp 45ndash54 2017

[6] ldquoWork-related carpal tunnel syndrome diagnosis and treatmentguidelinerdquo Washington State Department of Labor andIndustries 2016 httpswwwlniwagovClaimsInsFilesOMDMedTreatCarpalTunnelpdf

[7] M Hadianfard E Bazrafshan H Momeninejad and N JahanildquoEfficacies of acupuncture and anti-inflammatory treatment forcarpal tunnel syndromerdquo Journal of Acupuncture and MeridianStudies vol 8 no 5 pp 229ndash235 2015

[8] G A Talebi P Saadat Y Javadian et al ldquoManual therapy inthe treatment of carpal tunnel syndrome in diabetic patients Arandomized clinical trialrdquoCaspian Journal of Internal Medicinevol 9 no 3 pp 283ndash289 2018

[9] T Wolny and P Linek ldquoIs manual therapy based on neurody-namic techniques effective in the treatment of carpal tunnel

syndrome A randomized controlled trialrdquo Clinical Rehabilita-tion 2018

[10] S Maddali Bongi M Signorini M Bassetti A Del Rosso MOrlandi and G De Scisciolo ldquoA manual therapy interventionimproves symptoms in patients with carpal tunnel syndrome Apilot studyrdquoRheumatology International vol 33 no 5 pp 1233ndash1241 2013

[11] L Newington E C Harris and K Walker-Bone ldquoCarpaltunnel syndrome and workrdquo Best Practice amp Research ClinicalRheumatology vol 29 no 3 pp 440ndash453 2015

[12] ldquoLaying down conditions for the classification of work into cat-egories biological exposure test limit values conditions for thetaking of biological samples for biological exposure tests anddetails to be included in the reporting of works with asbestosand biological agentsrdquo Decree No 1072013 Coll amendingDecree No 4322003 Coll Ministry of Health of the CzechRepublic 2013 httpswwwzakonyprolidiczcs2013-107

[13] ldquoBulletin of theministry of health of the czech republic 102003rdquoMinistry of Health of the Czech Republic 2003 httpwwwmzcrczLegislativadokumentyvestnik 3661 1782 11html

[14] V Maslova M Nakladalova and P Bastlova ldquoKinezioterapie usyndromu karpalnıho tunelurdquo Pracovnı Lekarstvı vol 66 no23 pp 98ndash101 2014

[15] J Leipner F Iten and R Saller ldquoTherapy with proteolyticenzymes in rheumatic disordersrdquo BioDrugs vol 15 no 12 pp779ndash789 2001

[16] ldquoSummary of product characteristicsrdquo State Institute of DrugControl 2018 httpwwwsukleumodulesmedicationsearchphp

[17] G J Macfarlane ldquoIdentification and prevention of work-relatedcarpal-tunnel syndromerdquo The Lancet vol 357 no 9263 pp1146-1147 2001

[18] S Aroori and R A Spence ldquoCarpal tunnel syndromerdquo UlsterMedical Journal vol 77 no 1 pp 6ndash17 2008

[19] A E Oskouei G A Talebi S K Shakouri and K Gha-bili ldquoEffects of neuromobilization maneuver on clinical andelectrophysiological measures of patients with carpal tunnelsyndromerdquo Journal of Physical Therapy Science vol 26 no 7pp 1017ndash1022 2014

[20] A Kwolek and J Zwolinska ldquoImmediate and long-term effectsof selected physiotherapy methods in patients with carpaltunnel syndromerdquo Ortopedia Traumatologia Rehabilitacja vol13 no 6 pp 555ndash564 2011

[21] A I De-la-Llave-Rincon R Ortega-Santiago S Ambite-Quesada et al ldquoResponse of pain intensity to soft tissue mobi-lization and neurodynamic technique A series of 18 patientswith chronic carpal tunnel syndromerdquo Journal of Manipulativeand Physiological Therapeutics vol 35 no 6 pp 420ndash427 2012

[22] M L Heebner and T S Roddey ldquoThe effects of neuralmobilization in addition to standard care in persons with carpaltunnel syndrome from a community hospitalrdquo Journal of HandTherapy vol 21 no 3 pp 229ndash241 2008

[23] A Zlamal ldquoLze zvyit efektivitu lecby profesionalnıch poruchpohyboveho aparaturdquo Pracovnı Lekarstvı vol 61 no 3 pp 113ndash116 2009

[24] M Nakladalova B Matusova P Smolkova M NakladalovaB Matusova and P Smolkova ldquoSystemova enzymoterapie jakomoznost konzervativnı lecby syndromu karpalnıho tunelundashpilotnı sledovanırdquo Pracovnı Lekarstvı vol 64 no 23 pp 99ndash102 2012

BioMed Research International 3

Table 2 Assessment of symptoms

Asking about symptoms presence of symptomsdifficulties points handright le

Type of symptoms (DAYNIGHT)intensity of symptomsno ndash unbearable (0-5)

pains 0ndash50ndash5tingling burning 0ndash50ndash5

other 0ndash50ndash5

When symptoms occur

never 0during work 1

at rest 1at night 1

How long symptoms last

never 0less than 101015840 1

10ndash601015840 2more than 601015840 3Permanently 4

DAYHow oen symptomsoccur

never 01ndash2x 13ndash5x 2

more than 5x 3permanently 4

NIGHTHow oen symptomswoke himher up

never 01ndash2x 13ndash5x 2

more than 5x 3permanently 4

Difficulties performingactivities needing finehand motor skills

yesno 10

Provocative tests PhalenTinelDelPino 111TOTAL

technique with the neurophysiological effect of postisometricrelaxation The technique requires that the person stands orsits straightThe palms are clasped in front of the chest Firstthe fingers press against each other for 5 seconds and then thepressure is released for another 5 seconds Then the palmsare placed together and moved towards the abdomen Aswith the third technique minimal and maximal numbers ofrepetitions are set and the actual number of repetitions is upto the individual tolerance This technique is repeated two orthree times

The third technique (Figure 1(c)) is a neuromobilizationtechnique using slide and strain of the median nerve Toperform the technique the person stands with their side toa wall with the arm stretched and the palm leaning againstthe wall the hand is slightly rotated The extended arm isbent at the elbow and extended againThus the elbow joint isslowly extended from the flexed position bymoving the entiretrunkThe technique is performed 6 to 8 times Additionallyif possible the head is tilted towards the opposite shoulder

which makes the technique more effective through acting onmore proximal parts of the median nerve As a result of thesetechniques the nerve adapts to the change in pressure overvarious extreme positions

24 EnzymeTherapy The second group was put on a 9-weekcourse of oral enzyme therapy with Wobenzym (MUCOSPharma GmbH amp Co KG Germany) an over-the-counterdrug in enterosolvent tablets containing in the administereddaily dose (20 pills divided into two doses) 2000 mg pan-creatin 900 mg bromelain 1200 mg papain 480 mg trypsin20 mg chymotrypsin 200 mg amylase 200 mg lipase and1000 mg rutin It has anti-inflammatory antiedematous andanalgesic effects For these properties it is used for treatmentof various types of musculoskeletal disorders [15 16] At thebeginning of the study all workers were informed about thereasons for and effects of the therapy way of administrationand potential adverse effects

4 BioMed Research International

(a) (b)

(c)

Figure 1 Three exercise techniques performed by the exercise group

Tolerability of the enzyme therapy was assessed duringeach appointment through targeted questions Five cases ofadverse effects were reported These were previously knowncommon side effects affecting the digestive system (changedstool consistency abdominal discomfort) of mild intensity intwo women and three men The difficulties lasted for 3 to20 days spontaneously resolved and were not a reason todiscontinue the medication

25 Statistical Analysis Statistical analysis was performedwith IBM SPSS Statistics Version 21 Release 21000 Nor-mality of initial values in the groups was assessed withthe KolmogorovndashSmirnov test which ruled out statisticallysignificant differences in age and gender distribution betweenthe groups SCV was evaluated using ANOVA repeatedmeasures The significance of changes in DML was analyzedwith the paired samples t-test The significance of changes inthe final score of symptoms as compared with the initial scorewas tested with the Wilcoxon signed-rank test

3 Results

In all observed groups isolated sensory or motor conduc-tion lesions in one or both extremities were detected aswell as combined sensorimotor lesions Motor conductionlesions and combined sensorimotor lesions indicate moresevere states In all extremities with symptoms abnormalNCS findings were also noted the only exception was onecase in the exercise group On the other hand there wereseveral asymptomatic cases with positiveNCS findingsTheseincluded two cases in the enzyme therapy group and five inthe control group (Table 1) The effects of interventions wereevaluated in the three following parameters

31 Symptoms The analysis included all extremities withsymptoms on initial examination namely 22 extremities inthe exercise group 24 extremities in the enzyme therapygroup and 13 extremities in the control group In both theexercise and enzyme therapy groups statistically significantdecreases in the total score were achieved (plt0001) Incontrols the total score remained practically unchanged(Table 3)

Difficulties performing aforementioned common dailyactivities were not frequent They were noticed in 7 extrem-ities of the enzyme therapy group (5 of them stated as onlyoccasionally) in 4 extremities of the exercise group (2 of themonly occasionally) and in 3 extremities of the control groupProvocative tests were positive only in 5 extremities 3 of themwere in the exercise group 2 in the control group and nonein the enzyme therapy group

32 Sensory Conduction (SCV) The statistical evaluationincluded 48 extremities with impairment of the sensoryconduction in the median nerve at the wrist There wasno statistically significant difference in initial SCV valuesbetween the three groups On final examination both theexercise and enzyme therapy groups demonstrated signif-icantly increased SCV as compared with the initial values(plt0001) In controls the mean SCV did not significantlychange compared to the initial value (p=0660) as seenfrom Table 4 There was no significant difference in theintervention effect between the exercise and enzyme therapygroups (p=04)

33 Motor Conduction (DML) The study assessed a total of28 extremities with impairment of the motor conduction inthe median nerve Most abnormal findings were observed in

BioMed Research International 5

Table 3 Development in symptoms

extremities withsymptoms in the group(N)

medicalexamination

total score of symptoms(mean) plusmn SD ME percentile statistical

significance25 75ExerciseN=22

initial 96plusmn48 7 7 98 plt0001final 20plusmn28 0 0 5

enzyme therapyN=24

initial 115plusmn76 8 7 148 plt0001final 55plusmn65 6 0 8

controlsN=13

initial 117plusmn49 9 8 145 p=0161final 109plusmn57 10 8 135

SD standard deviation ME median

Table 4 Assessment of the development in sensory conduction of the median nerve

sensory lesions in the group (N) NCS mean SCV (ms) plusmnSD

95 confidence interval for themean significance

of the changelower limit upper limit

ExerciseN=16

initial 4714plusmn153 4632 4795 plt0001final 5311plusmn757 4907 5714

enzyme therapyN=17

initial 4532plusmn303 4376 4688 plt0001final 5475plusmn844 5041 5909

controlsN=15

initial 4570plusmn264 4424 4716 p=0660final 4638plusmn194 4531 4745

NCS nerve conduction study SCV sensory conduction velocity SD standard deviation

the enzyme therapy group Distribution of DML findings inall groups and their development is shown in Table 5 Uponcompletion of oral enzyme therapy a statistically significantimprovement inDML compared to the initial valuewas noted(p=0008) In that group improvement was achieved in 10out of 17 abnormal NCS findings of those 6 cases were inthe normal range after 9 weeks Given the small number ofabnormal NCS findings of DML in the exercise and controlgroups statistical analysis was not possible

A certain minute improvement in the mean DML SCVand total scores for symptoms was also noted in the controlgroup this may be explained by the fact that unfortunatelytwo control subjects did not adhere to the study protocol andtook several days off work during the observation period

4 Discussion

In the present study a significant positive effect of spe-cific exercise techniques and oral enzyme therapy on CTSmanifestations was achieved The effectiveness of appliedprocedures was confirmed on both symptoms and NCSparameters

CTS is a major global health burden In the literaturevarious definitions for diagnosing CTS are used these arebased on the presence of various symptoms clinical signsprovocative test results and electrodiagnostic abnormalitieswhich is associated with the absence of international stan-dards for diagnosing the condition [17] Therefore thereare considerable differences in the incidence and prevalencerates stated in the literature depending on the criteriaused [18] Thus CTS therapy is a current issue recently

it has also involved kinesiotherapy and neuromobilizationtechniques that are based on a series of both active andpassivemovements aimed at restoring normal properties of the nerve[11 14]

Oskouei et al compared the efficacy of neuromobilizationtechniques in individuals with mild to moderate CTS (20persons and 32 CTS cases) The patients were divided intotwo groups Both groups underwent standard physiotherapy(a wrist splint worn night and day electrical nerve stimu-lation and therapeutic ultrasound) Additionally one groupreceived two neuromobilizationmaneuversThe study resultsshowed that in both groups symptoms such as tinglingnumbness weakness and pain were significantly reducedThere were also improvements in the median nerve tensiontest and Phalenrsquos sign (p = 0005) However NCS andhand function test results were significantly improved in theneuromobilization group The authors therefore concludedthat neuromobilization in combination with routine phys-iotherapy improved certain clinical findings more effectivelythan routine physiotherapy alone [19] In our study the ben-efit of neuromobilization was confirmed as well Althoughthe exercise techniques differ from those in our study aneuromobilization effect on themedian nervemay be similar

Kwolek and Zwolinska reported significant improve-ments in the quality of sensation range ofmotion at the wristand handmuscle strength in 61 patients not only immediatelyafter completion of rehabilitation (therapeutic ultrasoundmassage and kinesiotherapy) but also one year later [20]

De-la-Llave-Rincon et al carried out a prospective caseseries to examine the combined effect of soft tissue mobi-lization and neurodynamicmobilization of the entire median

6 BioMed Research International

Table 5 Assessment of the development in motor conduction of the median nerve

motor lesions in the group (N) NCS Mean DML (ms) plusmnSD

95 confidence interval for themean significance of

the changelower limit upper limit

ExerciseN=5

initial 424plusmn009 413 435final 414plusmn007 406 422

enzyme therapyN=17

initial 444plusmn028 43 458 p=0008final 410plusmn041 388 433

controlsN=6

initial 445plusmn021 423 467final 422plusmn028 392 451

NCS nerve conduction study DML distal motor latency SD standard deviation

nerve in 18 women suffering from chronic CTS The assess-ments were performed at baseline immediately after theintervention and 1 week after completion of the therapy Theabove techniques decreased the intensity of pain but failed toimprove pressure pain sensitivity The intensity of pain wasnoticed also in our study as a part of the symptom scorereduction Exercise techniques in this study performed witha physiotherapist are focused also on proximal parts of themedian nerve In case of our suggested exercise techniquesthe proximal parts are slid in the third technique [21]

However the effect of neuromobilization was not alwaysobserved Heebner and Roddey studied the effect of neuro-mobilization added to standard therapy Sixty CTS patientswere assigned to two groups The first group underwentstandard therapy including patient education (discussionon the definition anatomy cause and risk factors of CTSstressing healthy lifestyle choices such as posture correctionexercises changing work ergonomics to reduce repetitiveor sustained hand strain limiting repetitive overuse stressreducing prolonged wrist flexion or extension decreasingsalt intake and not smoking) wearing neutral wrist splintsat night and performing eight tendon-gliding exercisesIn addition to that individuals in the other group wereinstructed to repeat a neuromobilization exercise ten timeson three to five occasions a day (with the exercise beingsimilar to the third technique in the present study) Theoutcomes were assessed at baseline and after one and sixmonths using the Arm Shoulder and Hand Questionnairethe Brigham and Womanrsquos Hospital Carpal Tunnel SpecificQuestionnaire (CTSQ) and elbow extension range of motionduring amedian nerve tension test No significant differencesbetween the groups were noted with the only exceptionbeing improved scores on the CTSQ function scale in thefirst group after six months However the authors admit thatchronicity of symptoms poor self-reported compliance andinadequate follow-up sessions may have adversely affectedthe study outcomes The frequency of reeducation probablydid not provide sufficient compliance compared to our higherfrequency Additionally more severe forms of CTS wereincluded in the study by Heebner and Roddey than in ourobservation [22]

Studies confirming the beneficial effects of enzyme ther-apy in musculoskeletal and extremity peripheral nerve dis-orders due to overuse are difficult to find in the literature

Specific problems related to upper extremity overuse and theresulting conditions (tendinitis tenosynovitis epicondylitisentrapment neuropathy) leading to sick leave were addressedin a retrospective study by Zlamal showing that workers withthe above-mentioned occupational exposure and conditionswhounderwent oral enzyme therapy in addition to obligatorytherapy (rest oral analgesics topical analgesic and anti-inflammatory ointments) required a significantly shortertreatment time [23]

Nakladalova et al studied the effects of enzyme therapyin female electric motor winders with CTS Oral enzymetherapy was shown to have beneficial effects on both theincidence and severity ofmedian neuropathy at the wristTheassessment was performed using both a symptom question-naire and NCS tests [24]

In the present study subjects themselves could selecttheir experimental group Therefore the enzyme therapygroup was filled earlier The study showed that workersmostly preferred medication to exercise On the other handthose who learned the recommended techniques continuedperforming them even after the study was completed as theybrought them relief

The study outcomes suggest beneficial effects of bothexercise techniques with neuromobilization and oral enzymetherapy in early CTS There were improvements in bothsymptoms and NCS test results Another benefit of thestudy is that after the initial education the subjects wereable to perform the techniques on their own which savesthe patientrsquos time as well as the physiotherapistrsquos work assessions are not required Moreover patients may exercisein accordance with their needs and possibilities We planto continue the research by extending the sample size andassessing the effect of oral enzyme therapy combined withexercise techniques

41 Limitations The study has its limitations Boston CTSquestionnaire was not applied however there is significantsimilarity with the questionnaire used in our study Relativelysmall sample size is another limitation A certain limitationof the study was the fact that two control subjects did notcompletely adhere to the study protocol and took severaldays off work on the other hand the effect of resting wasnoticeable

BioMed Research International 7

5 Conclusions

The pilot observation confirmed the efficiency of both exer-cise techniques and oral enzyme therapy on early stagesof occupational median neuropathy at the wristmdashthe CTSThese methods may be recommended for improving CTSmanifestations and preventing more severe forms of CTS

Data Availability

The data used to support the findings of this study areavailable from the corresponding author upon request

Conflicts of Interest

The authors declare that there are no conflicts of interestregarding the publication of this paper

Acknowledgments

The studywas supported by theUniversityHospital OlomoucFund [RVO 619895592 RVO 00098892] and by the projectMUCOS Pharma CZ sro [MUC-0114]

References

[1] ldquoImplementing the social security actrdquo Act No 1281975 CollFederal Ministry of Labor and Social Affairs of Czechoslovakia1975 httpswwwzakonyprolidiczcs1975-128

[2] J Jarolımek and PUrban ldquoTwenty year development of occupa-tional diseases in the czech republic Medical and geographicalaspectsrdquo Central European Journal of Public Health vol 22 no4 pp 251ndash256 2014

[3] ldquoOccupational diseases in the czech republic 2017rdquoTheNationalInstitute of Public Health 2017 httpwwwszuczuploadsNZPHlaseni NzP 2017pdf

[4] J Jarolımek P Urban P Pavlınek and D Dzurova ldquoOccu-pational diseases in the automotive industry in Czechia ndashGeographic and medical contextrdquo International Journal ofOccupational Medicine and Environmental Health vol 30 no3 pp 455ndash468 2017

[5] V Zıdkova M Nakladalova J Zapletalova Z Nakladal andH Kollarova ldquoExperiences with preventing carpal tunnelsyndrome in an automotive plantrdquo International Journal ofOccupational Medicine and Environmental Health vol 30 no1 pp 45ndash54 2017

[6] ldquoWork-related carpal tunnel syndrome diagnosis and treatmentguidelinerdquo Washington State Department of Labor andIndustries 2016 httpswwwlniwagovClaimsInsFilesOMDMedTreatCarpalTunnelpdf

[7] M Hadianfard E Bazrafshan H Momeninejad and N JahanildquoEfficacies of acupuncture and anti-inflammatory treatment forcarpal tunnel syndromerdquo Journal of Acupuncture and MeridianStudies vol 8 no 5 pp 229ndash235 2015

[8] G A Talebi P Saadat Y Javadian et al ldquoManual therapy inthe treatment of carpal tunnel syndrome in diabetic patients Arandomized clinical trialrdquoCaspian Journal of Internal Medicinevol 9 no 3 pp 283ndash289 2018

[9] T Wolny and P Linek ldquoIs manual therapy based on neurody-namic techniques effective in the treatment of carpal tunnel

syndrome A randomized controlled trialrdquo Clinical Rehabilita-tion 2018

[10] S Maddali Bongi M Signorini M Bassetti A Del Rosso MOrlandi and G De Scisciolo ldquoA manual therapy interventionimproves symptoms in patients with carpal tunnel syndrome Apilot studyrdquoRheumatology International vol 33 no 5 pp 1233ndash1241 2013

[11] L Newington E C Harris and K Walker-Bone ldquoCarpaltunnel syndrome and workrdquo Best Practice amp Research ClinicalRheumatology vol 29 no 3 pp 440ndash453 2015

[12] ldquoLaying down conditions for the classification of work into cat-egories biological exposure test limit values conditions for thetaking of biological samples for biological exposure tests anddetails to be included in the reporting of works with asbestosand biological agentsrdquo Decree No 1072013 Coll amendingDecree No 4322003 Coll Ministry of Health of the CzechRepublic 2013 httpswwwzakonyprolidiczcs2013-107

[13] ldquoBulletin of theministry of health of the czech republic 102003rdquoMinistry of Health of the Czech Republic 2003 httpwwwmzcrczLegislativadokumentyvestnik 3661 1782 11html

[14] V Maslova M Nakladalova and P Bastlova ldquoKinezioterapie usyndromu karpalnıho tunelurdquo Pracovnı Lekarstvı vol 66 no23 pp 98ndash101 2014

[15] J Leipner F Iten and R Saller ldquoTherapy with proteolyticenzymes in rheumatic disordersrdquo BioDrugs vol 15 no 12 pp779ndash789 2001

[16] ldquoSummary of product characteristicsrdquo State Institute of DrugControl 2018 httpwwwsukleumodulesmedicationsearchphp

[17] G J Macfarlane ldquoIdentification and prevention of work-relatedcarpal-tunnel syndromerdquo The Lancet vol 357 no 9263 pp1146-1147 2001

[18] S Aroori and R A Spence ldquoCarpal tunnel syndromerdquo UlsterMedical Journal vol 77 no 1 pp 6ndash17 2008

[19] A E Oskouei G A Talebi S K Shakouri and K Gha-bili ldquoEffects of neuromobilization maneuver on clinical andelectrophysiological measures of patients with carpal tunnelsyndromerdquo Journal of Physical Therapy Science vol 26 no 7pp 1017ndash1022 2014

[20] A Kwolek and J Zwolinska ldquoImmediate and long-term effectsof selected physiotherapy methods in patients with carpaltunnel syndromerdquo Ortopedia Traumatologia Rehabilitacja vol13 no 6 pp 555ndash564 2011

[21] A I De-la-Llave-Rincon R Ortega-Santiago S Ambite-Quesada et al ldquoResponse of pain intensity to soft tissue mobi-lization and neurodynamic technique A series of 18 patientswith chronic carpal tunnel syndromerdquo Journal of Manipulativeand Physiological Therapeutics vol 35 no 6 pp 420ndash427 2012

[22] M L Heebner and T S Roddey ldquoThe effects of neuralmobilization in addition to standard care in persons with carpaltunnel syndrome from a community hospitalrdquo Journal of HandTherapy vol 21 no 3 pp 229ndash241 2008

[23] A Zlamal ldquoLze zvyit efektivitu lecby profesionalnıch poruchpohyboveho aparaturdquo Pracovnı Lekarstvı vol 61 no 3 pp 113ndash116 2009

[24] M Nakladalova B Matusova P Smolkova M NakladalovaB Matusova and P Smolkova ldquoSystemova enzymoterapie jakomoznost konzervativnı lecby syndromu karpalnıho tunelundashpilotnı sledovanırdquo Pracovnı Lekarstvı vol 64 no 23 pp 99ndash102 2012

4 BioMed Research International

(a) (b)

(c)

Figure 1 Three exercise techniques performed by the exercise group

Tolerability of the enzyme therapy was assessed duringeach appointment through targeted questions Five cases ofadverse effects were reported These were previously knowncommon side effects affecting the digestive system (changedstool consistency abdominal discomfort) of mild intensity intwo women and three men The difficulties lasted for 3 to20 days spontaneously resolved and were not a reason todiscontinue the medication

25 Statistical Analysis Statistical analysis was performedwith IBM SPSS Statistics Version 21 Release 21000 Nor-mality of initial values in the groups was assessed withthe KolmogorovndashSmirnov test which ruled out statisticallysignificant differences in age and gender distribution betweenthe groups SCV was evaluated using ANOVA repeatedmeasures The significance of changes in DML was analyzedwith the paired samples t-test The significance of changes inthe final score of symptoms as compared with the initial scorewas tested with the Wilcoxon signed-rank test

3 Results

In all observed groups isolated sensory or motor conduc-tion lesions in one or both extremities were detected aswell as combined sensorimotor lesions Motor conductionlesions and combined sensorimotor lesions indicate moresevere states In all extremities with symptoms abnormalNCS findings were also noted the only exception was onecase in the exercise group On the other hand there wereseveral asymptomatic cases with positiveNCS findingsTheseincluded two cases in the enzyme therapy group and five inthe control group (Table 1) The effects of interventions wereevaluated in the three following parameters

31 Symptoms The analysis included all extremities withsymptoms on initial examination namely 22 extremities inthe exercise group 24 extremities in the enzyme therapygroup and 13 extremities in the control group In both theexercise and enzyme therapy groups statistically significantdecreases in the total score were achieved (plt0001) Incontrols the total score remained practically unchanged(Table 3)

Difficulties performing aforementioned common dailyactivities were not frequent They were noticed in 7 extrem-ities of the enzyme therapy group (5 of them stated as onlyoccasionally) in 4 extremities of the exercise group (2 of themonly occasionally) and in 3 extremities of the control groupProvocative tests were positive only in 5 extremities 3 of themwere in the exercise group 2 in the control group and nonein the enzyme therapy group

32 Sensory Conduction (SCV) The statistical evaluationincluded 48 extremities with impairment of the sensoryconduction in the median nerve at the wrist There wasno statistically significant difference in initial SCV valuesbetween the three groups On final examination both theexercise and enzyme therapy groups demonstrated signif-icantly increased SCV as compared with the initial values(plt0001) In controls the mean SCV did not significantlychange compared to the initial value (p=0660) as seenfrom Table 4 There was no significant difference in theintervention effect between the exercise and enzyme therapygroups (p=04)

33 Motor Conduction (DML) The study assessed a total of28 extremities with impairment of the motor conduction inthe median nerve Most abnormal findings were observed in

BioMed Research International 5

Table 3 Development in symptoms

extremities withsymptoms in the group(N)

medicalexamination

total score of symptoms(mean) plusmn SD ME percentile statistical

significance25 75ExerciseN=22

initial 96plusmn48 7 7 98 plt0001final 20plusmn28 0 0 5

enzyme therapyN=24

initial 115plusmn76 8 7 148 plt0001final 55plusmn65 6 0 8

controlsN=13

initial 117plusmn49 9 8 145 p=0161final 109plusmn57 10 8 135

SD standard deviation ME median

Table 4 Assessment of the development in sensory conduction of the median nerve

sensory lesions in the group (N) NCS mean SCV (ms) plusmnSD

95 confidence interval for themean significance

of the changelower limit upper limit

ExerciseN=16

initial 4714plusmn153 4632 4795 plt0001final 5311plusmn757 4907 5714

enzyme therapyN=17

initial 4532plusmn303 4376 4688 plt0001final 5475plusmn844 5041 5909

controlsN=15

initial 4570plusmn264 4424 4716 p=0660final 4638plusmn194 4531 4745

NCS nerve conduction study SCV sensory conduction velocity SD standard deviation

the enzyme therapy group Distribution of DML findings inall groups and their development is shown in Table 5 Uponcompletion of oral enzyme therapy a statistically significantimprovement inDML compared to the initial valuewas noted(p=0008) In that group improvement was achieved in 10out of 17 abnormal NCS findings of those 6 cases were inthe normal range after 9 weeks Given the small number ofabnormal NCS findings of DML in the exercise and controlgroups statistical analysis was not possible

A certain minute improvement in the mean DML SCVand total scores for symptoms was also noted in the controlgroup this may be explained by the fact that unfortunatelytwo control subjects did not adhere to the study protocol andtook several days off work during the observation period

4 Discussion

In the present study a significant positive effect of spe-cific exercise techniques and oral enzyme therapy on CTSmanifestations was achieved The effectiveness of appliedprocedures was confirmed on both symptoms and NCSparameters

CTS is a major global health burden In the literaturevarious definitions for diagnosing CTS are used these arebased on the presence of various symptoms clinical signsprovocative test results and electrodiagnostic abnormalitieswhich is associated with the absence of international stan-dards for diagnosing the condition [17] Therefore thereare considerable differences in the incidence and prevalencerates stated in the literature depending on the criteriaused [18] Thus CTS therapy is a current issue recently

it has also involved kinesiotherapy and neuromobilizationtechniques that are based on a series of both active andpassivemovements aimed at restoring normal properties of the nerve[11 14]

Oskouei et al compared the efficacy of neuromobilizationtechniques in individuals with mild to moderate CTS (20persons and 32 CTS cases) The patients were divided intotwo groups Both groups underwent standard physiotherapy(a wrist splint worn night and day electrical nerve stimu-lation and therapeutic ultrasound) Additionally one groupreceived two neuromobilizationmaneuversThe study resultsshowed that in both groups symptoms such as tinglingnumbness weakness and pain were significantly reducedThere were also improvements in the median nerve tensiontest and Phalenrsquos sign (p = 0005) However NCS andhand function test results were significantly improved in theneuromobilization group The authors therefore concludedthat neuromobilization in combination with routine phys-iotherapy improved certain clinical findings more effectivelythan routine physiotherapy alone [19] In our study the ben-efit of neuromobilization was confirmed as well Althoughthe exercise techniques differ from those in our study aneuromobilization effect on themedian nervemay be similar

Kwolek and Zwolinska reported significant improve-ments in the quality of sensation range ofmotion at the wristand handmuscle strength in 61 patients not only immediatelyafter completion of rehabilitation (therapeutic ultrasoundmassage and kinesiotherapy) but also one year later [20]

De-la-Llave-Rincon et al carried out a prospective caseseries to examine the combined effect of soft tissue mobi-lization and neurodynamicmobilization of the entire median

6 BioMed Research International

Table 5 Assessment of the development in motor conduction of the median nerve

motor lesions in the group (N) NCS Mean DML (ms) plusmnSD

95 confidence interval for themean significance of

the changelower limit upper limit

ExerciseN=5

initial 424plusmn009 413 435final 414plusmn007 406 422

enzyme therapyN=17

initial 444plusmn028 43 458 p=0008final 410plusmn041 388 433

controlsN=6

initial 445plusmn021 423 467final 422plusmn028 392 451

NCS nerve conduction study DML distal motor latency SD standard deviation

nerve in 18 women suffering from chronic CTS The assess-ments were performed at baseline immediately after theintervention and 1 week after completion of the therapy Theabove techniques decreased the intensity of pain but failed toimprove pressure pain sensitivity The intensity of pain wasnoticed also in our study as a part of the symptom scorereduction Exercise techniques in this study performed witha physiotherapist are focused also on proximal parts of themedian nerve In case of our suggested exercise techniquesthe proximal parts are slid in the third technique [21]

However the effect of neuromobilization was not alwaysobserved Heebner and Roddey studied the effect of neuro-mobilization added to standard therapy Sixty CTS patientswere assigned to two groups The first group underwentstandard therapy including patient education (discussionon the definition anatomy cause and risk factors of CTSstressing healthy lifestyle choices such as posture correctionexercises changing work ergonomics to reduce repetitiveor sustained hand strain limiting repetitive overuse stressreducing prolonged wrist flexion or extension decreasingsalt intake and not smoking) wearing neutral wrist splintsat night and performing eight tendon-gliding exercisesIn addition to that individuals in the other group wereinstructed to repeat a neuromobilization exercise ten timeson three to five occasions a day (with the exercise beingsimilar to the third technique in the present study) Theoutcomes were assessed at baseline and after one and sixmonths using the Arm Shoulder and Hand Questionnairethe Brigham and Womanrsquos Hospital Carpal Tunnel SpecificQuestionnaire (CTSQ) and elbow extension range of motionduring amedian nerve tension test No significant differencesbetween the groups were noted with the only exceptionbeing improved scores on the CTSQ function scale in thefirst group after six months However the authors admit thatchronicity of symptoms poor self-reported compliance andinadequate follow-up sessions may have adversely affectedthe study outcomes The frequency of reeducation probablydid not provide sufficient compliance compared to our higherfrequency Additionally more severe forms of CTS wereincluded in the study by Heebner and Roddey than in ourobservation [22]

Studies confirming the beneficial effects of enzyme ther-apy in musculoskeletal and extremity peripheral nerve dis-orders due to overuse are difficult to find in the literature

Specific problems related to upper extremity overuse and theresulting conditions (tendinitis tenosynovitis epicondylitisentrapment neuropathy) leading to sick leave were addressedin a retrospective study by Zlamal showing that workers withthe above-mentioned occupational exposure and conditionswhounderwent oral enzyme therapy in addition to obligatorytherapy (rest oral analgesics topical analgesic and anti-inflammatory ointments) required a significantly shortertreatment time [23]

Nakladalova et al studied the effects of enzyme therapyin female electric motor winders with CTS Oral enzymetherapy was shown to have beneficial effects on both theincidence and severity ofmedian neuropathy at the wristTheassessment was performed using both a symptom question-naire and NCS tests [24]

In the present study subjects themselves could selecttheir experimental group Therefore the enzyme therapygroup was filled earlier The study showed that workersmostly preferred medication to exercise On the other handthose who learned the recommended techniques continuedperforming them even after the study was completed as theybrought them relief

The study outcomes suggest beneficial effects of bothexercise techniques with neuromobilization and oral enzymetherapy in early CTS There were improvements in bothsymptoms and NCS test results Another benefit of thestudy is that after the initial education the subjects wereable to perform the techniques on their own which savesthe patientrsquos time as well as the physiotherapistrsquos work assessions are not required Moreover patients may exercisein accordance with their needs and possibilities We planto continue the research by extending the sample size andassessing the effect of oral enzyme therapy combined withexercise techniques

41 Limitations The study has its limitations Boston CTSquestionnaire was not applied however there is significantsimilarity with the questionnaire used in our study Relativelysmall sample size is another limitation A certain limitationof the study was the fact that two control subjects did notcompletely adhere to the study protocol and took severaldays off work on the other hand the effect of resting wasnoticeable

BioMed Research International 7

5 Conclusions

The pilot observation confirmed the efficiency of both exer-cise techniques and oral enzyme therapy on early stagesof occupational median neuropathy at the wristmdashthe CTSThese methods may be recommended for improving CTSmanifestations and preventing more severe forms of CTS

Data Availability

The data used to support the findings of this study areavailable from the corresponding author upon request

Conflicts of Interest

The authors declare that there are no conflicts of interestregarding the publication of this paper

Acknowledgments

The studywas supported by theUniversityHospital OlomoucFund [RVO 619895592 RVO 00098892] and by the projectMUCOS Pharma CZ sro [MUC-0114]

References

[1] ldquoImplementing the social security actrdquo Act No 1281975 CollFederal Ministry of Labor and Social Affairs of Czechoslovakia1975 httpswwwzakonyprolidiczcs1975-128

[2] J Jarolımek and PUrban ldquoTwenty year development of occupa-tional diseases in the czech republic Medical and geographicalaspectsrdquo Central European Journal of Public Health vol 22 no4 pp 251ndash256 2014

[3] ldquoOccupational diseases in the czech republic 2017rdquoTheNationalInstitute of Public Health 2017 httpwwwszuczuploadsNZPHlaseni NzP 2017pdf

[4] J Jarolımek P Urban P Pavlınek and D Dzurova ldquoOccu-pational diseases in the automotive industry in Czechia ndashGeographic and medical contextrdquo International Journal ofOccupational Medicine and Environmental Health vol 30 no3 pp 455ndash468 2017

[5] V Zıdkova M Nakladalova J Zapletalova Z Nakladal andH Kollarova ldquoExperiences with preventing carpal tunnelsyndrome in an automotive plantrdquo International Journal ofOccupational Medicine and Environmental Health vol 30 no1 pp 45ndash54 2017

[6] ldquoWork-related carpal tunnel syndrome diagnosis and treatmentguidelinerdquo Washington State Department of Labor andIndustries 2016 httpswwwlniwagovClaimsInsFilesOMDMedTreatCarpalTunnelpdf

[7] M Hadianfard E Bazrafshan H Momeninejad and N JahanildquoEfficacies of acupuncture and anti-inflammatory treatment forcarpal tunnel syndromerdquo Journal of Acupuncture and MeridianStudies vol 8 no 5 pp 229ndash235 2015

[8] G A Talebi P Saadat Y Javadian et al ldquoManual therapy inthe treatment of carpal tunnel syndrome in diabetic patients Arandomized clinical trialrdquoCaspian Journal of Internal Medicinevol 9 no 3 pp 283ndash289 2018

[9] T Wolny and P Linek ldquoIs manual therapy based on neurody-namic techniques effective in the treatment of carpal tunnel

syndrome A randomized controlled trialrdquo Clinical Rehabilita-tion 2018

[10] S Maddali Bongi M Signorini M Bassetti A Del Rosso MOrlandi and G De Scisciolo ldquoA manual therapy interventionimproves symptoms in patients with carpal tunnel syndrome Apilot studyrdquoRheumatology International vol 33 no 5 pp 1233ndash1241 2013

[11] L Newington E C Harris and K Walker-Bone ldquoCarpaltunnel syndrome and workrdquo Best Practice amp Research ClinicalRheumatology vol 29 no 3 pp 440ndash453 2015

[12] ldquoLaying down conditions for the classification of work into cat-egories biological exposure test limit values conditions for thetaking of biological samples for biological exposure tests anddetails to be included in the reporting of works with asbestosand biological agentsrdquo Decree No 1072013 Coll amendingDecree No 4322003 Coll Ministry of Health of the CzechRepublic 2013 httpswwwzakonyprolidiczcs2013-107

[13] ldquoBulletin of theministry of health of the czech republic 102003rdquoMinistry of Health of the Czech Republic 2003 httpwwwmzcrczLegislativadokumentyvestnik 3661 1782 11html

[14] V Maslova M Nakladalova and P Bastlova ldquoKinezioterapie usyndromu karpalnıho tunelurdquo Pracovnı Lekarstvı vol 66 no23 pp 98ndash101 2014

[15] J Leipner F Iten and R Saller ldquoTherapy with proteolyticenzymes in rheumatic disordersrdquo BioDrugs vol 15 no 12 pp779ndash789 2001

[16] ldquoSummary of product characteristicsrdquo State Institute of DrugControl 2018 httpwwwsukleumodulesmedicationsearchphp

[17] G J Macfarlane ldquoIdentification and prevention of work-relatedcarpal-tunnel syndromerdquo The Lancet vol 357 no 9263 pp1146-1147 2001

[18] S Aroori and R A Spence ldquoCarpal tunnel syndromerdquo UlsterMedical Journal vol 77 no 1 pp 6ndash17 2008

[19] A E Oskouei G A Talebi S K Shakouri and K Gha-bili ldquoEffects of neuromobilization maneuver on clinical andelectrophysiological measures of patients with carpal tunnelsyndromerdquo Journal of Physical Therapy Science vol 26 no 7pp 1017ndash1022 2014

[20] A Kwolek and J Zwolinska ldquoImmediate and long-term effectsof selected physiotherapy methods in patients with carpaltunnel syndromerdquo Ortopedia Traumatologia Rehabilitacja vol13 no 6 pp 555ndash564 2011

[21] A I De-la-Llave-Rincon R Ortega-Santiago S Ambite-Quesada et al ldquoResponse of pain intensity to soft tissue mobi-lization and neurodynamic technique A series of 18 patientswith chronic carpal tunnel syndromerdquo Journal of Manipulativeand Physiological Therapeutics vol 35 no 6 pp 420ndash427 2012

[22] M L Heebner and T S Roddey ldquoThe effects of neuralmobilization in addition to standard care in persons with carpaltunnel syndrome from a community hospitalrdquo Journal of HandTherapy vol 21 no 3 pp 229ndash241 2008

[23] A Zlamal ldquoLze zvyit efektivitu lecby profesionalnıch poruchpohyboveho aparaturdquo Pracovnı Lekarstvı vol 61 no 3 pp 113ndash116 2009

[24] M Nakladalova B Matusova P Smolkova M NakladalovaB Matusova and P Smolkova ldquoSystemova enzymoterapie jakomoznost konzervativnı lecby syndromu karpalnıho tunelundashpilotnı sledovanırdquo Pracovnı Lekarstvı vol 64 no 23 pp 99ndash102 2012

BioMed Research International 5

Table 3 Development in symptoms

extremities withsymptoms in the group(N)

medicalexamination

total score of symptoms(mean) plusmn SD ME percentile statistical

significance25 75ExerciseN=22

initial 96plusmn48 7 7 98 plt0001final 20plusmn28 0 0 5

enzyme therapyN=24

initial 115plusmn76 8 7 148 plt0001final 55plusmn65 6 0 8

controlsN=13

initial 117plusmn49 9 8 145 p=0161final 109plusmn57 10 8 135

SD standard deviation ME median

Table 4 Assessment of the development in sensory conduction of the median nerve

sensory lesions in the group (N) NCS mean SCV (ms) plusmnSD

95 confidence interval for themean significance

of the changelower limit upper limit

ExerciseN=16

initial 4714plusmn153 4632 4795 plt0001final 5311plusmn757 4907 5714

enzyme therapyN=17

initial 4532plusmn303 4376 4688 plt0001final 5475plusmn844 5041 5909

controlsN=15

initial 4570plusmn264 4424 4716 p=0660final 4638plusmn194 4531 4745

NCS nerve conduction study SCV sensory conduction velocity SD standard deviation

the enzyme therapy group Distribution of DML findings inall groups and their development is shown in Table 5 Uponcompletion of oral enzyme therapy a statistically significantimprovement inDML compared to the initial valuewas noted(p=0008) In that group improvement was achieved in 10out of 17 abnormal NCS findings of those 6 cases were inthe normal range after 9 weeks Given the small number ofabnormal NCS findings of DML in the exercise and controlgroups statistical analysis was not possible

A certain minute improvement in the mean DML SCVand total scores for symptoms was also noted in the controlgroup this may be explained by the fact that unfortunatelytwo control subjects did not adhere to the study protocol andtook several days off work during the observation period

4 Discussion

In the present study a significant positive effect of spe-cific exercise techniques and oral enzyme therapy on CTSmanifestations was achieved The effectiveness of appliedprocedures was confirmed on both symptoms and NCSparameters

CTS is a major global health burden In the literaturevarious definitions for diagnosing CTS are used these arebased on the presence of various symptoms clinical signsprovocative test results and electrodiagnostic abnormalitieswhich is associated with the absence of international stan-dards for diagnosing the condition [17] Therefore thereare considerable differences in the incidence and prevalencerates stated in the literature depending on the criteriaused [18] Thus CTS therapy is a current issue recently

it has also involved kinesiotherapy and neuromobilizationtechniques that are based on a series of both active andpassivemovements aimed at restoring normal properties of the nerve[11 14]

Oskouei et al compared the efficacy of neuromobilizationtechniques in individuals with mild to moderate CTS (20persons and 32 CTS cases) The patients were divided intotwo groups Both groups underwent standard physiotherapy(a wrist splint worn night and day electrical nerve stimu-lation and therapeutic ultrasound) Additionally one groupreceived two neuromobilizationmaneuversThe study resultsshowed that in both groups symptoms such as tinglingnumbness weakness and pain were significantly reducedThere were also improvements in the median nerve tensiontest and Phalenrsquos sign (p = 0005) However NCS andhand function test results were significantly improved in theneuromobilization group The authors therefore concludedthat neuromobilization in combination with routine phys-iotherapy improved certain clinical findings more effectivelythan routine physiotherapy alone [19] In our study the ben-efit of neuromobilization was confirmed as well Althoughthe exercise techniques differ from those in our study aneuromobilization effect on themedian nervemay be similar

Kwolek and Zwolinska reported significant improve-ments in the quality of sensation range ofmotion at the wristand handmuscle strength in 61 patients not only immediatelyafter completion of rehabilitation (therapeutic ultrasoundmassage and kinesiotherapy) but also one year later [20]

De-la-Llave-Rincon et al carried out a prospective caseseries to examine the combined effect of soft tissue mobi-lization and neurodynamicmobilization of the entire median

6 BioMed Research International

Table 5 Assessment of the development in motor conduction of the median nerve

motor lesions in the group (N) NCS Mean DML (ms) plusmnSD

95 confidence interval for themean significance of

the changelower limit upper limit

ExerciseN=5

initial 424plusmn009 413 435final 414plusmn007 406 422

enzyme therapyN=17

initial 444plusmn028 43 458 p=0008final 410plusmn041 388 433

controlsN=6

initial 445plusmn021 423 467final 422plusmn028 392 451

NCS nerve conduction study DML distal motor latency SD standard deviation

nerve in 18 women suffering from chronic CTS The assess-ments were performed at baseline immediately after theintervention and 1 week after completion of the therapy Theabove techniques decreased the intensity of pain but failed toimprove pressure pain sensitivity The intensity of pain wasnoticed also in our study as a part of the symptom scorereduction Exercise techniques in this study performed witha physiotherapist are focused also on proximal parts of themedian nerve In case of our suggested exercise techniquesthe proximal parts are slid in the third technique [21]

However the effect of neuromobilization was not alwaysobserved Heebner and Roddey studied the effect of neuro-mobilization added to standard therapy Sixty CTS patientswere assigned to two groups The first group underwentstandard therapy including patient education (discussionon the definition anatomy cause and risk factors of CTSstressing healthy lifestyle choices such as posture correctionexercises changing work ergonomics to reduce repetitiveor sustained hand strain limiting repetitive overuse stressreducing prolonged wrist flexion or extension decreasingsalt intake and not smoking) wearing neutral wrist splintsat night and performing eight tendon-gliding exercisesIn addition to that individuals in the other group wereinstructed to repeat a neuromobilization exercise ten timeson three to five occasions a day (with the exercise beingsimilar to the third technique in the present study) Theoutcomes were assessed at baseline and after one and sixmonths using the Arm Shoulder and Hand Questionnairethe Brigham and Womanrsquos Hospital Carpal Tunnel SpecificQuestionnaire (CTSQ) and elbow extension range of motionduring amedian nerve tension test No significant differencesbetween the groups were noted with the only exceptionbeing improved scores on the CTSQ function scale in thefirst group after six months However the authors admit thatchronicity of symptoms poor self-reported compliance andinadequate follow-up sessions may have adversely affectedthe study outcomes The frequency of reeducation probablydid not provide sufficient compliance compared to our higherfrequency Additionally more severe forms of CTS wereincluded in the study by Heebner and Roddey than in ourobservation [22]

Studies confirming the beneficial effects of enzyme ther-apy in musculoskeletal and extremity peripheral nerve dis-orders due to overuse are difficult to find in the literature

Specific problems related to upper extremity overuse and theresulting conditions (tendinitis tenosynovitis epicondylitisentrapment neuropathy) leading to sick leave were addressedin a retrospective study by Zlamal showing that workers withthe above-mentioned occupational exposure and conditionswhounderwent oral enzyme therapy in addition to obligatorytherapy (rest oral analgesics topical analgesic and anti-inflammatory ointments) required a significantly shortertreatment time [23]

Nakladalova et al studied the effects of enzyme therapyin female electric motor winders with CTS Oral enzymetherapy was shown to have beneficial effects on both theincidence and severity ofmedian neuropathy at the wristTheassessment was performed using both a symptom question-naire and NCS tests [24]

In the present study subjects themselves could selecttheir experimental group Therefore the enzyme therapygroup was filled earlier The study showed that workersmostly preferred medication to exercise On the other handthose who learned the recommended techniques continuedperforming them even after the study was completed as theybrought them relief

The study outcomes suggest beneficial effects of bothexercise techniques with neuromobilization and oral enzymetherapy in early CTS There were improvements in bothsymptoms and NCS test results Another benefit of thestudy is that after the initial education the subjects wereable to perform the techniques on their own which savesthe patientrsquos time as well as the physiotherapistrsquos work assessions are not required Moreover patients may exercisein accordance with their needs and possibilities We planto continue the research by extending the sample size andassessing the effect of oral enzyme therapy combined withexercise techniques

41 Limitations The study has its limitations Boston CTSquestionnaire was not applied however there is significantsimilarity with the questionnaire used in our study Relativelysmall sample size is another limitation A certain limitationof the study was the fact that two control subjects did notcompletely adhere to the study protocol and took severaldays off work on the other hand the effect of resting wasnoticeable

BioMed Research International 7

5 Conclusions

The pilot observation confirmed the efficiency of both exer-cise techniques and oral enzyme therapy on early stagesof occupational median neuropathy at the wristmdashthe CTSThese methods may be recommended for improving CTSmanifestations and preventing more severe forms of CTS

Data Availability

The data used to support the findings of this study areavailable from the corresponding author upon request

Conflicts of Interest

The authors declare that there are no conflicts of interestregarding the publication of this paper

Acknowledgments

The studywas supported by theUniversityHospital OlomoucFund [RVO 619895592 RVO 00098892] and by the projectMUCOS Pharma CZ sro [MUC-0114]

References

[1] ldquoImplementing the social security actrdquo Act No 1281975 CollFederal Ministry of Labor and Social Affairs of Czechoslovakia1975 httpswwwzakonyprolidiczcs1975-128

[2] J Jarolımek and PUrban ldquoTwenty year development of occupa-tional diseases in the czech republic Medical and geographicalaspectsrdquo Central European Journal of Public Health vol 22 no4 pp 251ndash256 2014

[3] ldquoOccupational diseases in the czech republic 2017rdquoTheNationalInstitute of Public Health 2017 httpwwwszuczuploadsNZPHlaseni NzP 2017pdf

[4] J Jarolımek P Urban P Pavlınek and D Dzurova ldquoOccu-pational diseases in the automotive industry in Czechia ndashGeographic and medical contextrdquo International Journal ofOccupational Medicine and Environmental Health vol 30 no3 pp 455ndash468 2017

[5] V Zıdkova M Nakladalova J Zapletalova Z Nakladal andH Kollarova ldquoExperiences with preventing carpal tunnelsyndrome in an automotive plantrdquo International Journal ofOccupational Medicine and Environmental Health vol 30 no1 pp 45ndash54 2017

[6] ldquoWork-related carpal tunnel syndrome diagnosis and treatmentguidelinerdquo Washington State Department of Labor andIndustries 2016 httpswwwlniwagovClaimsInsFilesOMDMedTreatCarpalTunnelpdf

[7] M Hadianfard E Bazrafshan H Momeninejad and N JahanildquoEfficacies of acupuncture and anti-inflammatory treatment forcarpal tunnel syndromerdquo Journal of Acupuncture and MeridianStudies vol 8 no 5 pp 229ndash235 2015

[8] G A Talebi P Saadat Y Javadian et al ldquoManual therapy inthe treatment of carpal tunnel syndrome in diabetic patients Arandomized clinical trialrdquoCaspian Journal of Internal Medicinevol 9 no 3 pp 283ndash289 2018

[9] T Wolny and P Linek ldquoIs manual therapy based on neurody-namic techniques effective in the treatment of carpal tunnel

syndrome A randomized controlled trialrdquo Clinical Rehabilita-tion 2018

[10] S Maddali Bongi M Signorini M Bassetti A Del Rosso MOrlandi and G De Scisciolo ldquoA manual therapy interventionimproves symptoms in patients with carpal tunnel syndrome Apilot studyrdquoRheumatology International vol 33 no 5 pp 1233ndash1241 2013

[11] L Newington E C Harris and K Walker-Bone ldquoCarpaltunnel syndrome and workrdquo Best Practice amp Research ClinicalRheumatology vol 29 no 3 pp 440ndash453 2015

[12] ldquoLaying down conditions for the classification of work into cat-egories biological exposure test limit values conditions for thetaking of biological samples for biological exposure tests anddetails to be included in the reporting of works with asbestosand biological agentsrdquo Decree No 1072013 Coll amendingDecree No 4322003 Coll Ministry of Health of the CzechRepublic 2013 httpswwwzakonyprolidiczcs2013-107

[13] ldquoBulletin of theministry of health of the czech republic 102003rdquoMinistry of Health of the Czech Republic 2003 httpwwwmzcrczLegislativadokumentyvestnik 3661 1782 11html

[14] V Maslova M Nakladalova and P Bastlova ldquoKinezioterapie usyndromu karpalnıho tunelurdquo Pracovnı Lekarstvı vol 66 no23 pp 98ndash101 2014

[15] J Leipner F Iten and R Saller ldquoTherapy with proteolyticenzymes in rheumatic disordersrdquo BioDrugs vol 15 no 12 pp779ndash789 2001

[16] ldquoSummary of product characteristicsrdquo State Institute of DrugControl 2018 httpwwwsukleumodulesmedicationsearchphp

[17] G J Macfarlane ldquoIdentification and prevention of work-relatedcarpal-tunnel syndromerdquo The Lancet vol 357 no 9263 pp1146-1147 2001

[18] S Aroori and R A Spence ldquoCarpal tunnel syndromerdquo UlsterMedical Journal vol 77 no 1 pp 6ndash17 2008

[19] A E Oskouei G A Talebi S K Shakouri and K Gha-bili ldquoEffects of neuromobilization maneuver on clinical andelectrophysiological measures of patients with carpal tunnelsyndromerdquo Journal of Physical Therapy Science vol 26 no 7pp 1017ndash1022 2014

[20] A Kwolek and J Zwolinska ldquoImmediate and long-term effectsof selected physiotherapy methods in patients with carpaltunnel syndromerdquo Ortopedia Traumatologia Rehabilitacja vol13 no 6 pp 555ndash564 2011

[21] A I De-la-Llave-Rincon R Ortega-Santiago S Ambite-Quesada et al ldquoResponse of pain intensity to soft tissue mobi-lization and neurodynamic technique A series of 18 patientswith chronic carpal tunnel syndromerdquo Journal of Manipulativeand Physiological Therapeutics vol 35 no 6 pp 420ndash427 2012

[22] M L Heebner and T S Roddey ldquoThe effects of neuralmobilization in addition to standard care in persons with carpaltunnel syndrome from a community hospitalrdquo Journal of HandTherapy vol 21 no 3 pp 229ndash241 2008

[23] A Zlamal ldquoLze zvyit efektivitu lecby profesionalnıch poruchpohyboveho aparaturdquo Pracovnı Lekarstvı vol 61 no 3 pp 113ndash116 2009

[24] M Nakladalova B Matusova P Smolkova M NakladalovaB Matusova and P Smolkova ldquoSystemova enzymoterapie jakomoznost konzervativnı lecby syndromu karpalnıho tunelundashpilotnı sledovanırdquo Pracovnı Lekarstvı vol 64 no 23 pp 99ndash102 2012

6 BioMed Research International

Table 5 Assessment of the development in motor conduction of the median nerve

motor lesions in the group (N) NCS Mean DML (ms) plusmnSD

95 confidence interval for themean significance of

the changelower limit upper limit

ExerciseN=5

initial 424plusmn009 413 435final 414plusmn007 406 422

enzyme therapyN=17

initial 444plusmn028 43 458 p=0008final 410plusmn041 388 433

controlsN=6

initial 445plusmn021 423 467final 422plusmn028 392 451

NCS nerve conduction study DML distal motor latency SD standard deviation

nerve in 18 women suffering from chronic CTS The assess-ments were performed at baseline immediately after theintervention and 1 week after completion of the therapy Theabove techniques decreased the intensity of pain but failed toimprove pressure pain sensitivity The intensity of pain wasnoticed also in our study as a part of the symptom scorereduction Exercise techniques in this study performed witha physiotherapist are focused also on proximal parts of themedian nerve In case of our suggested exercise techniquesthe proximal parts are slid in the third technique [21]

However the effect of neuromobilization was not alwaysobserved Heebner and Roddey studied the effect of neuro-mobilization added to standard therapy Sixty CTS patientswere assigned to two groups The first group underwentstandard therapy including patient education (discussionon the definition anatomy cause and risk factors of CTSstressing healthy lifestyle choices such as posture correctionexercises changing work ergonomics to reduce repetitiveor sustained hand strain limiting repetitive overuse stressreducing prolonged wrist flexion or extension decreasingsalt intake and not smoking) wearing neutral wrist splintsat night and performing eight tendon-gliding exercisesIn addition to that individuals in the other group wereinstructed to repeat a neuromobilization exercise ten timeson three to five occasions a day (with the exercise beingsimilar to the third technique in the present study) Theoutcomes were assessed at baseline and after one and sixmonths using the Arm Shoulder and Hand Questionnairethe Brigham and Womanrsquos Hospital Carpal Tunnel SpecificQuestionnaire (CTSQ) and elbow extension range of motionduring amedian nerve tension test No significant differencesbetween the groups were noted with the only exceptionbeing improved scores on the CTSQ function scale in thefirst group after six months However the authors admit thatchronicity of symptoms poor self-reported compliance andinadequate follow-up sessions may have adversely affectedthe study outcomes The frequency of reeducation probablydid not provide sufficient compliance compared to our higherfrequency Additionally more severe forms of CTS wereincluded in the study by Heebner and Roddey than in ourobservation [22]

Studies confirming the beneficial effects of enzyme ther-apy in musculoskeletal and extremity peripheral nerve dis-orders due to overuse are difficult to find in the literature

Specific problems related to upper extremity overuse and theresulting conditions (tendinitis tenosynovitis epicondylitisentrapment neuropathy) leading to sick leave were addressedin a retrospective study by Zlamal showing that workers withthe above-mentioned occupational exposure and conditionswhounderwent oral enzyme therapy in addition to obligatorytherapy (rest oral analgesics topical analgesic and anti-inflammatory ointments) required a significantly shortertreatment time [23]

Nakladalova et al studied the effects of enzyme therapyin female electric motor winders with CTS Oral enzymetherapy was shown to have beneficial effects on both theincidence and severity ofmedian neuropathy at the wristTheassessment was performed using both a symptom question-naire and NCS tests [24]

In the present study subjects themselves could selecttheir experimental group Therefore the enzyme therapygroup was filled earlier The study showed that workersmostly preferred medication to exercise On the other handthose who learned the recommended techniques continuedperforming them even after the study was completed as theybrought them relief

The study outcomes suggest beneficial effects of bothexercise techniques with neuromobilization and oral enzymetherapy in early CTS There were improvements in bothsymptoms and NCS test results Another benefit of thestudy is that after the initial education the subjects wereable to perform the techniques on their own which savesthe patientrsquos time as well as the physiotherapistrsquos work assessions are not required Moreover patients may exercisein accordance with their needs and possibilities We planto continue the research by extending the sample size andassessing the effect of oral enzyme therapy combined withexercise techniques

41 Limitations The study has its limitations Boston CTSquestionnaire was not applied however there is significantsimilarity with the questionnaire used in our study Relativelysmall sample size is another limitation A certain limitationof the study was the fact that two control subjects did notcompletely adhere to the study protocol and took severaldays off work on the other hand the effect of resting wasnoticeable

BioMed Research International 7

5 Conclusions

The pilot observation confirmed the efficiency of both exer-cise techniques and oral enzyme therapy on early stagesof occupational median neuropathy at the wristmdashthe CTSThese methods may be recommended for improving CTSmanifestations and preventing more severe forms of CTS

Data Availability

The data used to support the findings of this study areavailable from the corresponding author upon request

Conflicts of Interest

The authors declare that there are no conflicts of interestregarding the publication of this paper

Acknowledgments

The studywas supported by theUniversityHospital OlomoucFund [RVO 619895592 RVO 00098892] and by the projectMUCOS Pharma CZ sro [MUC-0114]

References

[1] ldquoImplementing the social security actrdquo Act No 1281975 CollFederal Ministry of Labor and Social Affairs of Czechoslovakia1975 httpswwwzakonyprolidiczcs1975-128

[2] J Jarolımek and PUrban ldquoTwenty year development of occupa-tional diseases in the czech republic Medical and geographicalaspectsrdquo Central European Journal of Public Health vol 22 no4 pp 251ndash256 2014

[3] ldquoOccupational diseases in the czech republic 2017rdquoTheNationalInstitute of Public Health 2017 httpwwwszuczuploadsNZPHlaseni NzP 2017pdf

[4] J Jarolımek P Urban P Pavlınek and D Dzurova ldquoOccu-pational diseases in the automotive industry in Czechia ndashGeographic and medical contextrdquo International Journal ofOccupational Medicine and Environmental Health vol 30 no3 pp 455ndash468 2017

[5] V Zıdkova M Nakladalova J Zapletalova Z Nakladal andH Kollarova ldquoExperiences with preventing carpal tunnelsyndrome in an automotive plantrdquo International Journal ofOccupational Medicine and Environmental Health vol 30 no1 pp 45ndash54 2017

[6] ldquoWork-related carpal tunnel syndrome diagnosis and treatmentguidelinerdquo Washington State Department of Labor andIndustries 2016 httpswwwlniwagovClaimsInsFilesOMDMedTreatCarpalTunnelpdf

[7] M Hadianfard E Bazrafshan H Momeninejad and N JahanildquoEfficacies of acupuncture and anti-inflammatory treatment forcarpal tunnel syndromerdquo Journal of Acupuncture and MeridianStudies vol 8 no 5 pp 229ndash235 2015

[8] G A Talebi P Saadat Y Javadian et al ldquoManual therapy inthe treatment of carpal tunnel syndrome in diabetic patients Arandomized clinical trialrdquoCaspian Journal of Internal Medicinevol 9 no 3 pp 283ndash289 2018

[9] T Wolny and P Linek ldquoIs manual therapy based on neurody-namic techniques effective in the treatment of carpal tunnel

syndrome A randomized controlled trialrdquo Clinical Rehabilita-tion 2018

[10] S Maddali Bongi M Signorini M Bassetti A Del Rosso MOrlandi and G De Scisciolo ldquoA manual therapy interventionimproves symptoms in patients with carpal tunnel syndrome Apilot studyrdquoRheumatology International vol 33 no 5 pp 1233ndash1241 2013

[11] L Newington E C Harris and K Walker-Bone ldquoCarpaltunnel syndrome and workrdquo Best Practice amp Research ClinicalRheumatology vol 29 no 3 pp 440ndash453 2015

[12] ldquoLaying down conditions for the classification of work into cat-egories biological exposure test limit values conditions for thetaking of biological samples for biological exposure tests anddetails to be included in the reporting of works with asbestosand biological agentsrdquo Decree No 1072013 Coll amendingDecree No 4322003 Coll Ministry of Health of the CzechRepublic 2013 httpswwwzakonyprolidiczcs2013-107

[13] ldquoBulletin of theministry of health of the czech republic 102003rdquoMinistry of Health of the Czech Republic 2003 httpwwwmzcrczLegislativadokumentyvestnik 3661 1782 11html

[14] V Maslova M Nakladalova and P Bastlova ldquoKinezioterapie usyndromu karpalnıho tunelurdquo Pracovnı Lekarstvı vol 66 no23 pp 98ndash101 2014

[15] J Leipner F Iten and R Saller ldquoTherapy with proteolyticenzymes in rheumatic disordersrdquo BioDrugs vol 15 no 12 pp779ndash789 2001

[16] ldquoSummary of product characteristicsrdquo State Institute of DrugControl 2018 httpwwwsukleumodulesmedicationsearchphp

[17] G J Macfarlane ldquoIdentification and prevention of work-relatedcarpal-tunnel syndromerdquo The Lancet vol 357 no 9263 pp1146-1147 2001

[18] S Aroori and R A Spence ldquoCarpal tunnel syndromerdquo UlsterMedical Journal vol 77 no 1 pp 6ndash17 2008

[19] A E Oskouei G A Talebi S K Shakouri and K Gha-bili ldquoEffects of neuromobilization maneuver on clinical andelectrophysiological measures of patients with carpal tunnelsyndromerdquo Journal of Physical Therapy Science vol 26 no 7pp 1017ndash1022 2014

[20] A Kwolek and J Zwolinska ldquoImmediate and long-term effectsof selected physiotherapy methods in patients with carpaltunnel syndromerdquo Ortopedia Traumatologia Rehabilitacja vol13 no 6 pp 555ndash564 2011

[21] A I De-la-Llave-Rincon R Ortega-Santiago S Ambite-Quesada et al ldquoResponse of pain intensity to soft tissue mobi-lization and neurodynamic technique A series of 18 patientswith chronic carpal tunnel syndromerdquo Journal of Manipulativeand Physiological Therapeutics vol 35 no 6 pp 420ndash427 2012

[22] M L Heebner and T S Roddey ldquoThe effects of neuralmobilization in addition to standard care in persons with carpaltunnel syndrome from a community hospitalrdquo Journal of HandTherapy vol 21 no 3 pp 229ndash241 2008

[23] A Zlamal ldquoLze zvyit efektivitu lecby profesionalnıch poruchpohyboveho aparaturdquo Pracovnı Lekarstvı vol 61 no 3 pp 113ndash116 2009

[24] M Nakladalova B Matusova P Smolkova M NakladalovaB Matusova and P Smolkova ldquoSystemova enzymoterapie jakomoznost konzervativnı lecby syndromu karpalnıho tunelundashpilotnı sledovanırdquo Pracovnı Lekarstvı vol 64 no 23 pp 99ndash102 2012

BioMed Research International 7

5 Conclusions

The pilot observation confirmed the efficiency of both exer-cise techniques and oral enzyme therapy on early stagesof occupational median neuropathy at the wristmdashthe CTSThese methods may be recommended for improving CTSmanifestations and preventing more severe forms of CTS

Data Availability

The data used to support the findings of this study areavailable from the corresponding author upon request

Conflicts of Interest

The authors declare that there are no conflicts of interestregarding the publication of this paper

Acknowledgments

The studywas supported by theUniversityHospital OlomoucFund [RVO 619895592 RVO 00098892] and by the projectMUCOS Pharma CZ sro [MUC-0114]

References

[1] ldquoImplementing the social security actrdquo Act No 1281975 CollFederal Ministry of Labor and Social Affairs of Czechoslovakia1975 httpswwwzakonyprolidiczcs1975-128

[2] J Jarolımek and PUrban ldquoTwenty year development of occupa-tional diseases in the czech republic Medical and geographicalaspectsrdquo Central European Journal of Public Health vol 22 no4 pp 251ndash256 2014

[3] ldquoOccupational diseases in the czech republic 2017rdquoTheNationalInstitute of Public Health 2017 httpwwwszuczuploadsNZPHlaseni NzP 2017pdf

[4] J Jarolımek P Urban P Pavlınek and D Dzurova ldquoOccu-pational diseases in the automotive industry in Czechia ndashGeographic and medical contextrdquo International Journal ofOccupational Medicine and Environmental Health vol 30 no3 pp 455ndash468 2017

[5] V Zıdkova M Nakladalova J Zapletalova Z Nakladal andH Kollarova ldquoExperiences with preventing carpal tunnelsyndrome in an automotive plantrdquo International Journal ofOccupational Medicine and Environmental Health vol 30 no1 pp 45ndash54 2017

[6] ldquoWork-related carpal tunnel syndrome diagnosis and treatmentguidelinerdquo Washington State Department of Labor andIndustries 2016 httpswwwlniwagovClaimsInsFilesOMDMedTreatCarpalTunnelpdf

[7] M Hadianfard E Bazrafshan H Momeninejad and N JahanildquoEfficacies of acupuncture and anti-inflammatory treatment forcarpal tunnel syndromerdquo Journal of Acupuncture and MeridianStudies vol 8 no 5 pp 229ndash235 2015

[8] G A Talebi P Saadat Y Javadian et al ldquoManual therapy inthe treatment of carpal tunnel syndrome in diabetic patients Arandomized clinical trialrdquoCaspian Journal of Internal Medicinevol 9 no 3 pp 283ndash289 2018

[9] T Wolny and P Linek ldquoIs manual therapy based on neurody-namic techniques effective in the treatment of carpal tunnel

syndrome A randomized controlled trialrdquo Clinical Rehabilita-tion 2018

[10] S Maddali Bongi M Signorini M Bassetti A Del Rosso MOrlandi and G De Scisciolo ldquoA manual therapy interventionimproves symptoms in patients with carpal tunnel syndrome Apilot studyrdquoRheumatology International vol 33 no 5 pp 1233ndash1241 2013

[11] L Newington E C Harris and K Walker-Bone ldquoCarpaltunnel syndrome and workrdquo Best Practice amp Research ClinicalRheumatology vol 29 no 3 pp 440ndash453 2015

[12] ldquoLaying down conditions for the classification of work into cat-egories biological exposure test limit values conditions for thetaking of biological samples for biological exposure tests anddetails to be included in the reporting of works with asbestosand biological agentsrdquo Decree No 1072013 Coll amendingDecree No 4322003 Coll Ministry of Health of the CzechRepublic 2013 httpswwwzakonyprolidiczcs2013-107

[13] ldquoBulletin of theministry of health of the czech republic 102003rdquoMinistry of Health of the Czech Republic 2003 httpwwwmzcrczLegislativadokumentyvestnik 3661 1782 11html

[14] V Maslova M Nakladalova and P Bastlova ldquoKinezioterapie usyndromu karpalnıho tunelurdquo Pracovnı Lekarstvı vol 66 no23 pp 98ndash101 2014

[15] J Leipner F Iten and R Saller ldquoTherapy with proteolyticenzymes in rheumatic disordersrdquo BioDrugs vol 15 no 12 pp779ndash789 2001

[16] ldquoSummary of product characteristicsrdquo State Institute of DrugControl 2018 httpwwwsukleumodulesmedicationsearchphp

[17] G J Macfarlane ldquoIdentification and prevention of work-relatedcarpal-tunnel syndromerdquo The Lancet vol 357 no 9263 pp1146-1147 2001

[18] S Aroori and R A Spence ldquoCarpal tunnel syndromerdquo UlsterMedical Journal vol 77 no 1 pp 6ndash17 2008

[19] A E Oskouei G A Talebi S K Shakouri and K Gha-bili ldquoEffects of neuromobilization maneuver on clinical andelectrophysiological measures of patients with carpal tunnelsyndromerdquo Journal of Physical Therapy Science vol 26 no 7pp 1017ndash1022 2014

[20] A Kwolek and J Zwolinska ldquoImmediate and long-term effectsof selected physiotherapy methods in patients with carpaltunnel syndromerdquo Ortopedia Traumatologia Rehabilitacja vol13 no 6 pp 555ndash564 2011

[21] A I De-la-Llave-Rincon R Ortega-Santiago S Ambite-Quesada et al ldquoResponse of pain intensity to soft tissue mobi-lization and neurodynamic technique A series of 18 patientswith chronic carpal tunnel syndromerdquo Journal of Manipulativeand Physiological Therapeutics vol 35 no 6 pp 420ndash427 2012

[22] M L Heebner and T S Roddey ldquoThe effects of neuralmobilization in addition to standard care in persons with carpaltunnel syndrome from a community hospitalrdquo Journal of HandTherapy vol 21 no 3 pp 229ndash241 2008

[23] A Zlamal ldquoLze zvyit efektivitu lecby profesionalnıch poruchpohyboveho aparaturdquo Pracovnı Lekarstvı vol 61 no 3 pp 113ndash116 2009

[24] M Nakladalova B Matusova P Smolkova M NakladalovaB Matusova and P Smolkova ldquoSystemova enzymoterapie jakomoznost konzervativnı lecby syndromu karpalnıho tunelundashpilotnı sledovanırdquo Pracovnı Lekarstvı vol 64 no 23 pp 99ndash102 2012

Stem Cells International

Hindawiwwwhindawicom Volume 2018

Hindawiwwwhindawicom Volume 2018

MEDIATORSINFLAMMATION

of

EndocrinologyInternational Journal of

Hindawiwwwhindawicom Volume 2018

Hindawiwwwhindawicom Volume 2018

Disease Markers

Hindawiwwwhindawicom Volume 2018

BioMed Research International

OncologyJournal of

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Oxidative Medicine and Cellular Longevity

Hindawiwwwhindawicom Volume 2018

PPAR Research

Hindawi Publishing Corporation httpwwwhindawicom Volume 2013Hindawiwwwhindawicom

The Scientific World Journal

Volume 2018

Immunology ResearchHindawiwwwhindawicom Volume 2018

Journal of

ObesityJournal of

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Hindawiwwwhindawicom Volume 2018

Computational and Mathematical Methods in Medicine

Hindawiwwwhindawicom Volume 2018

Behavioural Neurology

OphthalmologyJournal of

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Diabetes ResearchJournal of

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Research and TreatmentAIDS

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Gastroenterology Research and Practice

Hindawiwwwhindawicom Volume 2018

Parkinsonrsquos Disease

Evidence-Based Complementary andAlternative Medicine

Volume 2018Hindawiwwwhindawicom

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