Effectiveness of OMT for Carpal Tunnel Syndrome.

356 the opponens roll maneuver and “highamplitude springing” of the carpal bones. It is essential to apply vigorous manipulative release of the TCL at the distal carpal bone level (trapezium-hamate), and the results can be documented by palpatory assessment after treatment, as noted by my 1994 study4 when using a Likert-type rating scale of 0 to 5 (0=no restriction, 5=extremely marked restriction), with the critical level of restriction graded at 2/5. It was instructive that patients improved when the restriction decreased below a 2/5 level— once this threshold was reached, it could be used to motivate patients to continue treatment.4 Burnham et al1 did reassess patients with “tissue texture changes” and “restored range of motion,” but these measures are less specific than a quantitative determination of palpatory restriction. In addition, my 2005 study2 clarified that the optimal approach to managing carpal tunnel syndrome is to combine manipulation with self-stretching. I objectively documented that the maximum TCL lengthening occurred when stretching followed manipulative “priming” of the TCL.2 This laboratory finding mimics the optimal clinical situation where the patient obtains manipulation from the physician in the office and is provided stretching instruction to perform independently.2 Stretching exercise complements the manipulation, “building on the manipulative efforts” by making the TCL more responsive to the subsequent stretching, but the patients must be instructed in precise techniques to be performed several times daily.2,3 I agree with the authors1 when they acknowledge that objective measures taken after the final manipulation may have been too early to determine maximum changes in the electrophysiology and morphology of the median nerves,1 because such changes often lag several weeks behind clinical improvement.4 This limitation of the study’s conclusions is clinically significant, and I believe the authors should have repeated measurements 4 to 6 weeks after the final OMT session. (doi:10.7556/jaoa.2015.073)