our hands have a variety of functions , including activities of daily living and job 
 performance1 ; these functions can be 
 restricted by carpal tunnel syndrome ( cts ) , a compressive neuropathy of the median nerve 
 that occurs within the carpal tunnel at the wrist2,3,4,5 .
the 
 most common symptoms are pain and paresthesia of the fingers , which occur secondary to 
 impairment of median nerve functions ; cts can have a negative effect on a client s quality 
 of life7 .
conservative treatment options 
 include splinting , specific exercises , paraffin therapy , medications , and therapeutic 
 ultrasound .
of these conservative treatments , tendon and nerve gliding exercises are 
 popular , and have been used since 1990 in the management of cts5,6,7,8,9,10,11,12,13,14 . however , while evidence 
 for the efficacy of tendon and nerve gliding exercises for cts is emerging , the use of these 
 exercises for the treatment of cts remains controversial7 , 10 , 15 .
it has been stated previously that support for the use of tendon 
 and nerve gliding exercises in the treatment of cts will require high - quality studies with 
 rigorous methodological approaches7,8,9 , 12 , 16 .
therefore , the aim of this review was to assess the quality of 
 evidence for the efficacy of tendon and nerve gliding exercises in the management of 
 cts .
this review was planned and conducted in accordance with preferred reporting items for 
 systematic reviews and meta - analyses ( prisma ) guidelines16 and consolidated standards of reporting trials ( consort ) guidelines 
 for reporting parallel group randomized trials17 .
four electronic databases ( cumulative index to nursing and allied 
 health literature ( cinahl ) , the cochrane library , embase , and pubmed ) were searched to 
 identify randomized controlled trials ( rcts ) published in the period between 1963 and 
 january 2015 .
the search terms were carpal tunnel syndrome and tendon and nerve gliding 
 exercises or tendon gliding exercises or nerve gliding exercises .
all potentially eligible 
 studies were retrieved , and the full - text articles were reviewed to determine whether they 
 met the following selection criteria . to be eligible for inclusion , studies had to meet the following conditions : 1 ) participants 
 in the trials had to be diagnosed with cts .
2 ) the studies had to be rcts that used tendon 
 and nerve gliding exercises as an intervention to reduce symptoms associated with cts 
 compared with no tendon and nerve gliding exercises .
quality assessment of included articles was 
 conducted using a critical appraisal tool ( the cochrane collaboration s risk of bias tool ) , 
 as recommended in the cochrane handbook for systematic reviews of interventions18 .
the cochrane risk of bias tool is a 
 6-item list designed to assess sequence generation , allocation concealment , blinding , 
 incomplete outcome data , selective outcome reporting , and other potential sources of bias . 

each item was rated as  yes  ,  no  , or  unclear  . according to the cochrane handbook , there 
 are 3 levels of evidence : a , b , and c. the level assigned to a study gives an indication of 
 the quality of the trial19 . if the study 
 design fully met all of the preceding 6 criteria , its level was considered to be a ( low risk 
 of bias ) .
a study was assigned to be the b level when one or more criteria were partly met . 

if one or more criteria were not met , the study was assigned to be the c level , implying a 
 high risk of bias19 .
a total of 164 articles related to the search terms were screened . among them , potentially 
 relevant trials were identified in the chinal ( n=7 ) , cochrane library ( n=14 ) , embase ( n=25 ) , 
 and pubmed ( n=21 ) databases . after the titles of the articles were retrieved , a total of 48 
 studies were excluded due to retrieval of duplicate articles , study designs other than rcts 
 ( case studies , commentaries , or review articles ) , or a lack of target concepts in the 
 article ( i.e. , no cts ) .
after 
 assessing the abstracts , 4 studies were excluded on the basis of an absence of tendon and 
 nerve gliding exercises ; thus , a total of 15 potentially relevant trials were identified in 
 the search ; all 15 articles were retrieved for evaluation of their full texts .
after 
 assessment of the full articles , 11 studies were excluded ; 8 studies did not involve a 
 randomized trial , and 3 studies did not contain the full texts of the rcts .
characteristics of the included studies are presented in table 1table 1.characteristics of the included randomized controlled trialsauthor ( years ) , countryparticipants sample size ( n ) gender ( m / f ) mean age 
 ( range ) drop out n ( % ) interventionsoutcome measuresmain resultsadverse effectslimitationsrisk of biashorng et al.(2011 ) , taiwan53 ( 18/19/16)3/5050.5 ( -)7 ( 13.2)group 1 paraffin therapy , splint , tendon gliding 
 exercise ( 2 months)group 2 paraffin therapy , splint , nerve gliding exercise ( 2 
 months)group 3 paraffin therapy , splint ( 2 months ) 1 ) sss2 ) fss3 ) pain intensity4 ) dash5 ) 
 whoqol - bref1 ) improved in all groups2 ) improved in group 13 ) 
 improved in all groups4 ) improved in group 15 ) improved physical area in group 1 none- lack of generality ; no severity participants- 
 confounding factor- drop out- many different clinical testlowbardak et al.(2009 ) , turkey111 ( 41/35/35)10/10149.1 ( 2274)group 1 sct ( 11 months)group 2 sct , tendon and nerve 
 gliding exercises ( 11 months)group 3 tendon and nerve gliding exercises ( 11 
 months)1 ) sss2 ) fss3 ) physical examination  ( 1 ) phalen s 
 test  ( 2 ) tinel s test  ( 3 ) reverse tinel s test  ( 4 ) compression test1 ) improved in all groups2 ) improved in all groups3 ) 
 percentages of asymptomaticpatients in group 1 and 2 were higher than in group 
 snone- lack of electrophysiological assessment during the 
 posttreatment periodlowbrininger et al.(2007 ) , usa61 ( 13/14/13/11)3/5850.0 ( 2186)10 ( 16.3)group 1 nw / mcp splints ( 8 weeks)group 2 nw / mcp 
 splints , tendon and nerve gliding exercises ( 8 weeks)group 3 wcu splints ( 4 
 weeks)group 4 wcu splints , tendon and nerve gliding exercises ( 4 weeks)1 ) sss2 ) fss1 ) splint and time on the sss ( p<0.001)2 ) splint 
 and time on the fss ( p<0.001)none- halo effect- subjective outcome measures- 
 short - term follow - upmoderateakalin et al.(2002 ) , turkey36 ( 18/18)2/3451.9 ( 3864)group 1 neutral volar wrist splint ( 4 weeks)group 2 
 neutral volar wrist splint , tendon and nerve gliding exercises ( 4 weeks)1 ) sss2 ) fssthe differences between the 2 groups were not 
 statistically significant.none- small number of subjects- did not evaluate efficacy 
 of the treatmentlowm : male ; f : female ; n : number ; sct : standard conservative treatment ; nw : neutral 
 wrist ; wcu : wrist cock - up ; mcp : metacarpophalangeal ; sss : symptom severity scale ; fss : 
 functional status scale ; dash : disability of the arm , shoulder , and hand 
 questionnaire ; whoqol - bref : world health organization quality of life 
 questionnaire .
flowchart for the included studies from the literature searches m : male ; f : female ; n : number ; sct : standard conservative treatment ; nw : neutral 
 wrist ; wcu : wrist cock - up ; mcp : metacarpophalangeal ; sss : symptom severity scale ; fss : 
 functional status scale ; dash : disability of the arm , shoulder , and hand 
 questionnaire ; whoqol - bref : world health organization quality of life 
 questionnaire with regards to country of origin , 2 rcts were conducted in turkey6 , 11 , 1 was conducted 
 in the usa8 , and 1 was conducted in 
 taiwan7 .
studies were conducted at the 
 following centers : the university of pittsburgh medical center s orthopedic outpatient hand 
 clinic , the department of physical medicine and rehabilitation of a community hospital , the 
 outpatient clinic at the istanbul physical medicine and rehabilitation training and research 
 hospital , and the department of physical medicine and rehabilitation and the department of 
 neurology of dokuz eyll university .
sample sizes in the 4 studies ranged from 36 to 111 
 participants and totaled 261 participants overall , with 243 being female and 18 being male . 
 the mean age of participants reported in the different studies ranged from 49.151.9  years . 

types of intervention were 
 heterogeneous among the studies : 1 rct used paraffin therapy plus splints plus tendon 
 gliding exercises in group 1 , paraffin therapy plus splints plus nerve gliding exercises in 
 group 2 , and paraffin therapy plus splints in group 3 ; another rct used standard 
 conservative treatment ( sct ) in group 1 , sct plus tendon and nerve gliding exercises in 
 group 2 , and tendon and nerve gliding exercises in group 3 ; another rct used neutral 
 wrist / metacarpophalangeal ( nw / mcp ) splints in group 1 , nw / mcp splints plus tendon and nerve 
 gliding exercises in group 2 , wrist cock - up ( wcu ) splints in group 3 , and wcu splints plus 
 tendon and nerve gliding exercises in group 4 ; and the remaining rct used neutral volar 
 wrist splints in group 1 and neutral volar wrist splints plus tendon gliding exercises in 
 group 2 .
interventions 
 were performed under the guidance of physiotherapists , and a brochure describing the tendon 
 and nerve exercises was provided to all patients .
symptom severity and functional statuses were improved in groups that 
 received combined treatment with tendon and nerve gliding exercises and conventional 
 treatments compared with the groups that received conventional treatments alone .
no study 
 reports included data relating to adverse effects of treatment ( table 1 ) .
the purpose of this review was to assess the evidence for the efficacy of tendon and nerve 
 gliding exercises for cts when compared with other treatments .
a meta - analysis combining the 
 results from all the trials was not feasible due to the heterogeneity of the identified 
 studies .
the interventions in 
 all studies included tendon and nerve gliding exercises to manage cts .
all 4 trials reported a significant improvement in cts - related symptom severity and 
 functional status in all groups .
however , the efficacy of the tendon and nerve gliding 
 exercises alone could not be identified because the 4 trials involved different combinations 
 of tendon and nerve gliding exercises with standard conservative treatments that included 
 splints , paraffin therapy , and other exercises .
additional rcts are required to provide 
 evidence for the efficacy of tendon and nerve gliding exercises alone as a management option 
 for cts .
the quality ratings of the trials included in this review indicated low or moderate risks 
 of bias .
overall , 
 no strong conclusions can be made due to the small number of included trials and other 
 methodological considerations .
the use of rigorous methodological criteria is a strength of this systematic review . among 
 the included studies major strengths included the use of randomization , and the quality of 
 the measurement tools utilized .
there are no reported adverse effects associated with the 
 use of tendon and nerve gliding exercises in the treatment of cts
firstly , the generalizability of 
 results is limited because most of the participants had mild or moderate symptoms . 

therefore , caution should be exercised when attempting to apply these findings to patients 
 with more severe symptoms .
secondly , there were issues with blinding ; the persons who 
 administered the treatment and evaluated outcomes were not blinded to the subjects group 
 assignments . for strict and rigorous methodological research , blinding is necessary because 
 it may reduce the risk of ascertainment bias .
of the 4 rcts included in this review , two 
 articles involved single blinding , and none of the rcts included in this review involved 
 double blinding .
however , blinding is not easy to implement with interventions such as 
 physical exercises ; therefore post hoc research should be processed with strict blinding . 
 finally , none of the rcts used tendon and nerve gliding exercises alone as a treatment for 
 cts .
this may have led to difficulties in interpretation and identification of the efficacy 
 of the tendon and nerve gliding exercises in the management of cts .
all 4 rcts combined 
 tendon and nerve gliding exercises with standard conservative treatments . in conclusion , although this review included only a limited number of small trials , it had 
 several strengths , such as the inclusion of only rcts and the use of outcome measures that 
 are reliable , valid , and commonly used in clinics .
however further rigorous methodological 
 and high - quality rcts are needed to confirm and further understand the efficacy of 
 standardized tendon and nerve gliding exercises as an intervention to control symptom 
 severity and improve functional status in cts .
future studies need to take into 
 consideration the value of larger sample sizes and ensure a more strenuous and rigorous 
 adherence to the exercise protocols .
 [ purpose ] the purpose of this study was to assess the quality of evidence for the 
 efficacy of tendon and nerve gliding exercises in the management of carpal tunnel 
 syndrome . 
 [ subjects and methods ] four electronic databases were searched to identify 
 randomized controlled trials on the efficacy of tendon and nerve gliding exercises for 
 carpal tunnel syndrome . 
 quality assessment was conducted using the cochrane risk of bias 
 tool . 
 [ results ] four trials were identified and included in the review . 
 the results of 
 critical appraisal of quality ranged between low and moderate risk of bias . 
 the available 
 data could only be included as a narrative description . 
 symptom severity decreased and 
 functional status improved with combined treatment , involving a tendon or nerve gliding 
 exercise group plus conventional treatments , compared with the use of conventional 
 treatments alone . 
 [ conclusion ] evidence from 4 randomized controlled trials suggests that 
 tendon and nerve gliding exercises , when combined with conventional treatments , may have a 
 favorable effect in patients with carpal tunnel syndrome 
 . however , further randomized 
 controlled trials designed to assess the effect of tendon and nerve gliding exercises 
 alone are required to investigate the hypothesis that such exercises alleviate carpal 
 tunnel syndrome , and to confirm and further elucidate the efficacy of standardized 
 physical exercise programs in patients with carpal tunnel syndrome . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION