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THE EFFECTS OF TRANSCUTANEOUS AURICULAR VAGUS NERVE STIMULATION ON NERVE CONDUCTION VELOCITY, GRIP STRENGTH, PAIN, AND UPPER EXTREMITY FUNCTIONALITY IN INDIVIDUALS WITH CARPAL TUNNEL SYNDROME

Year 2024, Volume: 35 Issue: 1, 123 - 130, 20.04.2024
https://doi.org/10.21653/tjpr.1324406

Abstract

Purpose: This study aims to investigate the effects of transcutaneous auricular vagus nerve stimulation (taVNS) on key parameters, including nerve conduction velocity, grip strength, pain, and upper extremity functionality in individuals with carpal tunnel syndrome (CTS).
Methods: The study involved 51 patients (90 hands) diagnosed with carpal tunnel syndrome, comprising 12 males and 39 females, ranging in age from 18 to 58 years. Participants were divided into groups by random randomization method. Sensory branch conduction velocity of the median nerve was assessed via electromyography (EMG), hand grip strength was measured using a digital dynamometer, and pain intensity was quantified with a visual analog scale (VAS); additionally, upper extremity functionality was evaluated using the Upper Extremity Functional Index (UEFI) scale before and after the treatment. In the experimental group, in addition to the conventional physiotherapy program, 10 sessions of auricular vagus nerve stimulation were administered; for the sham and control groups, the conventional physiotherapy program alone was conducted over the course of 10 sessions.
Results: The analysis revealed no statistically significant differences between the groups concerning variables such as body mass index (BMI), age, gender, educational background, and smoking status (p>0.05). However, within-group evaluations exhibited significant differences compared to baseline values in terms of nerve conduction velocity, pain perception, and upper extremity functionality, with no such difference observed in grip strength (p<0.05). The intergroup comparisons indicated a significant difference in favor of the experimental group across all parameters, except for grip strength (p<0.05); conversely, no substantial differences were observed between the sham and control groups (p>0.05).
Conclusion: The findings suggest that the adjunctive use of taVNS alongside conventional rehabilitation programs in individuals diagnosed with CTS results in increased sensory nerve conduction velocity and enhanced upper extremity functional capacity, accompanied by a reduction in pain; nevertheless, grip strength remains unaffected.

References

  • Mondelli M, Grippo A, Mariani M, Baldasseroni A, Ansuini R, Ballerini M, et al. Carpal tunnel syndrome and ulnar neuropathy at the elbow in floor cleaners. Neurophysiologie Clinique/Clinical Neurophysiology. 2006;36(4):245-53.
  • Padua L, Coraci D, Erra C, Pazzaglia C, Paolasso I, Loreti C, et al. Carpal tunnel syndrome: clinical features, diagnosis, and management. The Lancet Neurology. 2016;15(12):1273-84.
  • Preston DC, Shapiro BE. Electromyography and neuromuscular disorders e-book: clinical-electrophysiologic-ultrasound correlations: Elsevier Health Sciences; 2020.
  • Ibrahim I, Khan W, Goddard N, Smitham P. Suppl 1: carpal tunnel syndrome: a review of the recent literature. The open orthopaedics journal. 2012;6:69.
  • Urits I, Gress K, Charipova K, Orhurhu V, Kaye AD, Viswanath O. Recent advances in the understanding and management of carpal tunnel syndrome: a comprehensive review. Current pain and headache reports. 2019;23:1-8.
  • Cioni R, Passero S, Paradiso C, Giannini F, Battistini N, Rushworth G. Diagnostic specificity of sensory and motor nerve conduction variables in early detection of carpal tunnel syndrome. Journal of neurology. 1989;236:208-13.
  • Kanaan N, Sawaya R. Carpal tunnel syndrome: modern diagnostic and management techniques. British Journal of General Practice. 2001;51(465):311-4.
  • Shi Q, MacDermid JC. Is surgical intervention more effective than non-surgical treatment for carpal tunnel syndrome? A systematic review. Journal of orthopaedic surgery and research. 2011;6:1-9.
  • Saunders R, Astifidis R, Burke SL, Higgins J, McClinton MA. Hand and upper extremity rehabilitation: a practical guide: Elsevier Health Sciences; 2015.
  • Wu YT, Ke MJ, Ho TY, Li TY, Shen YP, Chen LC. Randomized double𝑛 blinded clinical trial of 5% dextrose versus triamcinolone injection for carpal tunnel syndrome patients. Annals of neurology. 2018;84(4):601-10.
  • Courties A, Berenbaum F, Sellam J. Vagus nerve stimulation in musculoskeletal diseases. Joint Bone Spine. 2021;88(3):105149.
  • Cherian A, Kuruvilla A. Electrodiagnostic approach to carpal tunnel syndrome. Annals of Indian Academy of Neurology. 2006;9(3):177-82.
  • Dinç Yavaş A, Bıçak NK. Karpal tünel sendromu hastalarında elektromiyografi bulgularının klinik semptomlar ve işlevsellik ile ilişkisi. Fiziksel Tıp ve Rehabilitasyon Bilimleri Dergisi. 2020.
  • ÇALICIOĞLU MN. Karpal Tünel Sendromu Olan Hastalarda Klinik, Elektronöromyografik Ve Ultrasonografik Bulgularin Vücut Kitle İndeksi İle İlişkisinin Değerlendirilmesi [Tipta Uzmanlik Tezi]. ankara: hacettepe; 2020.
  • Kim CR, Jeon Y-J, Kim MC, Jeong T, Koo WR. Reference values for hand grip strength in the South Korean population. PloS one. 2018;13(4):e0195485.
  • Freyd M. The graphic rating scale. Journal of educational psychology. 1923;14(2):83.
  • Aytar A, Yuruk ZO, Tuzun EH, Baltaci G, Karatas M, Eker L. The Upper Extremity Functional Index (UEFI): Cross cultural adaptation, reliability, and validity of the Turkish version. Journal of back and musculoskeletal rehabilitation. 2015;28(3):489-95.
  • ŞAHİNTÜRK L, ÖZCAN B. The comparison of hypothesis tests determining normality and similarity of samples. Journal of Naval Sciences and Engineering. 2017;13(2):21-36.
  • Shapiro BE, Preston DC. Entrapment and compressive neuropathies. Medical Clinics of North America. 2009;93(2):285-315.
  • Horng Y-S, Hsieh S-F, Tu Y-K, Lin M-C, Horng Y-S, Wang J-D. The comparative effectiveness of tendon and nerve gliding exercises in patients with carpal tunnel syndrome: a randomized trial. American journal of physical medicine & rehabilitation. 2011;90(6):435-42.
  • Gelfman R, Melton III L, Yawn B, Wollan P, Amadio P, Stevens J. Long-term trends in carpal tunnel syndrome. Neurology. 2009;72(1):33-41.
  • Fournier E. Syndrome du canal carpien: des causes rares et des formes associées derrière une affection commune et stéréotypée. La Revue de Médecine Interne. 2020;41(7):451-8.
  • Borovikova LV, Ivanova S, Zhang M, Yang H, Botchkina GI, Watkins LR, et al. Vagus nerve stimulation attenuates the systemic inflammatory response to endotoxin. Nature. 2000;405(6785):458-62.
  • Koopman FA, Chavan SS, Miljko S, Grazio S, Sokolovic S, Schuurman PR, et al. Vagus nerve stimulation inhibits cytokine production and attenuates disease severity in rheumatoid arthritis. Proceedings of the National Academy of Sciences. 2016;113(29):8284-9.
  • Changeux J-P. Golden anniversary of the nicotinic receptor. Neuron. 2020;107(1):14-6.
  • Bonaz B, Sinniger V, Hoffmann D, Clarençon D, Mathieu N, Dantzer C, et al. Chronic vagus nerve stimulation in Crohn’s disease: a 6𝑛 month follow𝑛 up pilot study. Neurogastroenterology & Motility. 2016;28(6):948-53.
  • Sinniger V, Pellissier S, Fauvelle F, Trocmé C, Hoffmann D, Vercueil L, et al. A 12𝑛 month pilot study outcomes of vagus nerve stimulation in Crohn’s disease. Neurogastroenterology & Motility. 2020;32(10):e13911.
  • Aalbers MW, Klinkenberg S, Rijkers K, Verschuure P, Kessels A, Aldenkamp A, et al. The effects of vagus nerve stimulation on pro-and anti-inflammatory cytokines in children with refractory epilepsy: an exploratory study. Neuroimmunomodulation. 2012;19(6):352-8.
  • Majoie H, Rijkers K, Berfelo M, Hulsman J, Myint A, Schwarz M, et al. Vagus nerve stimulation in refractory epilepsy: effects on pro-and anti-inflammatory cytokines in peripheral blood. Neuroimmunomodulation. 2010;18(1):52-6.
  • De Herdt V, Bogaert S, Bracke KR, Raedt R, De Vos M, Vonck K, et al. Effects of vagus nerve stimulation on pro-and anti-inflammatory cytokine induction in patients with refractory epilepsy. Journal of neuroimmunology. 2009;214(1-2):104-8.
  • Clough R, Neese S, Sherill L, Tan A, Duke A, Roosevelt R, et al. Cortical edema in moderate fluid percussion brain injury is attenuated by vagus nerve stimulation. Neuroscience. 2007;147(2):286-93.
  • Neese SL, Sherill LK, Tan AA, Roosevelt RW, Browning RA, Smith DC, et al. Vagus nerve stimulation may protect GABAergic neurons following traumatic brain injury in rats: An immunocytochemical study. Brain research. 2007;1128:157-63.
  • Zhang R, Gan Y, Li J, Feng Y. Vagus Nerve Stimulation Transiently Mitigates Chemotherapy-Induced Peripheral Neuropathy in Rats. Journal of Pain Research. 2020:3457-65.
  • Farrand AQ, Verner RS, McGuire RM, Helke KL, Hinson VK, Boger HA. Differential effects of vagus nerve stimulation paradigms guide clinical development for Parkinson’s disease. Brain Stimulation. 2020;13(5):1323-32.

KARPAL TÜNEL SENDROMU TANILI BİREYLERDE TRANSKÜTANÖZ AURİKÜLER VAGUS SİNİR UYARIMININ SİNİR İLETİ HIZI, KAVRAMA KUVVETİ, AĞRI VE ÜST EKSTREMİTE FONKSİYONELLİĞİNE ETKİSİ

Year 2024, Volume: 35 Issue: 1, 123 - 130, 20.04.2024
https://doi.org/10.21653/tjpr.1324406

Abstract

Amaç: Transkütanöz auriküler vagus uyarımının(taVNS) KTS’de sinir ileti hızı, kavrama kuvveti, ağrı ve üst ekstremite fonksiyonelliği gibi parametrelerdeki etkisinin araştırılması amaçlanmaktadır.
Yöntem: Çalışmaya karpal tünel sendromu tanısı almış, yaşları 18-58 aralığında değişen 51 hasta (90 el) 12 erkek 39 kadın dahil edilmiştir. Katılımcılar, rastgele randomizasyon yöntemi ile gruplara ayrılmışlardır. Tedavi öncesi ve sonrasında olacak şekilde median sinirin duyusal dalının ileti hızını ölçmek amacı ile elektromyografi (EMG) değerlendirmesi, bir dijital dinamometre yardımı ile el kavrama kuvveti, vizüel analog skalası (VAS) ölçeği ile ağrı sorgulaması ve üst ekstremitenin fonksiyonelliğini ölçmek amacı ile üst ekstremite fonksiyonel indeksi (ÜEFİ) ölçeği uygulanmıştır. Çalışmada yer alan deney, sham ve kontrol gruplarına konvansiyonel fizyoterapi programı 10 seans olacak şekilde uygulanırken, deney grubuna konvansiyonel fizyoterapi programıyla birlikte ek olarak 10 seans auriküler vagus sinir uyarımı da gerçekleştirilmiştir.
Sonuçlar: Çalışmada gruplar arasında VKİ, yaş, cinsiyeti eğitim durumu, sigara kullanma durumu gibi parametreler açısından anlamlı farklılıklar bulunmamıştır (p>0,05). Grup içi yapılan değerlendirmelerde kavrama kuvveti dışında kalan sinir ileti hızı, ağrı ve üst ekstremite fonksiyonelliği açısından başlangıç durumuna göre anlamlı farklılık bulunmuştur (p<0,05). Grupların karşılaştırılması için yapılan analizde ise kavrama kuvveti parametresi dışında kalan tüm parametrelerde deney grubu lehine anlamlı farklılık bulunurken (p<0,05), sham ve kontrol grupları arasında anlamlı bir farklılık bulunmamıştır (p>0,05).
Tartışma: Çalışma sonucunda KTS tanısı almış bireylerde konvansiyonel rehabilitasyon programına ek olarak uygulanan taVNS’nin duyusal sinir ileti hızını ve üst ekstremite fonksiyonellik seviyesini yükselttiği, ağrıyı azalttığı ancak kavrama kuvveti üzerinde herhangi bir etki oluşturmadığı bulunmuştur.

References

  • Mondelli M, Grippo A, Mariani M, Baldasseroni A, Ansuini R, Ballerini M, et al. Carpal tunnel syndrome and ulnar neuropathy at the elbow in floor cleaners. Neurophysiologie Clinique/Clinical Neurophysiology. 2006;36(4):245-53.
  • Padua L, Coraci D, Erra C, Pazzaglia C, Paolasso I, Loreti C, et al. Carpal tunnel syndrome: clinical features, diagnosis, and management. The Lancet Neurology. 2016;15(12):1273-84.
  • Preston DC, Shapiro BE. Electromyography and neuromuscular disorders e-book: clinical-electrophysiologic-ultrasound correlations: Elsevier Health Sciences; 2020.
  • Ibrahim I, Khan W, Goddard N, Smitham P. Suppl 1: carpal tunnel syndrome: a review of the recent literature. The open orthopaedics journal. 2012;6:69.
  • Urits I, Gress K, Charipova K, Orhurhu V, Kaye AD, Viswanath O. Recent advances in the understanding and management of carpal tunnel syndrome: a comprehensive review. Current pain and headache reports. 2019;23:1-8.
  • Cioni R, Passero S, Paradiso C, Giannini F, Battistini N, Rushworth G. Diagnostic specificity of sensory and motor nerve conduction variables in early detection of carpal tunnel syndrome. Journal of neurology. 1989;236:208-13.
  • Kanaan N, Sawaya R. Carpal tunnel syndrome: modern diagnostic and management techniques. British Journal of General Practice. 2001;51(465):311-4.
  • Shi Q, MacDermid JC. Is surgical intervention more effective than non-surgical treatment for carpal tunnel syndrome? A systematic review. Journal of orthopaedic surgery and research. 2011;6:1-9.
  • Saunders R, Astifidis R, Burke SL, Higgins J, McClinton MA. Hand and upper extremity rehabilitation: a practical guide: Elsevier Health Sciences; 2015.
  • Wu YT, Ke MJ, Ho TY, Li TY, Shen YP, Chen LC. Randomized double𝑛 blinded clinical trial of 5% dextrose versus triamcinolone injection for carpal tunnel syndrome patients. Annals of neurology. 2018;84(4):601-10.
  • Courties A, Berenbaum F, Sellam J. Vagus nerve stimulation in musculoskeletal diseases. Joint Bone Spine. 2021;88(3):105149.
  • Cherian A, Kuruvilla A. Electrodiagnostic approach to carpal tunnel syndrome. Annals of Indian Academy of Neurology. 2006;9(3):177-82.
  • Dinç Yavaş A, Bıçak NK. Karpal tünel sendromu hastalarında elektromiyografi bulgularının klinik semptomlar ve işlevsellik ile ilişkisi. Fiziksel Tıp ve Rehabilitasyon Bilimleri Dergisi. 2020.
  • ÇALICIOĞLU MN. Karpal Tünel Sendromu Olan Hastalarda Klinik, Elektronöromyografik Ve Ultrasonografik Bulgularin Vücut Kitle İndeksi İle İlişkisinin Değerlendirilmesi [Tipta Uzmanlik Tezi]. ankara: hacettepe; 2020.
  • Kim CR, Jeon Y-J, Kim MC, Jeong T, Koo WR. Reference values for hand grip strength in the South Korean population. PloS one. 2018;13(4):e0195485.
  • Freyd M. The graphic rating scale. Journal of educational psychology. 1923;14(2):83.
  • Aytar A, Yuruk ZO, Tuzun EH, Baltaci G, Karatas M, Eker L. The Upper Extremity Functional Index (UEFI): Cross cultural adaptation, reliability, and validity of the Turkish version. Journal of back and musculoskeletal rehabilitation. 2015;28(3):489-95.
  • ŞAHİNTÜRK L, ÖZCAN B. The comparison of hypothesis tests determining normality and similarity of samples. Journal of Naval Sciences and Engineering. 2017;13(2):21-36.
  • Shapiro BE, Preston DC. Entrapment and compressive neuropathies. Medical Clinics of North America. 2009;93(2):285-315.
  • Horng Y-S, Hsieh S-F, Tu Y-K, Lin M-C, Horng Y-S, Wang J-D. The comparative effectiveness of tendon and nerve gliding exercises in patients with carpal tunnel syndrome: a randomized trial. American journal of physical medicine & rehabilitation. 2011;90(6):435-42.
  • Gelfman R, Melton III L, Yawn B, Wollan P, Amadio P, Stevens J. Long-term trends in carpal tunnel syndrome. Neurology. 2009;72(1):33-41.
  • Fournier E. Syndrome du canal carpien: des causes rares et des formes associées derrière une affection commune et stéréotypée. La Revue de Médecine Interne. 2020;41(7):451-8.
  • Borovikova LV, Ivanova S, Zhang M, Yang H, Botchkina GI, Watkins LR, et al. Vagus nerve stimulation attenuates the systemic inflammatory response to endotoxin. Nature. 2000;405(6785):458-62.
  • Koopman FA, Chavan SS, Miljko S, Grazio S, Sokolovic S, Schuurman PR, et al. Vagus nerve stimulation inhibits cytokine production and attenuates disease severity in rheumatoid arthritis. Proceedings of the National Academy of Sciences. 2016;113(29):8284-9.
  • Changeux J-P. Golden anniversary of the nicotinic receptor. Neuron. 2020;107(1):14-6.
  • Bonaz B, Sinniger V, Hoffmann D, Clarençon D, Mathieu N, Dantzer C, et al. Chronic vagus nerve stimulation in Crohn’s disease: a 6𝑛 month follow𝑛 up pilot study. Neurogastroenterology & Motility. 2016;28(6):948-53.
  • Sinniger V, Pellissier S, Fauvelle F, Trocmé C, Hoffmann D, Vercueil L, et al. A 12𝑛 month pilot study outcomes of vagus nerve stimulation in Crohn’s disease. Neurogastroenterology & Motility. 2020;32(10):e13911.
  • Aalbers MW, Klinkenberg S, Rijkers K, Verschuure P, Kessels A, Aldenkamp A, et al. The effects of vagus nerve stimulation on pro-and anti-inflammatory cytokines in children with refractory epilepsy: an exploratory study. Neuroimmunomodulation. 2012;19(6):352-8.
  • Majoie H, Rijkers K, Berfelo M, Hulsman J, Myint A, Schwarz M, et al. Vagus nerve stimulation in refractory epilepsy: effects on pro-and anti-inflammatory cytokines in peripheral blood. Neuroimmunomodulation. 2010;18(1):52-6.
  • De Herdt V, Bogaert S, Bracke KR, Raedt R, De Vos M, Vonck K, et al. Effects of vagus nerve stimulation on pro-and anti-inflammatory cytokine induction in patients with refractory epilepsy. Journal of neuroimmunology. 2009;214(1-2):104-8.
  • Clough R, Neese S, Sherill L, Tan A, Duke A, Roosevelt R, et al. Cortical edema in moderate fluid percussion brain injury is attenuated by vagus nerve stimulation. Neuroscience. 2007;147(2):286-93.
  • Neese SL, Sherill LK, Tan AA, Roosevelt RW, Browning RA, Smith DC, et al. Vagus nerve stimulation may protect GABAergic neurons following traumatic brain injury in rats: An immunocytochemical study. Brain research. 2007;1128:157-63.
  • Zhang R, Gan Y, Li J, Feng Y. Vagus Nerve Stimulation Transiently Mitigates Chemotherapy-Induced Peripheral Neuropathy in Rats. Journal of Pain Research. 2020:3457-65.
  • Farrand AQ, Verner RS, McGuire RM, Helke KL, Hinson VK, Boger HA. Differential effects of vagus nerve stimulation paradigms guide clinical development for Parkinson’s disease. Brain Stimulation. 2020;13(5):1323-32.
There are 34 citations in total.

Details

Primary Language English
Subjects Allied Health and Rehabilitation Science (Other)
Journal Section Araştırma Makaleleri
Authors

Rıdvan Yıldız 0000-0001-8160-1470

Ali Veysel Özden 0000-0003-2349-996X

Publication Date April 20, 2024
Published in Issue Year 2024 Volume: 35 Issue: 1

Cite

APA Yıldız, R., & Özden, A. V. (2024). THE EFFECTS OF TRANSCUTANEOUS AURICULAR VAGUS NERVE STIMULATION ON NERVE CONDUCTION VELOCITY, GRIP STRENGTH, PAIN, AND UPPER EXTREMITY FUNCTIONALITY IN INDIVIDUALS WITH CARPAL TUNNEL SYNDROME. Türk Fizyoterapi Ve Rehabilitasyon Dergisi, 35(1), 123-130. https://doi.org/10.21653/tjpr.1324406
AMA Yıldız R, Özden AV. THE EFFECTS OF TRANSCUTANEOUS AURICULAR VAGUS NERVE STIMULATION ON NERVE CONDUCTION VELOCITY, GRIP STRENGTH, PAIN, AND UPPER EXTREMITY FUNCTIONALITY IN INDIVIDUALS WITH CARPAL TUNNEL SYNDROME. Turk J Physiother Rehabil. April 2024;35(1):123-130. doi:10.21653/tjpr.1324406
Chicago Yıldız, Rıdvan, and Ali Veysel Özden. “THE EFFECTS OF TRANSCUTANEOUS AURICULAR VAGUS NERVE STIMULATION ON NERVE CONDUCTION VELOCITY, GRIP STRENGTH, PAIN, AND UPPER EXTREMITY FUNCTIONALITY IN INDIVIDUALS WITH CARPAL TUNNEL SYNDROME”. Türk Fizyoterapi Ve Rehabilitasyon Dergisi 35, no. 1 (April 2024): 123-30. https://doi.org/10.21653/tjpr.1324406.
EndNote Yıldız R, Özden AV (April 1, 2024) THE EFFECTS OF TRANSCUTANEOUS AURICULAR VAGUS NERVE STIMULATION ON NERVE CONDUCTION VELOCITY, GRIP STRENGTH, PAIN, AND UPPER EXTREMITY FUNCTIONALITY IN INDIVIDUALS WITH CARPAL TUNNEL SYNDROME. Türk Fizyoterapi ve Rehabilitasyon Dergisi 35 1 123–130.
IEEE R. Yıldız and A. V. Özden, “THE EFFECTS OF TRANSCUTANEOUS AURICULAR VAGUS NERVE STIMULATION ON NERVE CONDUCTION VELOCITY, GRIP STRENGTH, PAIN, AND UPPER EXTREMITY FUNCTIONALITY IN INDIVIDUALS WITH CARPAL TUNNEL SYNDROME”, Turk J Physiother Rehabil, vol. 35, no. 1, pp. 123–130, 2024, doi: 10.21653/tjpr.1324406.
ISNAD Yıldız, Rıdvan - Özden, Ali Veysel. “THE EFFECTS OF TRANSCUTANEOUS AURICULAR VAGUS NERVE STIMULATION ON NERVE CONDUCTION VELOCITY, GRIP STRENGTH, PAIN, AND UPPER EXTREMITY FUNCTIONALITY IN INDIVIDUALS WITH CARPAL TUNNEL SYNDROME”. Türk Fizyoterapi ve Rehabilitasyon Dergisi 35/1 (April 2024), 123-130. https://doi.org/10.21653/tjpr.1324406.
JAMA Yıldız R, Özden AV. THE EFFECTS OF TRANSCUTANEOUS AURICULAR VAGUS NERVE STIMULATION ON NERVE CONDUCTION VELOCITY, GRIP STRENGTH, PAIN, AND UPPER EXTREMITY FUNCTIONALITY IN INDIVIDUALS WITH CARPAL TUNNEL SYNDROME. Turk J Physiother Rehabil. 2024;35:123–130.
MLA Yıldız, Rıdvan and Ali Veysel Özden. “THE EFFECTS OF TRANSCUTANEOUS AURICULAR VAGUS NERVE STIMULATION ON NERVE CONDUCTION VELOCITY, GRIP STRENGTH, PAIN, AND UPPER EXTREMITY FUNCTIONALITY IN INDIVIDUALS WITH CARPAL TUNNEL SYNDROME”. Türk Fizyoterapi Ve Rehabilitasyon Dergisi, vol. 35, no. 1, 2024, pp. 123-30, doi:10.21653/tjpr.1324406.
Vancouver Yıldız R, Özden AV. THE EFFECTS OF TRANSCUTANEOUS AURICULAR VAGUS NERVE STIMULATION ON NERVE CONDUCTION VELOCITY, GRIP STRENGTH, PAIN, AND UPPER EXTREMITY FUNCTIONALITY IN INDIVIDUALS WITH CARPAL TUNNEL SYNDROME. Turk J Physiother Rehabil. 2024;35(1):123-30.