Carpal tunnel is a confined space between the carpal bones dorsally and the flexor retinaculum volarly. The extrinsic finger flexor tendons and median nerve course through the tunnel.
DEFINITION Carpal Tunnel Syndrome
A common painful disorder of the wrist and hand, induced by compression on the median nerve between the inelastic carpal ligament and other structures within the carpal tunnel.
Mosby’s pocket dictionary of Medicine, Nursing & Health Professions. (2006). Missouri: Elsevier
PATHOLOGY
- Repetitive wrist flexion-extension or gripping activities, trauma, pregnancy, RA & OA
- Tenosynovium thickens from irritation or inflammation
- Pressure to build inside the carpal tunnel: Pressure to build inside the carpal tunnel
- Blood supply to outer covering of nerve slows down and may even be cut off.
- Pressure keeps building up, inside of the nerve also will start to become thickened
- New cells (fibroblasts) form within the nerve and create scar tissue.
- Pain, numbness, tingling
ETIOLOGY
- Repetitive wrist flexion-extension or gripping activities : Irritation, inflammation & swelling. Synovial thickness & scarring in tendon sheaths.
- Trauma (blow/fall to the wrist) : Swelling of wrist joint
- Pregnancy : Hormonal changes and water retention
- Rheumatoid arthritis and osteoarthritis : Decrease carpal tunnel space
- Vibration
- Compressive forces
- Awkward wrist posture
SIGNS & SYMPTOMS
- Increasing pain in median nerve distribution
- Muscle weakness/ atrophy – thenar muscles and 1st two lumbricles (Ape hand deformity)
- Muscle tightness – adductor pollicis longus, thumb and digit 2&3 extrinsic extensor.
- Sensory loss (hypoaesthesia) at median nerve distribution
- Decreased joint mobility in the wrist and MCP joint of thumb and digits 2&3
Ape Hand Deformity
COMMON FUNCTIONAL LIMITATIONS
1- REDUCE NEURO- MUSCULAR CONTROL
Decreased prehension in 1) tip-to-tip 2) tip-to-pad 3) pad-to-pad
2)UNABLE TO PERFORM PROVOKING REPETITIVE WRIST MOTION Such as :-
1) Typing
2) Cashier checkout scanning
3) Fine tool manipulation
DIAGNOSIS
1) NERVE CONDUCTION VELOCITY (NCV) TEST
- To check how well the median nerve is functioning.
- To measure fast of nerve impulses move through the nerve.
2)Non-operative treatment
A wrist brace will sometimes decrease the symptoms in the early stages of CTS. It’s
- keeps the wrist in a resting position
- not bent back
- not bent down too far
Helpful for easing the numbness and pain felt at night because it can keep hand from curling under as sleep
3) Oral medications may be used to relieve the symptoms of carpal tunnel syndrome such as
- nonsteroidal anti-inflammatory medications
-oral corticosteroids
4)Cortisone injection is used to reduce the swelling in the tunnel andmay give temporary relief of symptoms
5)operation
Surgical decompression of the tunnel by release of the transverse carpal ligament and removal of tissue compressing the median nerve can be beneficial.
The procedure is generally recommended if symptoms persist for 6 months. Even after surgery though, symptoms may recur.
It is important to treat carpal tunnel syndrome.
open release
ENDOSOCPIC RELEASE
An endoscope is a thin, fiber-optic TV camera that allows to see inside the carpal tunnel as the transverse carpal ligament is carefully released.
PHYSIOTHERAPY MANAGEMENT
SUBJECTIVE ASSESSMENT
Patient’s data
Name :
Age :
Gender :
R/N :
D.O.Ax :
Dr. Dx :
Dr. Mx :
Problem :
Pain
Area of pain
Intensity of pain:
- Depth of pain:
Abnormal sensation:
Constant or intermittent of symptoms:
Relationship of symptom:
Easing factor:
Aggravating / triggering factor:
Irritability:
Special Question
General health :
PMHx/Surgery :
X-ray/MRI :
Medication/drugs :
History of present condition (HPC)
Past history
Social History (SHx.)
OBJECTIVE ASSESSMENT
OBSERVATION
General :
Body size :
Facial expression :
Gait :
Posture :
Local :
Palpation
PHYSIOLOGICAL MOVEMENT
Shoulder joint
Elbow joint
Wrist joint Flecion/extension/ulnar deviation/ radial deviation
MUSCLE STRENGTH
Shoulder muscle
Elbow muscle
Wrist muscle
NEUROLOGICAL TEST
Sensation (Dermatomes, Myotomes, Neurodynamic Test)
SPECIAL TEST
1) Phalen Test
Pt’s position : sitting or standing with the dorsal aspect of both hands in full contact, both wrist maximally flexed.
Therapist’s : sitting or standing to the patient position
Method : A steady compressive force is applied through the patient’s forearms such that the patient’s wrists are maximally flexed for 1 minute.
Positive findings: Numbness and tingling in the median nerve distribution of the fingers (thumb, index finger, middle finger and lateral aspect of the ring finger) are indicative of CTS, secondary to the median nerve compression.
2) Tinel Test
Pt’s position: sitting on the chair
Therapist’s position : sitting besides patient
Method : taps the volar aspect of the patient’s wrist over the area of the carpal tunnel.
Pt’s position: sitting on the chair
Therapist’s position: sitting besides patient
Method: taps the volar aspect of the patient’s wrist over the area of the carpal tunnel.
Positive findings: complaint’s of tingling, paresthesia or pain by the subject in the area of the thumb, index finger, middle finger and radial one-half of the ring finger signal a positive test.This may be indicative of a compression of the median nerve in the carpal tunnel, or CTS.
Special considerations: a +ve tinel test at the wrist may appear if the median nerve is disrupted at any point of its path. +ve finding should warrant the examiner to assess THE integrity of the median nerve at the elbow, shoilder and neck to rule out other pathology.
problem listing
PHYSIOTHERAPIST IMPRESSION
short term goals
long term goals
PHYSIO TREATMENTS
1) ELECTROMODALITIES
wax therapy
2- MOBILITY
1. Joint mobilization
- condition where joint mobility is restricted, mobilize the carpals for increased carpal tunnel space.
2.Tendon-gliding exercise
- teach the patient, for mobility in the extrinsic tendons, should be performed gently to prevent increased swelling. ( Kisner & Colby, 2007)
3. Median nerve mobilization
- Begin with position 1 and progress to each succeeding position until median nerve symptoms begin to be provoked(tingling).
- That is maximum position to use.
- Sustain that position for 5-30 seconds without making symptoms worse.
- Then, alternate between that position and preceding position.
- When patient, can moved into that position without symptoms, progress to stretch position and repeat mobilizing.
- Done 3-4 times per day as long as symptoms are not exacerbated.
3-Muscle Performance
Strengthening and endurance exercise
- add dynamic strengthening and endurance exs when symptoms are not increased with isometric exs.
- utilize exercises that prepare patient for a return to functional activities.
4- Stretching & Joint Mobilisation of Restricted Tissue
- If restricted, lengthen abductor polisis brevis and opponens pollicis
- Mobilize restricted tendons or nerve tissue
5-Dexterity Exercises
- Include picking up small objects using pad-to-pad, tip-to-tip and tip-to pad prehension patterns (turning over cards, stacking checkers, writing, holding perimeter of a jar lid and having thumb move around the edge in circumduction motion.
6- Patient’s education
7) Acupuncture
