CARPAL TUNNEL SYNDROME

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INTRODUCTION

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This is a syndrome characterised by the compression of the median nerve (C5-C8, T1) as it passes beneath the transverse carpal ligament in the carpal tunnel leads to mechanical compression and local ischemia, causing the median nerve to be impaired in the carpal tunnel. It occurs both in males and females between the ages of 25 to 70 years. They complain of intermittent attacks pain in the distribution of the median nerve on one or both sides. The attacks frequently occur at night. Pain may be referred proximally to the forearm and arm. It is more common because of excessive working on the computer.

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IMPAIRMENTS

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BODY STRUCTURES

• Compression of median nerve.

• Thickening followed by fibrosis of the perineurium and epineurium, inhibition of nerve gliding; injury to mesoneurium- scar formation.

• Localised segmental nerve fiber demyelination leading block of nerve transmission leading to neuropraxia.

• Breach in the blood-nerve barrier; infiltration of inflammatory cells and proteins endoneurial oedema ; neuritis and axonal degeneration.

• Inflammation and hypertrophy of the synovial lining of the tendon which run beneath the flexor retinaculum.

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BODY FUNCTIONS

• Pain

• Edema at the site of nerve compression.

• Paresthesias/Tingling/altered sensation.

• The skin areas with sensory loss is warmer and drier due to absence of sweating due to loss

• of sympathetic supply.

• Atrophy of the pulp of fingers.

• Atrophy of the thenar eminence.

• Dry and scaly skin.

• Restricted ROM at wrist, MCP and IP joints.

• Reduced muscle power of the muscles supplied by the median nerve leading to difficulty in performing small tasks. Reduced grip strength.

• Numbness/tingling in the sensory distribution of median nerve.

• Loss of proprioceptive awareness.

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GOALS

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Short term

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Patient and family awareness of the presenting condition

To protect the part

To avoid injury due to loss of sensation and to enhance understanding and compliance –

• mention the possible causes.

• changing wrist positions (i.e. avoiding prolonged bent wrist positions) proper neck and upper back posture (i.e. avoiding forward head or slouching)

• stretch breaks during your work or daily routine.

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Instructions for preventive care:

• Inspect skin regularly; provide prompt treatment of wounds or blisters.

• Compensate for dryness with massage creams or oils.

• Avoid holding hot, cold, sharp , or abrasive objects.

• Avoid sustained grasps; change use of tools frequently.

• Wear protective gloves.

• Redistribute hand pressure by building up the size of the handles.

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• Maximize tendon and nerve excursion within the carpal tunnel.

• Minimize swelling.

• Provide protection to the median nerve at the wrist via orthotic program.

• Maximize AROM.

• Maximize strength of the affected muscles.

• Goals after the surgery in case of severe carpal tunnel syndrome:

• Stretching to improve mobility of the wrist/fingers and improve function.

• Scar management to keep the skin supple and flexible.

 

Long term

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• Restore maximum function in the hand.

• Provide home management program and workstation ergonomic principles.

• Reduce force. Most people use more force than needed when performing work with their hands. Relax your grip to avoid muscle fatigue and strain. For prolonged handwriting, use a larger-handle pen or soft gel grip.

• Take frequent breaks. When doing repeated activities, give your hands a break by performing stretching exercises once in a while. If possible, alternate your hands when completing some tasks.

• Neutral wrist position. Avoid bending your wrists by keeping them in a straight or “neutral” position. This means your wrist should not be bent up (extended) or down (flexed).

• Work area adjustment. Have a physical therapist examine your work area to make sure it fits your height, posture, and the tasks required.

• Simple adjustments can help avoid unnecessary strain.

• Improve your posture. Make sure your posture is appropriate to the task you are performing. Proper alignment of your trunk, neck, and shoulders can prevent excessive strain and improper positioning of the wrists and hands.

• Keep your hands warm. You are more likely to develop hand pain and stiffness  if you work in a cold environment. If you cant control the temperature, be sure to wear gloves to keep your hands and wrists warm.

• Maintain good health. Staying physically fit and maintaining a healthy weight may help control diseases and conditions that may contribute to the onset of CTS.

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MANAGEMENT

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ACUTE STAGE: Immediately after injury or surgery following decompression and release or repair of the lacerated nerve.

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To protect the nerve from undue stress, minimize inflammation, and minimize tension at the injured/repaired site.

• Immobilisation:

  • Position thumb in opposition.

  • Time: as per dictated by surgeon.

 

To minimize joint and connective contractures and adhesions

• PROM exercises followed by AAROM- amount and intensity

• depends on the type of injury and surgical repair.

• Patient education regarding the protection of the part (given above).

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RECOVERY STAGE: Begins with signs of re-innervation.

 

To retrain motor function and gain strength

• Electrical stimulation: Instruct the patient to perform movement at the time of muscle contraction induced by stimulation.

• Begin gravity-eliminated, AAROM.

  • Wrist extension stretch- 5 reps* 4x a day

  • Wrist flexion stretch- 5 reps* 4x a day

  • Medial nerve glides-10-15 reps x a day

    • Make a fist with your thumb outside your fingers.

    • Extend your fingers while keeping your thumb close to the side of your hand.

    • Keep your fingers straight and extend your wrist (bend your hand backward toward your forearm).

    • Keep your fingers and wrist in position and extend your thumb.

    • Keep your fingers, wrist, and thumb extended and turn your forearm palm up.

    • Keep your fingers, wrist, and thumb extended and use your other hand to gently stretch the thumb.

• Tendon glides- 5-10 reps x 2-3x a day

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To decrease the irritability and increase sensory awareness

• Use of multiple types of textures or contact for sensory stimulation, such as cotton, rough material, sandpaper, of various grades and Velcro. The textures can be prevented around dowel rods for finger manipulation or to stroke along the skin.

• Place contact particles, such as cotton balls, beans ,macaroni, sand or other material, with various degrees of roughness in tubs or cans, so the patient can run the involved hand through the material for 10mins. Maximum progress occurs when the most irritating texture is tolerated.

• Use vibration

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To recognize a stimulus by brain once the hypersensitivity diminishes

• Begin by using a moving touch stimulus, such as the eraser end of a pencil, and stroke over the area. The patient first watches, then closes his or her eyes, and tries to identify where touch occurred.

• Progress from stroking to using constant touch.

• When the patient is able to localize constant touch, progress to identification of familiar objects of various sizes, shapes, and textures.

• For the hand, use familiar household and personal care objects, such as keys, eating utensils, blocks, toothbrush, and safety pins.

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Patient education: (given above)

 

CHRONIC STAGE:

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Emphasize training for compensatory function

Continue to wear the supportive splint or brace if the symptoms still persist and preventive care must be emphasized 

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REFERENCES

THERAPEUTIC EXERCISE, CAROLYN KISNER, 6 TH EDITION.

PHYSIOTHERAPY IN NEURO-CONDITIONS, GLADY SAMUEL RAJ

HUMAN ANATOMY, B.D. CHAURASIA, 8 TH EDITION.

CARPAL TUNNEL SYNDROME AND RELATED MEDIAN NEUROPATHIES, SCOTT F.M.DUNCAN AND RYOSUKE KAKINOKI.