Carpal Tunnel Syndrome:A Patient Case

Meliza Barillo, Laura Beynon, Josh D'Angelo, Jane Kruszewski,

Brendan Keena, and Emily Macklin

Patient Presentation: Patient X

DOB: 10/20/75, 35 yo female; R hand dominant Height: 5'3", Weight: 155 lbs. Referring Physician: Dr. Lawson

Dx: Evaluate and treat Carpal Tunnel Syndrome Tests: Normal EMG, Abnormal Nerve Conduction Velocity

Medications: OTC anti-inflammatories, Ramapril (diuretics for fluid retention), received Methylprednisolone injections in B wrists 4 months ago. Provided temporary relief.

Patient's Symptoms & Signs● Onset of CTS symptoms: 9 - 10 months ago● Symptoms have progressively gotten worse over the last 3

months● Tingling and numbness

- B wrists, thenar eminence and radiates into lateral 3 digits● Dull, aching (sometimes sharp) pain

- On the palmar side of (B) wrists and thenar eminance - VRS at time of evaluation: 5/10 at worst: 10/10 sharp pain with extended use at best: 4 - 5/10 dull, ache in the AM - Shaking hands and rubbing wrists help alleviate pain● Weak grip ● Wears (B) splints at night, while cooking and lifting. It helps pt.

to sleep longer and wake up with less pain in the AM.

Personal Medical History ● HTN● Past surgeries

○ C-sections with both children

Family Medical History● Mother

○ Diabetes Mellitus with above knee amputation● Father

○ Died of Congestive Heart Failure

Social History● Home: Lives with husband and 2 boys (age 7 & 9)● Employment: On medical leave from data entry job.

Volunteers at childrens' school and at church● Denies smoking and recreactional drug use● Drinks ETOH 1 - 2 drinks/week

Prior Level of Function● Worked, drove and participated in daily activities of living

without pain● Frequently participated in kids' school activities● Played with children● Involved in church group activities involving arts & crafts● Knitting● Playing the piano

Current Functional Abilities & Limitations● Can drive for short distances (< 30 minutes) ● Inability to effectively use both hands and cannot work● Inability to sleep through the night due to pain ● Frequently drops items due to numbness● Difficulty cooking (holding pots handles)● Cannot knit

● Return to work pain free (contributes to family income) ● Be able to cook, do laundry and other home maintenance

activities without pain ● Be able to play the piano without pain

● Be able to knit without pain

Patient's Goals

http://2.bp.blogspot.com/_pDHsByudxY0/S-Gzw3QvE9I/AAAAAAAAALc/w8FooC8x774/S600/cooking_with_kids.jpg

http://2.bp.blogspot.com/_pDHsByudxY0/S-Gzw3QvE9I/AAAAAAAAALc/w8FooC8x774/S600/cooking_with_kids.jpg

Systems ReviewCardiopulmonary: Unimpaired. BP: 140/84; HR: 66bpm; RR: 14bpm; B Edema: 2.

Integumentary: Unimpaired. C-section scar.

Musculoskeletal: Impaired Gross ROM: B wrist flexion, extension, radial deviation, supination and pronation. Impaired Gross Strength: B wrist flexion and extension; digit flexion, extension, abduction and adduction. Posture: L shoulder higher, rounded shoulders, forward head, R > L carrying angle.

Neuromuscular: Unimpaired.

Physician's Tests & Measures

Electromyography (EMG)

● A diagnostic test that records electrical activity of a muscle to determine the integrity of the upper motor neuron, lower motor neuron, neuromuscular junction and muscle fibers

● Electrodes placed over the muscle or within the muscle belly

● Potential is recorded at rest or with very low muscle activation levels

(O'Sullivan)

Physician's Tests & Measures

Nerve Conduction Velocity Test ● An EMG technique● Stimulation of peripheral nerve,

the conduction time is measured and the evoked response of the desired muscle is recorded

● Recording electrode over the abductor pollicis brevis

● Stimulating electrode over the median nerve at wrist

(O'Sullivan)

Tests and Measures

Katz Hand Diagram

http://jama.ama-assn.org

Patient X results: Probable/Classic Pattern

Tinel's TestLight tapping over site of median nerve as it runs through the carpal tunnel, at distal wrist crease.

http://www.med.und.edu/users/jwhiting/tinel.html

Patient X results: Positive (bilateral tingling and "shooting" or "electric" pain in digits 2 & 3 and thenar eminence)

Phalen's SignForced wrist flexion and median nerve compression by pressing dorsal surfaces of hands together for 1 minute.

http://www.positivehealth.com

Patient X results: Positive (bilateral tingling, pain, and numbness after 40 seconds in thumb and digits 2 & 3)

Semmes-Weinstein Sensory TestUse of 3.61 mm monofilament applied along thenar eminence, digits 2-5, and forearm (palmar and dorsal surfaces) 90˚ to surface until monofilament begins to bend.

http://www.wisdomking.com/product/semmes-weinstein-monofilament-aesthesiometer-10

Patient X results: Abnormal (bilateral impaired sensation in distal palmar C7 dermatome) C6, dorsal C7, and C8 sensation intact

Hand Grip StrengthHand grip dynamometer (on 2nd setting), measured in kg of force.

Trial 1 Trial 2 Trial 3 AverageRight 4kg 4.5kg 4kg 4.17kg Poor

Left 9kg 9kg 5kg 7.67kg Poor

Patient X results: http://mentoneeducational.com.au/

Range of Motion

http://www.netterimages.com/image/measurements.htm

Extension Flexion Radial Dev. Ulnar Dev. End Feel

Right 25˚ 28˚ 20˚ 17˚ Empty

Left 48˚ 34˚ 20˚ 30˚ Empty

Patient X results:

Manual Muscle Testing

WRIST Extension Ext/Radial Dev Ext/Ulnar Dev Flexion Flex/RadialDev Flex/Ulnar Dev

Left 3+ 3+ 3+ 2+ 4 4

Right 3 3 3 2+ 2+ 3+

HAND MCP Flex MCP Flexion (digit 2)

MCP Flexion (digit 3)

MCP Flexion (digit 4)

MCP Flexion (digit 5)

Bilateral 3+ 4 3 5 5

THUMB (digit 1)

MCP Flex CMC Flex IP Flexion Oppostion

Bilateral 3+ 3+ 3+ 3+

http://www.accessphysiotherapy.com http://thetahealingevolutions.com/theta-healing/muscle-testing/

Patient X results:

Outcome MeasuresBoston Questionnaire Carpal Tunnel Syndrome● Self administered assessment with 11 questions for

symptoms and 8 for function (ranked 1-5)● Scored by taking the mean of the symptoms severity score

(SSS) and the mean of the functional severity score (FSS)● Patient X results:

○ SSS = 3.2○ FSS = 2.5

● With effective treatment, both scores would decrease

Compare re-tests to the baseline established in the initial evaluation for the following:● Grip Strength● Range of Motion● Manual Muscle Testing

Other Available Tests and Measures

● Two-point Discrimination● Flick Sign● Square-Wrist Sign● Tethered Median Nerve Stress Test● Pressure Provocation Test● Closed Fist Sign● Tourniquet Test

Typical Presentation of CTSSigns

● Weakness of resisted thumb abduction● Sensory hypalgesia ● Decreased grip strength● Thenar atrophy● Paresthesia in the median nerve

distribution after:○ Hyperflexion of the wrist for 60

seconds ○ Tapping the volar wrist over the

median nerve ● Shaking or flicking one's hands for relief

during maximal symptoms● Loss of 2-point discrimination in the

median nerve distribution

Symptoms● Intermittent pain, numbness or

paresthesias in hand and digits 1-3● Subjective hand swelling and

stiffness ● Wrist pain

Patient X Signs

● Weakness of resisted thumb abduction● Sensory hypalgesia ● Decreased grip strength● Thenar atrophy● Paresthesia in the median nerve

distribution after:○ Hyperflexion of the wrist for 60

seconds ○ Tapping the volar wrist over the

median nerve ● Shaking or flicking one's hands for

relief during maximal symptoms● Loss of 2-point discrimination in the

median nerve distribution

Symptoms

● Intermittent pain, numbness or paresthesia in hand and digits 1-3

● Subjective hand swelling and stiffness

● Wrist pain

Differential Diagnosis ● Pregnancy Induced CTS

○ Swelling in wrists compresses median nerve

● Cervical Root Impingement○ Radiculopathy of nerve roots C6 and C7 in the cervical spine

● Thoracic Outlet Syndrome○ Compression of Lower Trunk (C8,T1): Median & Ulnar nerves ○ Sensory changes in the ring and little finger

● Proximal Median Nerve Compression○ Pronator Teres Syndrome○ Anterior Interosseus Syndrome

● Distal Polyneuropathy○ Bilat. sensory symptoms in all fingers and usually lower limbs

● Ulnar Neuropathy○ Sensory disturbance in ulnar distribution

Problem List● Pain● Decreased ROM 2° pain● Decreased wrist strength● Decreased grip strength● Decreased sensation on palmar side of C7 dermatome● Difficulty sleeping 2° pain● Decreased ability to perform ADLs/IADLs● Inability to work● Inability to participate in volunteer activities● Inability to play piano and knit● Inability to maintain proper sitting posture● Inability to drive for prolonged period of time

PT Diagnosis: 5F Impaired Peripheral Nerve Integrity and Muscle Performance Associated With Peripheral Nerve Injury

PrognosisCarpal tunnel syndrome can range from a minor discomfort to a disabling condition.

● Pregnancy induced CTS: Post-partum the swelling in wrists subsides and symptoms resolve

● Mild CTS○ Symptoms don't last long and often resolve on their own.

● Severe (untreated) CTS○ Muscles at the base of the thumb may whither○ At risk for permanent sensation loss○ Debilitation can result in inability to work and loss of

independence with ADLs

Patient X Prognosis

Guide to Physical Therapy Practice: ● Pt will demonstrate optimal peripheral nerve integrity● Pt will demonstrate optimal muscle performance● Pt will demonstrate the highest level of functioning in home,

work, community, and leisure environments ● Pt will achieve the anticipated goals and expected outcome.● Pt will achieve the global outcomes for patients classified in

the same practice pattern

Physical Therapy GoalsSTG:● Pt will report reduction of pain to 3/10 in the morning, as

demonstrated by sleeping through the night, in 2 weeks.● Pt's (B) grip strength will improve by 3kg in 2 weeks to

improve independence with gripping cooking utensils and laundry basket.

● Pt will maintain 10 minutes of appropriate sitting posture at a computer without any cueing in 2 weeks.

LTG:● Pt will be able to work a full (6 hour) day with (B) pain of

<3/10 within 8 weeks.● Pt will have (B) ROM WFL in 10 weeks for independence in

ADLs and IADs.● Pt will have average (B) grip strength of 30kg in 10 weeks for

independence in ADLs and IADs.

Interventions

Guide to PT Practice: ● Therapeutic Exercise

● Functional training in self-care and home management

● Manual Therapy Techniques

● Electrotherapeutic Modalities

● Physical Agents and Mechanical Modalities

Manual Therapy Techniques

● "The carpal canal is a distensible structurewith the potential to yield to a relatively simple, aggressive, nonsurgical treatment for carpal tunnel syndrome" (Sucher)

● Effective interventions include:

○ Myofascial Release Manipulation (Sucher)○ Carpal bone mobilization (O'Connor, Muller)

■ Just as we did in Foundations of Examination last semester!

○ Soft tissue mobilization (Burke)

Therapeutic Exercise

● Exercise Therapy alone is not effective (Piazzini et al) and not more effective than splinting alone (Akalin et al)

● However, some support for exercise therapy in conjunction

with other interventions such as ultrasound, splinting, and carpal bone mobilization (Baysal et al; Muller at al)

● Specifically, most of the research was focused on nerve and

tendon gliding exercises

Tendon Gliding Exercise

● Which tendons are being used in which motions?

● 4 FDS● 4 FDP● FPL

Nerve Gliding Exercise

These exercises are designed to glide the median nerve through the tunnel without irritation.

Functional training in self-care and home managment

• Injury prevention and reduction: with use of protective devices and equipment, safety awareness training during self-care and home management (Guide)

○ Posture○ Ergonomic Keyboards

■ Multiple component ergonomics programs, alternative keyboard supports and other adjustments may be beneficial, but there is no support that it could be used as a primary prevention method of carpal tunnel syndrome (Lincoln et al).

LASER and TENS

● LASER○ Low Level Laser Therapy versus a placebo therapy group both

improve pain, pinch grip, and functional capacity but show no significant differences. (Evcik et al & Irvine et al).

● LASER with TENS (transcutaneous electrical nerve stimulation)○ Significant decreases in pain (McGill Pain Questionnaire),

median nerve sensory latencies, Tinel's and Phalen's signs with real LLLT and TENS over the sham LLLT and TENS (Naeser et al).

Physical Agents and Mechanical Modalities

●Cryotherapy●Pulsed Electromagnetic Fields ●Phonophoresis●Ultrasound (controversial)

○Bilateral CTS: pain (VAS) and electroneurographic measures were significantly improved in the wrist treated with active US compared to the wrist with the sham US (Ebenbichler et al).

○Groups treated with continuous US at 1Mhz at: 1.5W/cm2, 0.8W/cm2, and Zero W/cm2 all provided equal symptomatic relief (Oztas et al).

Other Interventions● Yoga

○ More effective than no treatment or splinting alone (Garfinkel et al)

○ Short term benefits (O'Connor et al; Muller et al)● Splinting

○ Slight extension and ulnar deviation provided most relief in carpal tunnel pressure (Weiss et al).

○ Carpal tunnel pressure relief with specific positioning in splint insignificant, but splints limit repetitive motions that may increase carpal tunnel pressure (Rempel et al).

● Steroid Injections○ Injections with 15mg of methylprednisolone acetate

showed significant improvements in symptoms than injections of saline. 50% of the nerves became worse after 6 months and 90% became worse after 18 months (Girlanda et al).

Plan of Care●Treatment Plan: (Guide to PT Practice)

Frequency: 2-3x/week Duration: 4-8 months

● First sessions○ Gentle manual therapy techniques

■ Carpal Bone Mobilization■ Myofascial Release■ Soft Tissue Mobilization

○ Nerve and tendon gliding exercises■ HEP: Tendon and Nerve Gliding Exercise

○ Ultrasound ○ Continue splinting when not in treatment

Plan of Care

● Assuming improvement, advance to:○ More aggressive manual therapy techniques○ Increased frequency, intensity, duration of exercise○ Advanced to functional exercises ○ Postural education for secondary prevention

● In addition, we can use other adjunct therapies:○ LASER ○ TENS○ Ergonomic Keyboard

Alternative Treatment Option

If treatment is unsuccessful for severe CTS, a referral to their physician could lead to the following options as seen in the literature:

Efficacy of surgical release of carpal tunnel● After 3 months: 80% success

rate for surgery, 54% for the splinting group after 3 months.

● After 18 months: increased to 90% for surgery and 75% for splinting (Gerritsen et al).

http://www.anshuguptamd.com/images/content/90-adam.jpg

Questions?

http://graphics8.nytimes.com/images/2007/08/01/health/adam/19242.jpg

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