Carpal Tunnel Syndrome

Carpal Tunnel Syndrome and its conservative physiotherapy treatment

1. Carpal Tunnel Syndrome BY:HEMANT AGGARWAL MPT(ORTHO) Roll No.-1801717120002

2. Introduction: Carpal Tunnel Syndrome (CTS) is characterized by the sensory loss and motor weakness that occur when the Median Nerve is compromised in the carpal tunnel Anything that decreases the space in the carpal tunnel or causes the contents of the tunnel to enlarge could compress or restrict the mobility of the median nerve,causing a compression or traction injury and neurological symptoms distal to the wrist Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment world wide about 90% of all the entrapment neuropathethies (reference: the ulster medical society,2008)

3. Anatomy of carpal tunnel: Boundaries of Carpal Tunnel : Volarly : Flexor Retinaculum (Transverse Carpal Ligaments) Dorsally : Carpal bones,Deep Volar ligaments and Volar interosseous ligaments Laterally : Tubercle of scaphoid & Crest of trapezium Medially : Pisiform Bone & Hook of Hamate Contents: 9 tendons and Median Nerve 4 tendons of Flexor Digitorum Superficialis 4 tendons of Flexor Digitorum Profundus Tendon of Flexor Pollicis Longus

4. Etiology: Aberrant Anatomy : Anamalous Flexor Tendons CongenItally Small Carpal Tunnel Lipoma Proximal lumbrical muscle insertion Infections : Septic Arthritis Mycobacterial Infections

5. Cont. Inflammatory Conditions : Flexor tenosynovitis Gout Rheumatoid Arthritis Metabolic Disorder : Hypothyroidism Diabetes Increased Canal Volume : Pregnancy 2.Obesity 3. Edema

6. Pathophysiology: The tendons of the hands are wrapped with a lining that produce a synovium fluid which lubricates the tendons With repetitive movement of the hand , the lubrication system may malfunction This reduction in lubrication results in the inflammation and swelling of the tendon area Abnormally high carpal tunnel pressures exist in the patients with CTS The pressure causes obstruction to venous outflow , back pressure, edema formation, and ultimately , ischemia in the nerve

7. Clinical features: Pain : increases with repetitive use Numbness: lateral three and half digits including nail beds and distal phalanges on dorsum of hand Tingling Nocturnal dysesthesia: Patient will complain of waking up due to “painful numbness” of the their hand.Pt. will shake their hand. Progressive weakness or atrophy in the thenar muscles and first two lumbricals (ape hand deformity) Tightness in the adductor pollicis and extrinsic extensors of the thumb and digits 2 and 3 Irritability or sensory loss in the median nerve distribution Possible decreased joint mobility in the wrist and MCP joint of the thumb and digits 2 & 3 May develop sympathetic changes: skin area with sensory loss is warmer due to arteriolar dilatation , dryness and scaly skin

8. Carpal Compression Test Ames Test

9. Cont. Ape like hand apperance Paper holding test: Unable to hold paper b/w thumb & fingers because of paralysis of paralysis of m/s of thenar eminance Electrodiagnosis : EMG Nerve conduction velocity

10. PHYSIOTHERAPY MANAGEMENT NONOPERATIVE MANAGEMENT: Ultrasonic therapy and IFT Nerve protection - Rest & splinting Activity modification and education Mobility : Joint mobilization Tendon gliding exercises Median nerve mobilisation Muscle performance : Gentle multiple angle muscle setting exercises Strengthening and endurance exercises fine finger dexterity – exercise with small objects using tip to tip , pad to pad and tip to pad prehension patterns

11. Ergonomics & Brace:

12. Tendon gliding exercises:

13. Manual Therapy 1. Opening - horizontal flexion – opener POP: supine with elbow flexed to approx. 90° as forearm & hand point almost vertically. POT: The therapist's proximal hand gently clasps the patient's distal forearm radially so that the therapist's thumb is located on the ventral surface of the patient's forearm between, and parallel to, the patient's radius and ulna. This is so that the end of the therapist's thumb reaches up to the patient's distal palmar crease. No pressure is exerted by the thumb over the carpal tunnel during the test movement. The therapist's distal hand then passes dorsally around the patient's wrist, so that ventral pressure is applied on the radial side by therapist's fingers and ulnarly by the therapist's thumb. The wrist and forearm are stabilized by the therapist's proximal hand. This manoeuvre makes the carpal bones and first and fifth metacarpals form an arch with the concave surface being on the ventral aspect of the wrist. When performed gently, it is likely that the ensuing movements produce reduced tension in the transverse carpal ligament and reduce pressure on the median nerve.

14. Horizontal wrist flexion: Positioning technique

15. Cont. 2. Closing - horizontal extension - dynamic closer therapist's hands approach the patient's wrist from the dorsal aspect Each hand creates a gentle pincer action with the therapist's index fingers and thumbs around the medial and lateral aspects of the wrist complex and first and fifth metacarpals The hand that holds the radial aspect grips the first metacarpal and scaphoid bones whilst the hand that grips the ulnar structures clasps the hamate, pisiform and fifth metacarpal bones The movement is produced by the therapist levering gently over their thumbs as they apply a ventral pressure over the dorsum of the wrist and an outward wedging action of their index fingers . This movement produces an increase in tension in the transverse carpal ligament by angling the ulnar and radial structures posteriorly around the capitate

16. Proximal sliding of Median nerve: Positioning Technique

17. Distal sliding of median nerve: MNT1 TECHNIQUE

18. Article: Electroacupuncture and wrist splinting for carpal tunnel syndrome: a randomised trial: Researchers: C Wong , SM Griffiths et. al Hong Kong Medical j ournal, 2017 A total of 181 patients were randomly allocated to electroacupuncture plus night splinting (n=90) or the waiting list plus night splinting (n=91). The two groups were comparable in baseline characteristics, with a mean duration of symptoms of 50 and 51 months, respectively Patients in the electroacupuncture group also achieved greater improvement in the Functional Status Scale score at the 17th week

19. Article 2: Effect of the release exercise and exercise position in a patient with carpal tunnel syndrome : W on-gyu Yoo et. al JOURNAL:Department of Physical Therapy, College of Biomedical Science and Engineering, Republic of Korea,2015 The subject performed three exercises: (1) release, (2) wrist flexor stretching, and (3) wrist extensor stretching In session 1, the subject performed exercises 2 and 3 in the standing position for 2 weeks In session 2, the subject performed all three exercises in the supine position for 2 weeks Result: The pressure pain threshold decreased after session 1 and decreased further after session 2, and the Phalen’s test and Tinel sign became progressively less positive Conclusion : Exercises in the supine position, including release exercises, are recommended for CTS

20. Article 3: Evaluation of fascial manipulation in carpal tunnel syndrome: a pilot randomized clinical trial Researchers : Marco   PINTUCCI , Marta   IMAMU Journal: European Journal of Physical and Rehabilitation Medicine August 2017 Fascial manipulation (FM) 2 involves deep friction over specific points , namely the center of coordination (CC) and the center of fusion (CF), i.e., where the vector forces of the myofascial expansions of synergic muscles occur Patients allocated to the FM group received 5 sessions of 30-45 minutes, 1 session per week for 5 weeks The most dysfunctional CC’s and CF’s, in the hand, forearm, arm, chest, and neck, were submitted to a comparative palpation following the FM guidelines.After the selection of the points, friction was applied for 2 to 4 minutes Result: a significant effect of FM in patients with CTS after 5 weeks of treatment

21. References Essential of orthopaedics and applied physiotherapy/ jayant joshi /second edition Orthopedic physical asssessment / david j .magee /sixth edition Clinical neurodynamics / michecal shetlock

22. Thankyou…