1. Carpal Tunnel Syndrome
Alaitia Enjady, Brett Hager, Hannah Chaney & Stephanie Muther

2. Pathophysiology/epidemiology
Caused by compression of median nerve
Can cause edema, devascularization, demyelination
Myriad factors contribute to development
Irritation of flexor tendons, rheumatoid arthritis, congenital deformity of retinaculum
Repetitive use injury controversial
Not necessarily an inflammatory process
More prevalent in industrial setting
Significant contributor to workplace absence

3. Presentation
Classically pain and paresthesia in median nerve distribution
Often more severe at night
Relieved by shaking, wringing hands, running under water
Distribution of symptoms may vary
Wasting at Thenar Eminence
Weakness or clumsiness using hands
Often bilateral
Provoked by postural changes in the hand
Innervates flexor pollicis longus/brevis, opponens and abductor brevis

4. Differential Dx
Fairly easily diagnosed with clinical signs and symptoms
Number of provocative maneuvers use to diagnose
Tinels, Phalens, CT Compression, hands over head
What else could it be?
Nerve conduction studies and/or electromyography can be used to confirm diagnosis

5. Patient Claudia is a 42 year old woman who
works in a meat-packing plant.
After year 1- started to feel
numbness and tingling in her
right thumb, index, and middle finger
Pt c/o pain and swelling in her R wrist and hand
Pain- worse at night and keeps her awake
Beginning to drop things due to numbness and weakness in her hand
d559302a08fc#PatientExperience

6. Initial Evaluation Tests & Measures:
Tinel and Phalen tests performed on R side- (+)
AROM & PROM- WNL
Strength (arm, wrist & hand MMTs)- slight weakness in R wrist & hand
Treatment: Patient education on upper-back & neck posture, wrist positioning for activities, & alternating hands at work.

7. Impairments Weakness Pain Swelling
Functional Limitation: unable to safely & effectively complete work at meat-packing plant.

8. Treatment Plan Modalities/Pain Control:
Ultrasound* - Deep, pulsed was found to be effective while continuous, superficial was found to be ineffective
1 MHz, 1.0 W/cm2, pulsed mode 1:4, 15 minutes per session
E-Stim - Decrease swelling, inflammation and pain
TENS for pain control
NMES for neuro-reeducation after surgery?
STM* - Break up scar tissue,focus on palmar fascia, promote tissue compliance
Ice - Pain control at end of session
The interventions listed here are often appropriate for Week 1
Muller, Effectiveness of hand therapy interventions

9. Treatment Plan Cont’d Exercise - strengthening and stretching
Nerve gliding*
Dexterity exercises
Flexor retinaculum stretch*
Lengthen abductor pollicis brevis and opponens pollicis
Manual Therapy* - joint mobilization
Carpal bones
Hatha Yoga*
Biweekly 60- to 90-minute hatha yoga sessions for eight weeks
Splinting/bracing* - for home and workplace
Education - Ergonomic and postural training
Sensory stimulation and discriminative sensory reeducation
Muller, Effectiveness of hand therapy interventions

10. Example exercises

13. What about surgery??? You should know:
Use extreme caution for up to 3 weeks post-op to prevent bowstringing of flexor tendons
Usually a release of the flexor retinaculum
Actually has pretty good outcomes
49% of people are cured
28% of people were much better
7% were worse
You should know:
Precaution!
Avoid active wrist flexion past neutral as well as active finger flexion with wrist flexed during first 10 days post surgery
Severity and correct diagnosis P
Kisner,Therapeutic Exercise & Carpaltunnel.net

14. Home Exercise Program
Night-time splinting to keep wrist in neutral(wrist and MCP support)Brininger T, et al.
Ergonomical work station (avoiding wrist flexion & wrist only movements)
Anti-vibration gloves

15. Home exercise Program
Nerve Gliding
Limited evidence to support exercise as an effective treatment (Piazzini D,et al)
Tendon Gliding
Kisner Colby L. Therapeutic Exercise.

16. Take home points Decrease any compression on the median nerve
Education
Lifestyle modifications
Complications

17. References
Brininger T, Rogers J, Holm M, Baker N, Li Z, Goitz R. Efficacy of a Fabricated Customized Splint and Tendon and Nerve Gliding Exercises for the Treatment of Carpal Tunnel Syndrome: A Randomized Controlled Trial. Archives of Physical Medicine and Rehabilitation ;88(11): doi: /j.apmr
Carpal Tunnel Syndrome. American Physical Therapy Association Available at: Accessed July 18, 2016.
Carpal Tunnel Syndrome | Forster Physical Therapy. Forsterptcom Available at: Accessed July 15,
carpaltunnel.net - carpaltunnel Resources and Information. Carpaltunnelnet Available at: Accessed July 18,
Ebenbichler G, Resch K, Nicolakis P et al. Ultrasound treatment for treating the carpal tunnel syndrome: randomised "sham" controlled trial. BMJ. 1998;316(7133): doi: /bmj
Kisner Colby L. Therapeutic Exercise. Philadelphia: F.A. Davis; 2007.
Kothari MJ.. Carpal tunnel syndrome: Etiology and epidemiology. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA (Accessed on July 14, 2016.)

18. References cont’d
8. Kothari MJ.. Carpal tunnel syndrome: Clinical manifestations and diagnosis. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA (Accessed on July 14, 2016.)
9.Muller M, Tsui D, Schnurr R, Biddulph-Deisroth L, Hard J, MacDermid J. Effectiveness of hand therapy interventions in primary management of carpal tunnel syndrome: a systematic review. Journal of Hand Therapy. 2004;17(2): doi: /j.jht
10. Piazzini D, Aprile I, Ferrara P et al. A systematic review of conservative treatment of carpal tunnel syndrome. Clinical Rehabilitation. 2007;21(4): doi: /