1. Carpal tunnel syndrome

2. Introduction Definition Introduction Definition Carpal tunnel syndrome (CTS) is defined as compression of the median nerve at the carpal tunnel of the wrist Causes of compression * Decrease in the size of the canal * Decrease in the size of the canal * Increase in the size of the contents * Increase in the size of the contents

3. Manifestation Pain and paresthesia Pain and paresthesiaEtiology. Diabetes Diabetes Rheumatoid arthritis Rheumatoid arthritis Hypothyroidism Hypothyroidism Pregnancy Pregnancy local trauma local trauma Certain occupations Certain occupations.

4. Diagnosis. Visual analogue scale Clinical findings Grip strength Electrophysiological studies Ultrasonography Differential Diagnosis.

5. Clinical findings 1- Tinel's sign1- Tinel's sign is performed by lightly tapping the skin over the flexor flexor 1- Tinel's signflexor retinaculumretinaculum to elicit a sensation of tingling or "pins and needles" in fingers retinaculum innervated by the median nerve Phalen's maneuver is performed by flexing the wrist gently as far as possible, then holding this position for one minute and awaiting 2- Phalen's maneuver is performed by flexing the wrist gently as far as possible, then holding this position for one minute and awaiting Symptoms 3- Durkan test3- Durkan test, carpal compression test, or applying firm pressure to the palm over the nerve for up to 30 seconds to elicit symptoms

6. Grip strength Pinch dynamometer was used to assess pinch muscle power. Hand dynamometer was used to assess maximal hand grip

8. Nerve Conduction Study (NCs) The room temperature was maintained around 31°C. For the motor nerve conduction studies, compound muscle action potentials ampilitude were recorded with a pair of surface recording electrodes placed on the abductor pollicis brevis muscle. The stimulating electrodes were placed at the wrist proximal to carpal tunnel for the distal segment stimulation with a distance of 7 cm from the recording electrode and at the elbow for the proximal segment stimulation. The distal motor latency was measured from the onset of the stimulating artifact to the onset of the compound muscle action potential.

9. The nerve conduction velocity was also calculated to rule out any median nerve lesions such as polyneuropathy. In the study of sensory nerve conduction, a pair of ring electrodes were placed on the index finger for recording, and the sensory nerve was stimulated antidromically at the same site used for distal motor stimulation with a distance of 14 cm from the recording electrode. Sensory peak latency was measured from the stimulating artifact to the onset of the sensory nerve action potential.

10. Placement of distal segment stimulation

11. Placement of proximal segment stimulation

12. Treatment of CTS. 1- Non surgical TTT Rest Rest Occupational therapy Occupational therapy Acu laser Acu laser Local massage Local massage Nerve mobilization Nerve mobilization

13. 2- Surgical TTT Open carpal tunnel release Non surgical TTT Hand splint Non surgical TTT Hand splint Low level laser therapy Low level laser therapy Steroid therapy Steroid therapy Nonsteroidal anti-inflammatory drugs Ultrasound Ultrasound (1MHz, 1.0 W/cm², pulsed mode 1:5, 15 min/session) Tendon gliding exercise

14. Wrist splint

15. Ultrasound I.R, LASER 904nm

16. Median nerve mobilization in the form of wrist extension, supination, elbow extension, shoulder abduction, shoulder lateral rotation, and neck lateral bending to the opposite side will be utilized

17. Tendon gliding exercise

18. Thank you