Carpal Tunnel Syndrome: A Patient CaseMeliza Barillo, Laura Beynon, Josh DAngelo, Jane Kruszewski,Brendan Keena, and Emily Macklin
Patient Presentation: Patient XDOB: 10/20/75, 35 yo female; R hand dominantHeight: 53", Weight: 155 lbs.Referring Physician: Dr. LawsonDx: Evaluate and treat Carpal Tunnel SyndromeTests: Normal EMG, Abnormal Nerve Conduction VelocityMedications: OTC anti-inflammatories, Ramapril (diureticsfor fluid retention), received Methylprednisolone injections inB wrists 4 months ago. Provided temporary relief.
Patients 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 childrenFamily Medical History ● Mother ○ Diabetes Mellitus with above knee amputation ● Father ○ Died of Congestive Heart FailureSocial 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 pianoCurrent 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
Patients Goals ● 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 painhttp://2.bp.blogspot.com/_pDHsByudxY0/S- http://2.bp.blogspot.com/_pDHsByudxY0/S-Gzw3QvE9I/AAAAAAAAALc/w8FooC8x774/S600/cooking_ Gzw3QvE9I/AAAAAAAAALc/w8FooC8x774/S600/cooking_with
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. ImpairedGross 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.
Physicians Tests & MeasuresElectromyography (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 (OSullivan)
Physicians Tests & MeasuresNerve 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 (OSullivan)
Tests and Measures
Katz Hand Diagram Patient X results: Probable/Classic Pattern http://jama.ama-assn.org
Tinels TestLight tapping over site of median nerve as it runs through the carpaltunnel, at distal wrist crease. http://www.med.und.edu/users/jwhiting/tinel.htmlPatient X results: Positive (bilateral tingling and "shooting" or "electric"pain in digits 2 & 3 and thenar eminence)
Phalens SignForced wrist flexion and median nerve compression by pressingdorsal surfaces of hands together for 1 minute. http://www.positivehealth.comPatient X results: Positive (bilateral tingling, pain, and numbnessafter 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 untilmonofilament begins to bend. http://www.wisdomking.com/product/semmes-weinstein-monofilament- aesthesiometer-10Patient X results: Abnormal (bilateral impaired sensation in distalpalmar C7 dermatome) C6, dorsal C7, and C8 sensation intact
Hand Grip StrengthHand grip dynamometer (on 2nd setting), measured in kg of force.Patient X results: http: //mentoneeducation Trial 1 Trial 2 Trial 3 Average al.com.au/ Right 4kg 4.5kg 4kg 4.17kg Poor Left 9kg 9kg 5kg 7.67kg Poor
Range of Motion http://www.netterimages.com/image/measurements.htmPatient X results: Extension Flexion Radial Dev. Ulnar Dev. End FeelRight 25˚ 28˚ 20˚ 17˚ EmptyLeft 48˚ 34˚ 20˚ 30˚ Empty
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 decreaseCompare re-tests to the baseline established in the initialevaluation 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 CTS Signs Symptoms● Weakness of resisted thumb abduction ● Intermittent pain, numbness or● Sensory hypalgesia paresthesias in hand and digits 1-3● Decreased grip strength ● Subjective hand swelling and● Thenar atrophy● Paresthesia in the median nerve stiffness distribution after: ● Wrist pain ○ Hyperflexion of the wrist for 60 seconds ○ Tapping the volar wrist over the median nerve● Shaking or flicking ones hands for relief during maximal symptoms● Loss of 2-point discrimination in the median nerve distribution
Patient X Signs Symptoms● Weakness of resisted thumb abduction● Sensory hypalgesia ● Intermittent pain, numbness or● Decreased grip strength paresthesia in hand and digits 1-● Thenar atrophy 3● Paresthesia in the median nerve ● Subjective hand swelling and distribution after: stiffness ○ Hyperflexion of the wrist for 60 ● Wrist pain seconds ○ Tapping the volar wrist over the median nerve ● Shaking or flicking ones hands for relief during maximal symptoms● Loss of 2-point discrimination in the median nerve distribution
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 timePT Diagnosis: 5F Impaired Peripheral Nerve Integrityand Muscle Performance Associated With PeripheralNerve Injury
PrognosisCarpal tunnel syndrome can range from a minor discomfort to adisabling condition.● Pregnancy induced CTS: Post-partum the swelling in wrists subsides and symptoms resolve ● Mild CTS ○ Symptoms dont 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 PrognosisGuide 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. ● Pts (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.
InterventionsGuide 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 structure with 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 (OConnor, 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 ExerciseThese exercises aredesigned to glide themedian nervethrough the tunnelwithout irritation.
Functional training in self-care and home managment• Injury prevention and reduction: with use of protective devicesand equipment, safety awareness training during self-care andhome 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, Tinels and Phalens 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: 1.5 W/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 (OConnor 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 OptionIf treatment is unsuccessful for severe CTS, a referral to theirphysician could lead to the following options as seen in theliterature:Efficacy of surgical release ofcarpal 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
ReferencesBurke, D., Burke, M., Bell, R., Stewart, G., Mehdi, R., and Kim, H. "Subjective Swelling: A New Sign for Carpal Tunnel Syndrome". J. Am J Phys Med Rehabil 1999. Journal of Manipulative and Physiological Therapeutics. 23.5 (2000): 372-73Campbell WW. Diagnosis and management of common compression and entrapment neuropathies. Neurological Clinics 1997; 15(3) 549-66"Carpal Tunnel Syndrome Fact Sheet." National Institue of Neurological Disorders and Stroke (NINDS). 28 Dec. 2010. Web 22 Feb. 2011. <http://www.ninds.nih.gov/disorders/carpal_tunnel/detail_carpal_tunnel.htm>DArcy CA, McGee S. Does this patient have carpal tunnel syndrome? JAMA 2000; 283: 3110-7. "Differential Diagnosis of Carpal Tunnel Syndrome- Wheeless Textbook of Orthopaedics." Welcome to Wheeless Textbook of Orthopaedics - Wheeless Textbook of Orthopaedics. 02 Nov. 2008. Web. 22 Feb. 2011. <http://www.wheelessonline.com/orth/differential_diagnosis_of_carpal_tunnel_ syndrome>.Deniz Evcik, Vural Kavuncu, Tuncay Cakir, Volkan Subasi, Mehmet Yaman. Photomedicine and Laser Surgery. February 2007, 25(1): 34-39"Impaired Peripheral Nerve Integrity and Muscle Performance Associated With Peripheral Nerve Injury." Guide to Physical Therapist Practice. Alexandria, VA: American Physical Therapy Association, 2003. 393-409.Jablecki CM, Andary MT, et al. Practice parameter: Electrodiagnostic studies in carpal tunnel syndrome. Neurology 2002; 58: 1589-92.Jarvik JG, Comstock BA, Kliot M, Turner JA, Chan L, Heagerty PJ, et al. Surgery versus non-surgical therapy for carpal tunnel syndrome: a randomized parallel-group trial.Lancet. 2009;374(9695):1074-1081.Keith MW. American Academy of Orthopaedic Surgeons clinical practice guidelines on the diagnosis of carpal tunnel syndrome. J Bone Joint Surg Am. 2009;91(10):2478-2479.Keith MW. American Academy of Orthopaedic Surgeons clinical practice guidelines on the treatment of carpal tunnel syndrome. J Bone Joint Surg Am. 2009;91(1):218-219.Lincoln AE, Vernick JS, Ogaitis S, Smith GS, MItchell CS, Agnew J. Interventions for the primary prevention of work-related carpal tunnel syndrome. Am J Prev Med. 2000 May. 18(4 Suppl): 37-50.Meirelles LM, Gomes dos Santos JB, Leonel dos Santos L, Branco MA, Faloppa F, Leite VM, Fernandes CH. Evaluation of Boston Questionnaire applied at a late post operative period of carpal tunnel syndrome operated with the paine retinaculatome through palmar port. ATCA Ortop Bras. 2006. 14(3): 126-132.
ReferencesNorvell, J. and Steele, M. Carpal Tunnel Syndrome. eMedicine Specialties. 10 Sep 2009 <http://emedicine.medscape.com/article/ 822792-print>.OSullivan S and Schmitz T. Electromyography and Nerve Velocity Tests. Physical Rehabilitation, 2007; 273 - 290.Piazzini DB, Aprile I, Ferrara PE, Bertolini C, Tonali P, Maggi L, Rabini A, Piantelli S, Padua L. A systematic review of conservative treatment of carpal tunnel syndrome. Clin Rehabil April 2007; 21(4): 299-314.Muller M, Tsui D, Schnurr R, Biddulph-Deisroth L, Hard J, & MacDermid, JC. Effectiveness of hand therapy interventions in primary management of carpal tunnel syndrome: a systematic review. Journal of Hand Therapy. 2004;17(2): 210-28.OConnor D, Marshall S, Massy-Westropp N. Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome. Cochrane Database Syst Rev. 2003;(1):CD003219.Burke J, Buchberger DJ, Carey-Loghmani MT, Dougherty PE, Greco DS, Dishman JD. A pilot study comparing two manual therapy interventions for carpal tunnel syndrome. J Manipulative Physiol Ther. 2007 Jan;30(1):50-61.Garfinkel MS, Singhal A, Katz WA, Allan DA, Reshetar R, & Schumacher Jr HR. Yoga-Based Intervention for Carpal Tunnel Syndrome: A Randomized Trial. JAMA. 1998;280(18):1601-1603.Gerritsen AAM, de Vet HCW, Scholten RJPM, Bertelsmann FW, de Krom MCTFM, & Bouter LM. Splinting vs Surgery in the Treatment of Carpal Tunnel Syndrome: A Randomized Controlled Trial. JAMA. 2002;288(10):1245-1251.Sucher BM. Myofascial manipulative release of carpal tunnel syndrome: documentation with magnetic resonance imaging. Journal of the American Osteopathic Association. 1993; 93(12):1273-1273.Akalin E, El Ö, Peker Ö, Şenocak Ö, Tamci Ş, Gülbahar S, Çakmur R, Öncel S: Treatment of carpal tunnel syndrome with nerve and tendon gliding exercises. Am J Phys Med Rehabil 2002;81:108-113.Baysal O, Altay Z, Ozcan C, Ertem K, Yologlu S, and Kayhan A. (2006), Comparison of three conservative treatment protocols in carpal tunnel syndrome. International Journal of Clinical Practice, 60: 820–828.Portney LG and Watkins MP. Foundations of Clinical Research: Applications to Practice, 3rd edition. 2009. 620-621.Aroori A, Spence R AJ. Carpal tunnel syndrome. Ulster Med J. (77)1; 2008: 6-17.Dale AM, et al. Physical examination has a low yield in screening for carpal tunnel syndrome. American Journal of Industrial Medicine. 54; 2010: 1-9.Lifchez SD et al. Intra- and inter-examiner variability in performing Tinel’s test. J Hand Surg Am. 35(5); 2010: 212-216.Amirfeyz R, et al. Clinical tests for carpal tunnel syndrome in contemporary practice. Arch Orthop Trauma Surg. 201D’Arey DC and McGee S. Does this patient have carpal tunnel syndrome? The Journal of the American Medical Association. 283(23); 2000: 3110-3117.
ReferencesHansen PA, Micklesen P, Robinson LR. Clinical utility of the flick maneuver in diagnosing carpal tunnel syndrome. American Journal of Physical Medicine and Rehabilitation. 83; 2004: 363-367DW Levine, et al. A self-administered questionnaire for the assessment of severity of symptoms and functional status in carpal tunnel syndrome. J Bone Joint Surg Am. 75; 1993: 1585-1592.Irvine, J., Chong, S. L., Amirjani, N. and Chan, K. M. (2004), Double-blind randomized controlled trial of low-level laser therapy in carpal tunnel syndrome. Muscle & Nerve, 30: 182–187.Naeser MA, Hahn KA, Lieberman BE, Branco KF. Carpal tunnel syndrome pain treated with low-level laser and microamperes transcutaneous electric nerve stimulation: A controlled study. Arch Phys Med Rehab. 2002;83(7):978-88.Girlada P, Dattola R, Venuto C, Mangiapane R, Nicolosi C, Messina C. Local steroid treatment in idiopathic carpal tunnel syndrome short- and long-term efficacy. J Neurol. 1993. 240(3):187-90.Weiss ND, GOrdon L, Blood T, So Y, Rempel DM. Position of the wrist associated with the lowest carpal tunnel pressure: implications for splint design. J Bone Joint Surg. 1995. 77(11):1695-1699.Ebenbichler GR, Resch K, Nicolakis P, Wiessinger GF, Uhl F, Ghanem AH, Flaika V. Ultrasound treatment for treating the carpal tunnel syndrome: randomised "sham" controlled trial. BMJ 1998. 316:731-735.