1. Carpal Tunnel Syndrome:
A Patient Case
Meliza Barillo, Laura Beynon, Josh
D'Angelo, Jane Kruszewski,
Brendan Keena, and Emily Macklin
2. 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.
3. Patient's Symptoms & Signs
● Onset of CTS symptoms: 9 - 10 months ago
● Symptoms have progressively gotten worse over the last 3
● 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.
4. Personal Medical History
● Past surgeries
○ C-sections with both children
Family Medical History
○ Diabetes Mellitus with above knee amputation
○ Died of Congestive Heart Failure
● 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
5. Prior Level of Function
● Worked, drove and participated in daily activities of living
● Frequently participated in kids' school activities
● Played with children
● Involved in church group activities involving arts & crafts
● 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
6. Patient's 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 pain
7. Systems Review
Cardiopulmonary: 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.
8. Physician's Tests & Measures
● 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
● Potential is recorded at rest or
with very low muscle activation
9. 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
● Recording electrode over the
abductor pollicis brevis
● Stimulating electrode over the
median nerve at wrist
11. Katz Hand Diagram
Patient X results:
12. Tinel's Test
Light tapping over site of median nerve as it runs through the carpal
tunnel, at distal wrist crease.
Patient X results: Positive (bilateral tingling and "shooting" or "electric"
pain in digits 2 & 3 and thenar eminence)
13. Phalen's Sign
Forced wrist flexion and median nerve compression by pressing
dorsal surfaces of hands together for 1 minute.
Patient X results: Positive (bilateral tingling, pain, and numbness
after 40 seconds in thumb and digits 2 & 3)
14. Semmes-Weinstein Sensory Test
Use 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.
Patient X results: Abnormal (bilateral impaired sensation in distal
palmar C7 dermatome) C6, dorsal C7, and C8 sensation intact
15. Hand Grip Strength
Hand grip dynamometer (on 2nd setting), measured in kg of force.
Patient X results: http:
Trial 1 Trial 2 Trial 3 Average
Right 4kg 4.5kg 4kg 4.17kg Poor
Left 9kg 9kg 5kg 7.67kg Poor
16. Range of Motion
Patient X results:
Extension Flexion Radial Dev. Ulnar Dev. End Feel
Right 25˚ 28˚ 20˚ 17˚ Empty
Left 48˚ 34˚ 20˚ 30˚ Empty
17. Manual Muscle Testing
Patient X results:
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 MCP Flexion MCP Flexion MCP Flexion
(digit 2) (digit 3) (digit 4) (digit 5)
Bilateral 3+ 4 3 5 5
THUMB MCP Flex CMC Flex IP Flexion Oppostion
Bilateral 3+ 3+ 3+ 3+
18. Outcome Measures
Boston 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
19. 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
20. Typical Presentation of CTS
● 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
distribution after: ● Wrist pain
○ Hyperflexion of the wrist for 60
○ Tapping the volar wrist over the
● Shaking or flicking one's hands for relief
during maximal symptoms
● Loss of 2-point discrimination in the
median nerve distribution
21. Patient X
● 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
○ Tapping the volar wrist over the
● Shaking or flicking one's hands for
relief during maximal symptoms
● Loss of 2-point discrimination in the
median nerve distribution
22. 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
23. Problem List
● 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
Carpal tunnel syndrome can range from a minor discomfort to a
● 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
26. 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
27. Physical Therapy Goals
● 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
● Pt will maintain 10 minutes of appropriate sitting posture at a
computer without any cueing in 2 weeks.
● 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.
Guide to PT Practice:
● Therapeutic Exercise
● Functional training in self-care and home management
● Manual Therapy Techniques
● Electrotherapeutic Modalities
● Physical Agents and Mechanical Modalities
29. 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 (O'Connor, Muller)
■ Just as we did in Foundations of Examination last
○ Soft tissue mobilization (Burke)
30. 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
33. Functional training in self-care and
• Injury prevention and reduction: with use of protective devices
and equipment, safety awareness training during self-care and
home management (Guide)
○ 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).
34. LASER and TENS
○ 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
35. Physical Agents and Mechanical
● Pulsed Electromagnetic Fields
● 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).
36. Other Interventions
○ More effective than no treatment or splinting alone
(Garfinkel et al)
○ Short term benefits (O'Connor et al; Muller et al)
○ 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).
37. Plan of Care
●Treatment Plan: (Guide to PT Practice)
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
○ Continue splinting when not in treatment
38. 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:
○ Ergonomic Keyboard
39. 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
Efficacy of surgical release of
● 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).
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