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CARPAL TUNNEL
RELEASE
Prepared by :- Wesam Aljabali
Supervised by : Dr. Khaled Alsayni
Carpal tunnel syndrome (CTS
■ Carpal tunnel syndrome is a condition that develops when one of the major nerves in the wrist
becomes pinched. This nerve, called the median nerve, provides sensation and muscle function to the
hand and fingers .
■ Carpal tunnel syndrome (CTS) continues to be one of the most significant upper extremity (UE)
injuries, with more than 500,000 procedures performed each year.1 It results from compression of the
median nerve as it crosses the wrist and is characterized by numbness, tingling, pain, and complaints of
weakness in the hand. The symptoms of CTS can range from mild to severe. They may have far-
reaching effects on a person’s job, hobbies, and activities of daily living (ADL).
■ The prevalence in the United States of self-reported CTS is approximately 1 to 3 cases per 1000
subjects per year in the adult (working and nonworking) population.3-5 CTS affects people during
their most productive years. Its prevalence peaks between the ages of 35 and 44 years for both men and
women. Women are three times more likely to be affected than men.
Anatomy
■ The carpal tunnel is an anatomical
compartment located at the base of the
palm. Nine flexor tendons and the
median nerve pass through the carpal
tunnel that is surrounded on three sides
by the carpal bones that form an arch.
■ The carpal tunnel is located at the
middle third of the base of the palm.
■ From the anatomical position, the carpal
tunnel is bordered on the anterior
surface by the transverse carpal
ligament, also known as the flexor
retinaculum.
■ The flexor retinaculum is a strong,
fibrous band that attaches to the pisiform
and the hamulus of the hamate.
Pathophysiology
■ The median nerve passes through this space
along with the flexor tendons and their sheaths.
Increased compartmental pressure for any reason
can squeeze the median nerve, Specifically,
increased pressure can interfere with normal
intraneural blood flow, then causing
physiological changes in the nerve itself.
■ The greater and longer periods of pressure are
associated with greater nerve dysfunction ,Most
cases of carpal tunnel syndrome are idiopathic
(cause unknown), but common known causes are
hypertrophy of the synovial tissue surrounding
the flexor tendons of the forearm, and repetitive
wrist movements
What are the causes of carpal tunnel
syndrome?
Carpal tunnel syndrome is often the result of a combination of factors that increase pressure on the
median nerve and tendons in the carpal tunnel, rather than a problem with the nerve itself.
Contributing factors include trauma or injury to the wrist that cause swelling, such as sprain or
fracture; an overactive pituitary gland; an underactive thyroid gland; and rheumatoid arthritis.
Who is at risk of developing carpal tunnel syndrome?
Women are three times more likely than men to develop carpal tunnel syndrome. People with diabetes
or other metabolic disorders. CTS usually occurs only in adults.
Other factors that may contribute to the compression include mechanical problems in the wrist joint,
repeated use of vibrating hand tools, fluid retention during pregnancy or menopause, or the
development of a cyst or tumor in the canal.
SURGICAL INDICATIONS AND CONSIDERATIONS
The onset of CTS can be classified into two categories:
■ (1) Acute:- Acute CTS is associated with a traumatic event, such as blunt trauma to the wrist, wrist fracture,
infections, vascular disorders, rheumatologic disorders, hemorrhagic problems, burns, and high pressure
injection, injuries. These traumas produce a sudden and sustained increase in interstitial pressure resulting in a
median nerve conduction block from intercompartmental and intraneural ischemia. This form of CTS is a
medical emergency and requires immediate Carpal Tunnel decompression
■ (2) Chronic:- Chronic CTS is the result of an insidious rise of the interstitial pressure in the Carpal Tunnel and
is classified as early, intermediate, or advanced.
1. Early CTS experience mild, intermittent symptoms that have been present less than 1 year
2. Intermediate CTS more constant symptoms, including numbness and paresthesia, usually
worse at night, with little or no atrophy of the thenar muscles. Surgery performed at this time uncovers a nerve
that has undergone chronic changes, including epineural and interfascicular edema. If decompression is
performed at this time, then the neural changes are frequently reversible, although night symptoms may take a
year to resolve
3. Advanced CTS progressive paresthesia, atrophy of the thenar muscles, and pinch and grip
weakness. Even after a successful surgical decompression, the chronic changes in the median nerve may be
permanent
Diagnosis
■ Physical Examination
■ Routine laboratory tests and X-rays can reveal fractures, arthritis, and nerve-damaging diseases such as diabetes.
■ Specific tests may produce the symptoms of CTS. Such as Tinel test, Phalen
■ Electrodiagnostic tests may help confirm the diagnosis of CTSs. In a nerve conduction study, electrodes are placed on
the hand and wrist. Small electric shocks are applied and the speed with which nerves transmit impulses is measured.
In electromyography
■ Ultrasound imaging can show abnormal size of the median nerve
Clinical Electrodiagnostic Studies
Why perform Clinical Electrodiagnostic Studies??
To
■ Confirm a clinical diagnosis
■ Assess severity of the median nerve lesion
■ Provide an objective baseline for future comparison
■ Exclude alternative disease
CTS Grading Scale
0 No Electrodiagnostic abnormality
1 Very mild CTS Abnormality on 2 or more sensitive tests.
Examples of sensitive tests:
– Palm /wrist median-ulnar sensory velocity comparison, increased
– Second lumbrical-interosseous distal motor latency difference,
– Reduced terminal latency index (<0.34).
2 Mild CTS Median sensory velocity <40 m/s, and <50% reduction in median SNAPs compared with
contralateral side, or DML <4.5ms
3 Moderate CTS Reduced median SNAPs and DML >4.5 ms
4 Severe CTS Absent median SNAPs and DML >4.5 ms
5 Very severe CTS DML >6.5 ms, and Reduced APB CMAPs (>0.1 mV
6 Extremely severe CTS APB CMAP <0.1mV, severely wasted muscle
CTS: carpal tunnel syndrome; DML: distal motor latency; APB: abductor pollicis brevis; CMAP: compound muscle action potential; SNAP:
sensory nerve action potential
How is carpal tunnel syndrome treated?
■ Non-surgical treatments :- include
❖ Splinting. Initial treatment is usually a splint worn at night.
❖ Avoiding daytime activities that may provoke symptoms.
❖ Over-the-counter drugs. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin,
ibuprofen,
❖ Prescription medicines. Corticosteroids (such as prednisone) or the drug lidocaine can be
injected directly into the wrist or taken by mouth
❖ Physiotherapy
Physiotherapy
■ The best evidence-based conservative physical therapy treatments for CTS include splinting,
deep pulsed ultrasound (US), nerve-gliding exercises, Carpal bone mobilization, and yoga.
■ Splinting the patient’s wrist can be very helpful in controlling night time pain symptoms. The
wrist is splinted in a neutral position that maximizes the Carpal Tunnel space and minimizes
the Carpal Tunnel pressure.
■ The splint is chosen based on the patient’s needs and comfort.
■ All patients should sleep in their splints. Patients who have constant or activity induced
paresthesia may also wear their splints during the day.
■ When such conservative measures fail to resolve symptoms, surgery is indicated
SURGICAL PROCEDURE
There are three
general surgical
approaches to the
release of the TCL.
1. Classic open
technique
2. limited open palm
technique
3. Endoscopic
carpal tunnel
release (ECTR)
1. Classic open technique:-
The incision starting in the proximal third of the palm is made
that extends proximally along the axis of the ring metacarpal to
the wrist flexion crease and take crossing the volar flexion
crease of the wrist , is divided under direct vision and extended
to the superficial palmar arch distally and approximately 4 to 5
cm proximal to the volar flexion crease of the wrist
The advantage of this approach is the direct exposure to the
median Disadvantages of this approach include an increased
incidence of pillar pain, prolonged healing, prolonged
weakness of grip because of scar tissue
2- limited open palm technique : less invasive procedure , this method a smaller incision
is made in the palm following the same course as the palm segment of the classic open
technique but avoids crossing the volar flexion crease of the wrist, The transverse carpal
ligament has been divided, and the contents of the underlying carpal canal are exposed.
3- Endoscopic carpal tunnel release (ECTR)
■ There are several variations of this technique
including one or two portals—either one proximal to
the wrist crease, one in the mid palm, or both.
■ The endoscopic techniques were developed to
minimize recovery and absence from work.
■ Several studies comparing recovery rates between
open carpal tunnel release and ECTR indicate that the
advantages of ECTR diminish over time and there is
very little difference at 3 months follow-up
■ Complications in all technique include:
■ Injury to the median nerve including the motor
branch
■ Injury to the ulnar nerve
■ Injury to digital nerves; most often the common
digital nerve to the third web space
■ Complex regional pain syndrome
THERAPY GUIDELINES FOR
REHABILITATION
■ Phase I (Inflammatory Phase) TIME: Day 1 to 3 weeks after surgery Treatment of the patient
after Carpal Tunnel release is based on the phases of wound healing and tissue response to
stress. Treatment is directed toward patient education, edema control, scar modification,
restoration of ROM, and strength and full return of hand function. GOALS: Promote wound
healing, maintain tendon excursion, and prevent median nerve from adhering to tendon,
increase digit ROM to within normal limits (WNL) and maintain proximal ROM, decrease
pain, decrease edema, independence with ADL, independence with home program (Table
12-1)
■ Phase Ia TIME: 10 days to 3 weeks postoperative GOALS: Promote scar remodeling,
decrease hypersensitivity and pain, increase wrist ROM to WNL, begin to increase hand
strength, independence in home exercise program (Table 12-2)
■ Phase II (Proliferation Phase) TIME: 3 to 6 weeks after surgery GOALS: Improve
strength and endurance in hand and UE for independence in ADL, progress strength and
endurance in hand to prepare for return to work, return to full-time work activities (Table
12-3) Phase II focuses primarily on strengthening and education (see Table 12-3). It
begins on day 22 after surgery and continues until day 42 (6 weeks after surgery
■ Phase III (Remodeling and Maturation Phase) TIME: 6 weeks after surgery, ending
when the scar is mature. This phase can last for 1 year or longer. GOALS: Adequate
strength to return to full-time work activities, independent home exercise program, self-
management of symptoms (Table 12-4)
Evaluation
.The initial evaluation after Carpal Tunnel release includes the
following:
• Patient history
• Subjective pain report
• Edema measurement
• AROM measurements (Depending on the procedure,
simultaneous finger/wrist flexion may need to be deferred until
3 weeks postoperatively to avoid the risk of bowstringing.)
• Sensibility testing
• Wound and scar assessment
• Documentation of the patient’s previous and present
functional status
After 3 weeks postoperatively, in addition to the above
measurements, the evaluation can include:
• Grip and pinch assessment
• Finger dexterity assessment
• Neural tension testing as needed
• Manual muscle testing (MMT)
the flexor tendons
Forearm—pronation and supination
(begin with 1-2 lb and progress as
indicated.)
Clinical Insight
■ To prevent bowstringing (i.e., subluxing, or anterior displacement, of the flexor tendons
through the healing TCL), simultaneous wrist/finger flexion measurements should be
deferred until 3 weeks after an open incision surgery
■ Early forceful pinch, however, is not recommended until 3 weeks after surgery
■ Within 48 hours of suture removal, scar mobilization techniques may be initiated. Begin
with a light scar massage with lotion and progress to a more vigorous soft tissue
mobilization as tolerated.
■ Neutral wrist splinting can be helpful for controlling tension at the wound site/scar,
helping the patient to avoid simultaneous wrist/finger flexion, but a greater delay in
return to full activity level and less strength in patients who wore a splint postoperatively
for 2 weeks compared with those who did not wear a splint.
■ Composite flexion of the wrist and fingers is generally avoided until 21 days post
operation to prevent bowstringing of the tendons through the healing Carpal ligament
■ The patient can add active wrist flexion exercises after 21 days with the expectation of
full wrist flexion by the end of the sixth week after surgery
Clinical insight
■ The healing response of the nerve may take as much as 3 to 6 months. Besides the use of
anti-inflammatory modalities, wearing a night splint may help keep the wrist in a neutral
position and facilitate the healing response
■ Light retrograde massage may facilitate lymphatic return. Patients with persistent edema
may benefit from wearing a compression glove in conjunction with other edema
controlling modalities. Initially the glove should be worn almost continuously. As the
edema decreases, the patient only needs to wear the glove at night.
THANKS
References :- Rehabilitation for the Postsurgical
Orthopedic Patient, Third Edition 2013

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Carpal tunnel Syndrom Wesam Aljabali -1.pdf

  • 1. CARPAL TUNNEL RELEASE Prepared by :- Wesam Aljabali Supervised by : Dr. Khaled Alsayni
  • 2. Carpal tunnel syndrome (CTS ■ Carpal tunnel syndrome is a condition that develops when one of the major nerves in the wrist becomes pinched. This nerve, called the median nerve, provides sensation and muscle function to the hand and fingers . ■ Carpal tunnel syndrome (CTS) continues to be one of the most significant upper extremity (UE) injuries, with more than 500,000 procedures performed each year.1 It results from compression of the median nerve as it crosses the wrist and is characterized by numbness, tingling, pain, and complaints of weakness in the hand. The symptoms of CTS can range from mild to severe. They may have far- reaching effects on a person’s job, hobbies, and activities of daily living (ADL). ■ The prevalence in the United States of self-reported CTS is approximately 1 to 3 cases per 1000 subjects per year in the adult (working and nonworking) population.3-5 CTS affects people during their most productive years. Its prevalence peaks between the ages of 35 and 44 years for both men and women. Women are three times more likely to be affected than men.
  • 3. Anatomy ■ The carpal tunnel is an anatomical compartment located at the base of the palm. Nine flexor tendons and the median nerve pass through the carpal tunnel that is surrounded on three sides by the carpal bones that form an arch. ■ The carpal tunnel is located at the middle third of the base of the palm. ■ From the anatomical position, the carpal tunnel is bordered on the anterior surface by the transverse carpal ligament, also known as the flexor retinaculum. ■ The flexor retinaculum is a strong, fibrous band that attaches to the pisiform and the hamulus of the hamate. Pathophysiology ■ The median nerve passes through this space along with the flexor tendons and their sheaths. Increased compartmental pressure for any reason can squeeze the median nerve, Specifically, increased pressure can interfere with normal intraneural blood flow, then causing physiological changes in the nerve itself. ■ The greater and longer periods of pressure are associated with greater nerve dysfunction ,Most cases of carpal tunnel syndrome are idiopathic (cause unknown), but common known causes are hypertrophy of the synovial tissue surrounding the flexor tendons of the forearm, and repetitive wrist movements
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  • 6. What are the causes of carpal tunnel syndrome? Carpal tunnel syndrome is often the result of a combination of factors that increase pressure on the median nerve and tendons in the carpal tunnel, rather than a problem with the nerve itself. Contributing factors include trauma or injury to the wrist that cause swelling, such as sprain or fracture; an overactive pituitary gland; an underactive thyroid gland; and rheumatoid arthritis. Who is at risk of developing carpal tunnel syndrome? Women are three times more likely than men to develop carpal tunnel syndrome. People with diabetes or other metabolic disorders. CTS usually occurs only in adults. Other factors that may contribute to the compression include mechanical problems in the wrist joint, repeated use of vibrating hand tools, fluid retention during pregnancy or menopause, or the development of a cyst or tumor in the canal.
  • 7. SURGICAL INDICATIONS AND CONSIDERATIONS The onset of CTS can be classified into two categories: ■ (1) Acute:- Acute CTS is associated with a traumatic event, such as blunt trauma to the wrist, wrist fracture, infections, vascular disorders, rheumatologic disorders, hemorrhagic problems, burns, and high pressure injection, injuries. These traumas produce a sudden and sustained increase in interstitial pressure resulting in a median nerve conduction block from intercompartmental and intraneural ischemia. This form of CTS is a medical emergency and requires immediate Carpal Tunnel decompression ■ (2) Chronic:- Chronic CTS is the result of an insidious rise of the interstitial pressure in the Carpal Tunnel and is classified as early, intermediate, or advanced. 1. Early CTS experience mild, intermittent symptoms that have been present less than 1 year 2. Intermediate CTS more constant symptoms, including numbness and paresthesia, usually worse at night, with little or no atrophy of the thenar muscles. Surgery performed at this time uncovers a nerve that has undergone chronic changes, including epineural and interfascicular edema. If decompression is performed at this time, then the neural changes are frequently reversible, although night symptoms may take a year to resolve 3. Advanced CTS progressive paresthesia, atrophy of the thenar muscles, and pinch and grip weakness. Even after a successful surgical decompression, the chronic changes in the median nerve may be permanent
  • 8. Diagnosis ■ Physical Examination ■ Routine laboratory tests and X-rays can reveal fractures, arthritis, and nerve-damaging diseases such as diabetes. ■ Specific tests may produce the symptoms of CTS. Such as Tinel test, Phalen ■ Electrodiagnostic tests may help confirm the diagnosis of CTSs. In a nerve conduction study, electrodes are placed on the hand and wrist. Small electric shocks are applied and the speed with which nerves transmit impulses is measured. In electromyography ■ Ultrasound imaging can show abnormal size of the median nerve Clinical Electrodiagnostic Studies Why perform Clinical Electrodiagnostic Studies?? To ■ Confirm a clinical diagnosis ■ Assess severity of the median nerve lesion ■ Provide an objective baseline for future comparison ■ Exclude alternative disease
  • 9. CTS Grading Scale 0 No Electrodiagnostic abnormality 1 Very mild CTS Abnormality on 2 or more sensitive tests. Examples of sensitive tests: – Palm /wrist median-ulnar sensory velocity comparison, increased – Second lumbrical-interosseous distal motor latency difference, – Reduced terminal latency index (<0.34). 2 Mild CTS Median sensory velocity <40 m/s, and <50% reduction in median SNAPs compared with contralateral side, or DML <4.5ms 3 Moderate CTS Reduced median SNAPs and DML >4.5 ms 4 Severe CTS Absent median SNAPs and DML >4.5 ms 5 Very severe CTS DML >6.5 ms, and Reduced APB CMAPs (>0.1 mV 6 Extremely severe CTS APB CMAP <0.1mV, severely wasted muscle CTS: carpal tunnel syndrome; DML: distal motor latency; APB: abductor pollicis brevis; CMAP: compound muscle action potential; SNAP: sensory nerve action potential
  • 10. How is carpal tunnel syndrome treated? ■ Non-surgical treatments :- include ❖ Splinting. Initial treatment is usually a splint worn at night. ❖ Avoiding daytime activities that may provoke symptoms. ❖ Over-the-counter drugs. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen, ❖ Prescription medicines. Corticosteroids (such as prednisone) or the drug lidocaine can be injected directly into the wrist or taken by mouth ❖ Physiotherapy
  • 11. Physiotherapy ■ The best evidence-based conservative physical therapy treatments for CTS include splinting, deep pulsed ultrasound (US), nerve-gliding exercises, Carpal bone mobilization, and yoga. ■ Splinting the patient’s wrist can be very helpful in controlling night time pain symptoms. The wrist is splinted in a neutral position that maximizes the Carpal Tunnel space and minimizes the Carpal Tunnel pressure. ■ The splint is chosen based on the patient’s needs and comfort. ■ All patients should sleep in their splints. Patients who have constant or activity induced paresthesia may also wear their splints during the day. ■ When such conservative measures fail to resolve symptoms, surgery is indicated
  • 12. SURGICAL PROCEDURE There are three general surgical approaches to the release of the TCL. 1. Classic open technique 2. limited open palm technique 3. Endoscopic carpal tunnel release (ECTR)
  • 13. 1. Classic open technique:- The incision starting in the proximal third of the palm is made that extends proximally along the axis of the ring metacarpal to the wrist flexion crease and take crossing the volar flexion crease of the wrist , is divided under direct vision and extended to the superficial palmar arch distally and approximately 4 to 5 cm proximal to the volar flexion crease of the wrist The advantage of this approach is the direct exposure to the median Disadvantages of this approach include an increased incidence of pillar pain, prolonged healing, prolonged weakness of grip because of scar tissue
  • 14. 2- limited open palm technique : less invasive procedure , this method a smaller incision is made in the palm following the same course as the palm segment of the classic open technique but avoids crossing the volar flexion crease of the wrist, The transverse carpal ligament has been divided, and the contents of the underlying carpal canal are exposed.
  • 15. 3- Endoscopic carpal tunnel release (ECTR) ■ There are several variations of this technique including one or two portals—either one proximal to the wrist crease, one in the mid palm, or both. ■ The endoscopic techniques were developed to minimize recovery and absence from work. ■ Several studies comparing recovery rates between open carpal tunnel release and ECTR indicate that the advantages of ECTR diminish over time and there is very little difference at 3 months follow-up ■ Complications in all technique include: ■ Injury to the median nerve including the motor branch ■ Injury to the ulnar nerve ■ Injury to digital nerves; most often the common digital nerve to the third web space ■ Complex regional pain syndrome
  • 16. THERAPY GUIDELINES FOR REHABILITATION ■ Phase I (Inflammatory Phase) TIME: Day 1 to 3 weeks after surgery Treatment of the patient after Carpal Tunnel release is based on the phases of wound healing and tissue response to stress. Treatment is directed toward patient education, edema control, scar modification, restoration of ROM, and strength and full return of hand function. GOALS: Promote wound healing, maintain tendon excursion, and prevent median nerve from adhering to tendon, increase digit ROM to within normal limits (WNL) and maintain proximal ROM, decrease pain, decrease edema, independence with ADL, independence with home program (Table 12-1) ■ Phase Ia TIME: 10 days to 3 weeks postoperative GOALS: Promote scar remodeling, decrease hypersensitivity and pain, increase wrist ROM to WNL, begin to increase hand strength, independence in home exercise program (Table 12-2)
  • 17. ■ Phase II (Proliferation Phase) TIME: 3 to 6 weeks after surgery GOALS: Improve strength and endurance in hand and UE for independence in ADL, progress strength and endurance in hand to prepare for return to work, return to full-time work activities (Table 12-3) Phase II focuses primarily on strengthening and education (see Table 12-3). It begins on day 22 after surgery and continues until day 42 (6 weeks after surgery ■ Phase III (Remodeling and Maturation Phase) TIME: 6 weeks after surgery, ending when the scar is mature. This phase can last for 1 year or longer. GOALS: Adequate strength to return to full-time work activities, independent home exercise program, self- management of symptoms (Table 12-4)
  • 18. Evaluation .The initial evaluation after Carpal Tunnel release includes the following: • Patient history • Subjective pain report • Edema measurement • AROM measurements (Depending on the procedure, simultaneous finger/wrist flexion may need to be deferred until 3 weeks postoperatively to avoid the risk of bowstringing.) • Sensibility testing • Wound and scar assessment • Documentation of the patient’s previous and present functional status After 3 weeks postoperatively, in addition to the above measurements, the evaluation can include: • Grip and pinch assessment • Finger dexterity assessment • Neural tension testing as needed • Manual muscle testing (MMT)
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  • 23. the flexor tendons Forearm—pronation and supination (begin with 1-2 lb and progress as indicated.)
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  • 34. Clinical Insight ■ To prevent bowstringing (i.e., subluxing, or anterior displacement, of the flexor tendons through the healing TCL), simultaneous wrist/finger flexion measurements should be deferred until 3 weeks after an open incision surgery ■ Early forceful pinch, however, is not recommended until 3 weeks after surgery ■ Within 48 hours of suture removal, scar mobilization techniques may be initiated. Begin with a light scar massage with lotion and progress to a more vigorous soft tissue mobilization as tolerated. ■ Neutral wrist splinting can be helpful for controlling tension at the wound site/scar, helping the patient to avoid simultaneous wrist/finger flexion, but a greater delay in return to full activity level and less strength in patients who wore a splint postoperatively for 2 weeks compared with those who did not wear a splint. ■ Composite flexion of the wrist and fingers is generally avoided until 21 days post operation to prevent bowstringing of the tendons through the healing Carpal ligament ■ The patient can add active wrist flexion exercises after 21 days with the expectation of full wrist flexion by the end of the sixth week after surgery
  • 35. Clinical insight ■ The healing response of the nerve may take as much as 3 to 6 months. Besides the use of anti-inflammatory modalities, wearing a night splint may help keep the wrist in a neutral position and facilitate the healing response ■ Light retrograde massage may facilitate lymphatic return. Patients with persistent edema may benefit from wearing a compression glove in conjunction with other edema controlling modalities. Initially the glove should be worn almost continuously. As the edema decreases, the patient only needs to wear the glove at night.
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  • 38. THANKS References :- Rehabilitation for the Postsurgical Orthopedic Patient, Third Edition 2013