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
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.

4. Personal Medical History
● HTN
● Past surgeries
○ C-sections with both children
Family Medical History
● Mother
○ Diabetes Mellitus with above knee amputation
● Father
○ Died of Congestive Heart Failure
Social 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

5. 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 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
http://2.bp.blogspot.com/_pDHsByudxY0/S- http://2.bp.blogspot.com/_pDHsByudxY0/S-
Gzw3QvE9I/AAAAAAAAALc/w8FooC8x774/S600/cooking_ Gzw3QvE9I/AAAAAAAAALc/w8FooC8x774/S600/cooking_with

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.
Neuromuscular: Unimpaired.

8. Physician's Tests & Measures
Electromyography (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
(O'Sullivan)

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
is recorded
● Recording electrode over the
abductor pollicis brevis
● Stimulating electrode over the
median nerve at wrist
(O'Sullivan)

10. Tests and Measures

11. Katz Hand Diagram
Patient X results:
Probable/Classic Pattern
http://jama.ama-assn.org

12. Tinel's Test
Light tapping over site of median nerve as it runs through the carpal
tunnel, at distal wrist crease.
http://www.med.und.edu/users/jwhiting/tinel.html
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.
http://www.positivehealth.com
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.
http://www.wisdomking.com/product/semmes-weinstein-monofilament-
aesthesiometer-10
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:
//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

16. Range of Motion
http://www.netterimages.com/image/measurements.htm
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
http://thetahealingevolutions.com/theta-
http://www.accessphysiotherapy.com
healing/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
(digit 1)
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
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 one's hands for relief
during maximal symptoms
● Loss of 2-point discrimination in the
median nerve distribution

21. 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 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
● 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 time
PT Diagnosis: 5F Impaired Peripheral Nerve Integrity
and Muscle Performance Associated With Peripheral
Nerve Injury

25. Prognosis
Carpal tunnel syndrome can range from a minor discomfort to a
disabling condition.
● 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
STG:
● 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
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.

28. Interventions
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
semester!
○ 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

31. Tendon Gliding Exercise
● Which tendons
are being used
in which
motions?
● 4 FDS
● 4 FDP
● FPL

32. Nerve Gliding Exercise
These exercises are
designed to glide the
median nerve
through the tunnel
without irritation.

33. Functional training in self-care and
home managment
• Injury prevention and reduction: with use of protective devices
and equipment, safety awareness training during self-care and
home 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).

34. 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, Tinel's and Phalen's signs with
real LLLT and TENS over the sham LLLT and TENS (Naeser et
al).

35. 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).

36. Other Interventions
● Yoga
○ More effective than no treatment or splinting alone
(Garfinkel et al)
○ Short term benefits (O'Connor 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).

37. 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

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:
○ LASER
○ TENS
○ 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
literature:
Efficacy of surgical release of
carpal 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

40. Questions?
http://graphics8.nytimes.com/images/2007/08/01/health/adam/19242.jpg

41. References
Burke, 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): 372-73
Campbell 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>
D'Arcy 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.

42. References
Norvell, J. and Steele, M. Carpal Tunnel Syndrome. eMedicine Specialties. 10 Sep 2009
<http://emedicine.medscape.com/article/ 822792-print>.
O'Sullivan 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.
O'Connor 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. 201
D’Arey DC and McGee S. Does this patient have carpal tunnel syndrome? The Journal of the American Medical
Association. 283(23); 2000: 3110-3117.

43. References
Hansen 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: 363-367
DW 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.