Definition:
Carpal tunnel syndrome is the most common and widely studied nerve entrapment syndrome. It is caused by compression of the median nerve at the wrist as it passes through a space-limited canal.
The carpal canal is known as carpal tunnel that contains the wrist bones, transverse carpal ligament, median nerve, and digital flexor tendons.
So, edema, tendon inflammation, and manual activity can contribute to increased nerve compression and sometimes cause pain. In more severe cases, weakness of median nerve innervated muscles can occur, resulting in hand weakness.
Causes:
One of the causes of carpal tunnel syndrome is the increased intra-canal pressure have been implicated, and sustained pressures may cause damage to the median nerve by compromising the blood flow. This increase in pressure with flexion or extension of the wrist, and that maximum resting pressures occurs in the early morning, corresponding with symptoms.
Increases in the content of the carpal tunnel, such as tenosynovitis or synovial fibrosis, are one potential cause of an increase in canal pressure.
Some studies have demonstrated that loading by Palmaris longus can increase canal
pressure. The presence of a Palmaris longus is an independent risk factor for carpal tunnel syndrome.
Sings and symptoms:
- paraesthesiae, pain and numbness in the fingers and thumb in the
- distribution of the median nerve.
- Numbness or tingling in the sensory distribution of the nerve in the hand.
- In severe cases, weakness of the muscles of thumb abduction and opposition.
Risk Factors:
- Diabetes Mellitus.
- Menopause.
- Hypothyroidism .
- Obesity.
- Arthritis.
- Pregnancy.
- Computerized (keyboard or mouse).
- Tobacco smoking.
Assessment:
Special Tests
1)Phalens test:
Ask the patient to report any sensory changes in the median nerve after holding his wrists flexed and pressed against each others for 1 minute as in the picture. The intercarpal pressure is greatest with wrist flexed 90 degrees.
2) Tinel sign
The therapist taps the patient’s hand from the fingertips proximally to the palm
and asks the patient to report any electric shock’s or tingling when percussed along the distribution of median nerve.
Treatment:
1)Exercises:
A)Nerve tendon glide exercise:
These exercises are to mobilize the median nerve in the carpal tunnel. the median nerve is mobilized by putting the hand and wrist in six different positions as in the picture. In these exercises, the neck and the shoulder are in a neutral position, and the elbow is in supination and bent at 90 flexion.
The stretch over the nerve may be increased by bending the head to the opposite side and the shoulder is kept in neutral position.
ask the patient to place his fingers in five discrete positions. Those are straight, hook, fist, table top, and straight fist, and maintaun position for 5 seconds.
B)Range of motion exercises for the wrist:
Wrist flexion and extension:
The patient is sitting and his forearm is resting on the arm rest of the chair while his wrist is out.
Wrist flexion
Ask the patient to hold his palm up facing the ceiling. The therapist will be sitting in front of the patient, one of the therapist hand will be holding the wrist to prevent the patient from moving his forearm in flexion instead of his wrist.
Then, the therapist will ask the patient to move his wrist upward so his fingers will be pointing towards the ceiling. The therapist may increase the difficulty of exercise by putting his other hand over the patient’s fingers and giving him resistance. Repeat this exercise 20 times per day, hold for 3 seconds each time.
The therapist could use this exercise as a stretch exercise for the wrist extensors while Strengthening the wrist flexors at the same time.
If the therapist wants to stretch the wrist extensors, the hand of the patient will be in this exact position and the therapist holds the wrist in its place, and then moving the patient’s hand in flexion till the end of the range and hold for 15-30 seconds. Instruct the patient to perform this exercise 10 times daily.
wrist extension
repeat the same exercise but with the palm is held down facing the floor. This exercise could be considered as a stretch exercise for the wrist flexors while Strengthening the wrist extensors at the same time.
If the therapist wants to stretch the wrist flexors, the hand of the patient will be in this exact position and the therapist holds the wrist in its place, and then moving the patient’s hand in extension till the end of the patient’s range and hold for 15-30 seconds. Instruct the patient to perform this exercise 10 times daily.
2) Neural mobilization:
Neural mobilization maneuver is recently used to treat carpal tunnel syndrome. The patient will be sitting or laying on his back. The position of the upper limb: shoulder girdle depression, shoulder abduction, elbow extension, forearm supination, wrist extension, and finger extension. Median nerve mobilization maneuver includes wrist flexion-extension as in the picture.
3) Splints:
a standard light-weight wrist splint with a metal strip extending across the wrist to the mid-palm region). The splint is bending so the wrist will be in a neutral position. Ask the patient to wear the splints at night and during aggravating daytime activities for 3 months.
4) Electrotherapy:
Ultrasound:
Therapeutic ultrasound is a modality that produces high-frequency vibrations with both thermal and non-thermal effects. Deep, pulsed ultrasound over the carpal tunnel for 15 min for 20 treatments decreases pain and paresthesia symptoms, reduces sensory loss, and improves median nerve conduction.
Also Read: https://ptpainite.com/low-back-pain/
References
- Padua L, Coraci D and Erra C, et al.(2016) : “Carpal tunnel syndrome: Clinical features, diagnosis, and management.” Lancet Neurol.Edition;15(12):1273‐1284.
- Middleton.SD and Anakwe RE.(2014) : “Carpal tunnel syndrome.” BMJ. Edition;(349):g6437.
- Hamanaka I, Okutsu I, Shimizu K, et al. Evaluation of carpal canal Pressure in carpal tunnel syndrome. J Hand Surg [Am] 2007; 20:848–854.
- Ettema AM, Amadio PC, Zhao C. 2006Changes in the functional Structure of the tenosynovium in idiopathic carpal tunnel syndrome: a Scanning electron microscope study. PlastReconstrSurg; 118:1413–1422.
- Schuind F, Ventura M, Pasteels JL.2009 Idiopathic carpal tunnel Syndrome: histologic study of flexor tendon synovium. J Hand Surg [Am]; 15:497–503.
- Keese GR, Wongworawat MD, Frykman G.2006The clinical Significance of palmarislongus tendon in the pathophysiology of carpal Tunnel syndrome. J Hand Surg [Br]; 31:657–660.
- Presazzi, A., Bortolotto, C., Zacchino, M., Madonia, L., &Draghi, F. (2011). Carpal tunnel: Normal anatomy, anatomical variants and Ultrasound technique. Journal of Ultrasound, 14(1), 40–46.
- Gökoglu, F., Fndkoglu, G., Yorgancoglu, Z. R., Okumus, M., Ceceli, E., &Kocaoglu, S. (2005). Evaluation of iontophoresis and local Corticosteroid injection in the treatment of carpal tunnel syndrome. American journal of physical medicine & rehabilitation, 84(2), 92-96.
- Baysal, O., Altay, Z., Ozcan, C., Ertem, K., Yologlu, S., &Kayhan, A. (2006). Comparison of three conservative treatment protocols in carpal Tunnel syndrome. International journal of clinical practice, 60(7), 820-828.
- Esfehani, M., Haghighatzadeh, M., &Yekta, A. H. (2019) : “The Effectiveness of Exercise Therapy and Dry Needling on Wrist Range of Motion, Pinch and Grip Force in Carpal Tunnel Syndrome: A Randomized Clinical Trial.” Asian Journal of Sports Medicine, Edition10(4).
