diagnosis and treatment of carpal tunnel syndrome
TRANSCRIPT
![Page 1: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/1.jpg)
Diagnosis and Treatment of Carpal Tunnel Syndrome
www.fisiokinesiterapia.biz
![Page 2: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/2.jpg)
Overview of Peripheral Neuropathies
![Page 3: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/3.jpg)
Clinical Terminology
Peripheral Neuropathy (Neuritis)Damage or destruction of nerves outside brain and spinal cordAxonal lossMyelin loss Mixed loss Usually begins distally and progresses proximally
![Page 4: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/4.jpg)
Clinical Terminology
RadiculopathyAny disease of the spinal nerve roots and spinal nerves Synonymous with radiculitis
![Page 5: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/5.jpg)
Common Causes
EntrapmentAdjacent soft tissue structuresAberrant bone growthsFluid cystsEdemaProlonged poor positioningPoor fitting orthotics
Direct InjurySystemic disease
![Page 6: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/6.jpg)
Clinical Terminology
Motor neuropathyMotor axons affected
Sensory neuropathySensory fibers affected
Sensorimotor neuropathyMost common form of neuropathySensory and motor axons affected
![Page 7: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/7.jpg)
Loss of Sensory Fibers
Perception of abnormal sensationsDecreased sensationLack of sensationProprioceptive changes
![Page 8: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/8.jpg)
Loss of Motor Fibers
Impairs movement or functionWeakness, decreased movement or control of movementStructural changes in muscle, bone, skin, hair, nails, and body organsAtrophy
![Page 9: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/9.jpg)
Loss of Autonomic Fibers
Anhidrosisabsence of sweating
Decreased ability to regulate temperature
![Page 10: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/10.jpg)
Clinical Terminology
MononeuropathyDamage to single nerve or nerve group
PolyneuropathyDamage to multiple nerves
![Page 11: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/11.jpg)
Clinical TerminologyMononeuropathy Multiplex
At least 2 nerve areasAxonal destruction caused by lack of oxygen to local blood vesselsCommon causes are polyarteritisnodosum, diabetes mellitus, systemic lupus erythematosus, Wegener’s granulomatosis, or rheumatoid arthritisPain in multiple peripheral nerve distributions
![Page 12: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/12.jpg)
Upper Extremity Entrapment Neuropathy
Multiple Sites and Multiple Causes
![Page 13: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/13.jpg)
Differential Diagnosis
•• RadiculopathyRadiculopathy•• PlexopathyPlexopathy (Thoracic Outlet Syndrome)(Thoracic Outlet Syndrome)•• CubitalCubital Tunnel SyndromeTunnel Syndrome•• Radial Radial -- Spiral Groove TunnelSpiral Groove Tunnel•• PronatorPronator SyndromeSyndrome•• GuyonGuyon’’ss CanalCanal
![Page 14: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/14.jpg)
Cervical RadiculopathySpinal nerve root dysfunction - Root compression from protruded or herniated cervical intervertebral disc
Nerve root signs- paresthesias, decreased reflexes, sensory loss, and weakness in distribution of compressed nerve rootSpinal cord compression- spastic paraparesis with hyperactive DTRs (MSRs)Neck pain, muscle spasmC7 most common (31-81%)C6 (19-25%), C8 (4-10%), C5 (2-10%)
![Page 15: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/15.jpg)
The brachial plexus travels between the clavicle and the upper ribs
Brachial Plexus
![Page 16: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/16.jpg)
Plexopathies
Erb-Duchenne palsy - upper trunk (C5-6)“porter’s tip position”Forceful separation of the head and shoulder
Motorcycle accidentsWorse prognosis than infra-clavicular injuries
Klumpke-Dejerine palsy (C8-T1)Loss of muscles in the hand, loss sensation of ulnarnerveHorner’s syndrome (hyposympathetonia)
Ptosis, miosis, anhidrosisApical lung tumor, Pancoast tumor
![Page 17: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/17.jpg)
Plexopathies
Brachial plexus neuritisNeuralgic amyotrophy, Parsonage-Turner SyndromeAbrupt onset
Shoulder and neck pain (often beginning at night), worse by arm movementPain subsides then note paralysis Often associated with preceding illness or stress
![Page 18: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/18.jpg)
Thoracic Outlet Syndrome
Controversy in providing precise definitionNeuropathy of the brachial plexusCompression vasculopathy of subclavian vesselsMusculoskeletal dysfunction can involve: cervical rib, 1st rib and clavicle, scalenes (anterior, middle, and minimus), pectoralis minor (and major), scapula protraction, serratus anterior, subscapularis
![Page 19: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/19.jpg)
Ulnar Nerve Entrapment
Elbow2nd most common entrapment neuropathyEntrapment at the ulnar groove or cubital tunnel (two heads of the flexor carpi ulnaris)Sensory changes of 4th and 5th digitsFailure of active finger extension in ring (3rd) and “pinky”(4th)Clawhand if loss of all intrinsics
Hypothenar eminenceGuyon’s canal
![Page 20: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/20.jpg)
Ulnar Nerve Entrapment
Hypothenar eminenceLess commonGuyon’s canal
![Page 21: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/21.jpg)
Radial Neuropathy
Wrist dropDifficulty with extension of fingersPressure on radial nerve in axilla or upper armCrutch palsy and Saturday night palsy
![Page 22: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/22.jpg)
Median Nerve Entrapment
Not Just Carpal Tunnel Syndrome
![Page 23: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/23.jpg)
Median Nerve Entrapment
Shoulder – rare, usually traumaticElbow Region
1. Ligament of Struthers2. Pronator Syndrome3. Anterior Interosseous Nerve Wrist: Carpal Tunnel Syndrome
![Page 24: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/24.jpg)
Ligament of Struthers
Runs from medial epicondyle to aberrant bone spur 5cm above medial epicondyle.Present in 0.7 to 2.7% of population.Pain above elbow and local tenderness in region of ligament. Usually vague, mild, nonspecific symptoms.X-ray for supracondylar process.
![Page 25: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/25.jpg)
Pronator SyndromeCompression of median nerve as it passes:
Beneath the lacertus fibrosisBetween the superficial and deep head of the pronator teresBeneath the flexor superficialis arch
Classic findings: Exercise induced arm painTender pronator teresPositive Tinel’s over proximal forearmPalmar cutaneous and median n. hypesthesias
![Page 26: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/26.jpg)
Carpal Tunnel SyndromeIt results from compression/injury of the median nerve at the wrist within the compartment defined by the transverse carpal ligament (aka flexor retinaculum).
![Page 27: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/27.jpg)
Epidemiology &Demographics
Carpal Tunnel Syndrome is the most common entrapment neuropathy
2-3 Million in U.S10% Lifetime Incidence1% of Adult Population, 15% of High Risk PopFemale (30-60); Male Industrial (35-40)Prevalent sex: Females 5x’s > MalesBilateral up to 50%
![Page 28: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/28.jpg)
Carpal Tunnel Syndrome
Sensory component involved earlier than motor component
Autonomic disturbances are common55 % of CTSOccurring with increasing severity of electrophysiologic findingsConsisted of swelling of the fingers, dry palms, Raynaud’s phenomenon, and blanching of the hand
![Page 29: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/29.jpg)
Natural Hx: Duration of Symptoms
32% less than 6 months20% 6 months to 2 years48% greater than 2 years
![Page 30: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/30.jpg)
History & Physical Findings
Nocturnal painMedian nerve paresthesia (often only index & long finger)Positive Tinel’sTwo-point discrimination >5mm
Positive Phalen’s(1 min. of gentle flexion)Wormser (Reverse Phalen)Carpal compression Thenar atrophy: long
standing cases
![Page 31: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/31.jpg)
Mild/Moderate CTS
Intermittent pain and numbness in the fingers (1st–2nd)Pain and numbness:
Often occurs at nightDiminishes with gentle hand activity
but rapidly returns with grasping or pinching
![Page 32: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/32.jpg)
Severe CTS
Constant numbnessSevere painPinch becomes clumsy and weakThenar/thumb muscle atrophy
![Page 33: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/33.jpg)
Observation
Coarse hair, dry skin, thick fingernails, myxedema faciesAsymmetry of carrying angle at the elbowsThenar wasting, edemaErythemaRheumatoid nodules, ulnar drift of digitsHeberden’s (DIP) and Bouchard’s (PIP) nodes
![Page 34: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/34.jpg)
Screening Exam
Joint line tendernessTrigger/tender points in forearm and handTension in palmar fasciaTissue texture changesScreening for significant somatic dysfunction from C-spine to distal upper extremityRange of Motion: Cervical spine, shoulders, elbows, wrist, hand (% fist)
![Page 35: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/35.jpg)
Screening Exam
Neurological ExamForaminalcompression (Spurling’s) testDistraction testDTR’s (MSR’s)
biceps (C5)brachioradialis (C6)triceps (C7)
Muscle Strength: deltoid (C5)biceps (C5/C6) wrist extensors (C6) triceps (C7) wrist flexors (C7) finger flexors (C8) interossei (C8/T1)
![Page 36: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/36.jpg)
Muscle Stretch Reflexes (DTRs)
Upper motor neuron signs and symptomsHyper-reflexia, clonus, spasticity
Lower motor neuron signs and symptomsWeakness, atrophy, fasciculations, hypo-reflexia
![Page 37: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/37.jpg)
Screening ExamSensory Testing
Special TestingOpponens Strength TestTinel’s SignPhalen’s and Reverse Phalen’sTest
Checking sensationLight touch, vibration, proprioceptionPain, pinprick, temperature
Secondary sensationsStereoagnosis
loss or lack of the ability to understand the form and nature of objects that are touched
Double simultaneous stimulationGraphesthesia
the sense by which figures or numbers are recognized when written on the skin with a dull-pointed object.
![Page 38: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/38.jpg)
Palpation
Palpate for tension in transverse carpal ligament by inducing hyperextension at the proximal and distal carpal rows.
Proximal Carpal Row Distal Carpal Row
![Page 39: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/39.jpg)
Palpation
Palpate for tension in transverse carpal ligament by inducing thenar hyperextension.
![Page 40: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/40.jpg)
Somatic Dysfunction
Ulnohumeral JointAbduction -olecranon process glides mediallyAdduction -olecranon glides laterally
![Page 41: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/41.jpg)
Ulnar Treatment
Kimberly Manual Millennium Edition 2002
![Page 42: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/42.jpg)
Somatic Dysfunction
Proximal Radial Headreciprocal motion of radial head relative to distal radiuspronated hand: proximal radius head glides posteriorly (PP)supinated hand: opposite occurring with anteriorglide at the proximal radial head
![Page 43: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/43.jpg)
Proximal Radial Head Treatment
Muscle energy for posterior radial head:
Supinate to restrictive barrier. Pronate against physician counterforce.
Kimberly Manual Millennium Edition 2002
![Page 44: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/44.jpg)
Somatic Dysfunction
Radioulnar InterosseousMembrane
Functional symmetry & stabilityFibers extend cephalad from ulna to proximal radiusAllows bones to share forces of compression from hand upward or shoulder downward
![Page 45: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/45.jpg)
Interosseous Treatment
Gently separate the radius and ulna while patient attempts to supinate their hand against physician counterforce
Kimberly Manual Millennium Edition 2002
![Page 46: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/46.jpg)
Somatic Dysfunction
Radiocarpal JointFlexion: carpal bones glide dorsally (posterior)Extension: bones glide ventrally (anterior) Abduction: bones glide mediallyAdduction: bones glide laterally
![Page 47: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/47.jpg)
Somatic Dysfunction
Intercarpal Joints8 carpal bonescompression component to many different facet facingsfrom fall on outstretched handdiagnose by locating pain with wrist compression & check ant./post. med/lat glide
![Page 48: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/48.jpg)
Articular Treatment
Gently squeeze area over dysfunction
Then take wrist through an articular range of motion
Kimberly Manual Millennium Edition 2002
![Page 49: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/49.jpg)
Differential DiagnosisCervical radiculopathyThoracic Outlet SyndromeChronic tendinitisMuscular trigger pointsVascular occlusionReflex sympathetic dystrophyOsteoarthritisOther entrapment neuropathies
![Page 50: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/50.jpg)
Etiology
Idiopathic (most common)Space-occupying lesions (tenosynovitis, ganglia, aberrant m.)HypothyroidismDiabetesPregnancy
CHFMechanical overuseRheumatoid arthritis TraumaMultiple myelomaChronic renal failureAmyloidosisAcromegaly
![Page 51: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/51.jpg)
StudiesRoutine roentgenograms (X-rays)
may be helpful in r/o other conditions (ligament of Struthers)
Nerve conduction velocity & electromyography studiesMRI and ultrasound Appropriate lab tests for secondary CTS
![Page 52: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/52.jpg)
Treatment of CTS
Standard1. NSAIDs-oral/topical2. Orthoses3. Rest4. Steroids (oral, injection)5. SurgeryOsteopathic manipulationActivity modification -work site, ergonomics, etc
Stretching exercise1. Manual, self-stretch,
devices (the CTS)2. Nerve and tendon
“gliding”
Physical medicine modalities:1. Ultrasound - 3mhz;
around edges of canal2. Iontophoresis - directly
over nerve
![Page 53: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/53.jpg)
Oral Therapy Chang MH, et. al., Neurology, Aug ‘98
Placebo-controlled, double-blinded (73 pt.)Diuretic vs. NSAID vs. Steroid Prednisone 20mg qd x 2 wks then 10mg x 2 wkOnly pt’s in steroid group had significant symptom improvement
![Page 54: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/54.jpg)
Manipulation
C-spineUpper T-spineThoracic InletRibs
Upper extremityClavicle (SC & AC)ScapulaGlenohumeral jointElbowInterosseous membranewrist
![Page 55: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/55.jpg)
Techniques
Treat articular and fascialdysfunction in the region
Treat sympathetics to upper extremities T2-7
Direct Release of Transverse Carpal Ligament
Trigger PointsSpray & stretch
InjectionCounterstrain, MET, HVLA, etc
![Page 56: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/56.jpg)
Trigger PointsBrachioradialisRadial wrist extensorsFlexor carpi radialisPronator teresOpponens pollicisAdductor pollicisPalmaris longus
![Page 57: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/57.jpg)
Direct Techniques
1. Transverse carpal extension2. Thenar myofascial release3. Hyperextension of wrist and fingers4. Guy wire5. Combined technique
Techniques involve direct stretch for 1-2 minutes
![Page 58: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/58.jpg)
Transverse Carpal Extension
Apply three point pressureMedial border of the carpal ligamentLateral border of carpal ligamentRadial abduction with extension of the thumb
May be performed at proximal or distal carpal rows
Sucher BM: Myofascial release of carpal tunnel syndrome. JAOA 93:93, 1993.
![Page 59: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/59.jpg)
Thenar Myofascial Release
Add the following:Lateral axial rotation (opponens roll)
Sucher BM: Myofascial release of carpal tunnel syndrome. JAOA 93:93, 1993.
![Page 60: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/60.jpg)
Hyperextension of wrist and fingers
Add the following:Hyperextension of wrists and fingers
Sucher BM: Myofascial release of carpal tunnel syndrome. JAOA 93:93, 1993.
![Page 61: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/61.jpg)
Guy-Wire Technique
Adds additional extension and abduction of fifth digitWithout axial rotation of the thumb
![Page 62: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/62.jpg)
Combined Technique
Adds additional extension and abduction of fifth digitAdds Axial rotation of the thumb
![Page 63: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/63.jpg)
Osteopathic ManipulationSucher, et. al., JAOA, Dec. ‘93
Myofascial release of CTS: Documentation with MRIShowed improvement in nerve conduction velocity (NCV), MRI and subjective symptomsSmall study (larger study in progress)
![Page 64: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/64.jpg)
Self Stretches:Thenar Technique
Induce thenar abduction and extension by reaching over or under forearm
![Page 65: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/65.jpg)
Self Stretches - Knee
1. Hyperextend wrist 2. Abduct and extend
thumb3. Axial rotation of thumb
1
3
2
![Page 66: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/66.jpg)
Self Stretches - Wall
Fingers together - Target the forearm Fingers apart - Target the wrist
![Page 67: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/67.jpg)
Treatment and Self Stretches
Focus on where tension is greatestDistal carpalProximal carpal rowThenar tensionForearm tensionArticular restrictions
![Page 68: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/68.jpg)
Physical TherapySeptember 1995, Journal of Hand Surgery
1 minute of hand and wrist exercisesSignificantly decreased carpal tunnel pressuresAuthors rec. brief intermittent wrist and hand
exercises before, during and after work
![Page 69: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/69.jpg)
UltrasonographyEbenbichler GR, et al. BMJ, Mar ‘98
Randomized, placebo controlled (34 pt)Ultrasound (US) therapy qDaily x 10 days then
2X/wk x 5 wks74% of treated group: satisfactory
improvement to complete relief of sx’s with motor and sensory improvement on EMG20% of “sham” groupStudy was followed for 6 months
![Page 70: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/70.jpg)
Surgical ReleaseMorgenlander JC, et. al., Neurology, Oct’97
Retrospective study of 32 patients with PNNocturnal paresthesias, pain and weakness relieved almost universallyPt’s in study stated they would have the same procedure done againIndications: persistent numbness, weakness &/or thenar atrophy
![Page 71: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/71.jpg)
Surgical Treatment
Bland JDP: Do nerve conduction studies predict the outcome of carpal tunnel decompression? Muscle & Nerve 24: 935-940, 2001
Pre-operative neurophysiological grade 2-4 demonstrated the best outcomes with surgical treatment.
![Page 72: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/72.jpg)
Pre-operative neurophysiological grade
Bland JDP: Do nerve conduction studies predict the outcome of carpal tunnel decompression? Muscle & Nerve 24: 935-940, 2001.
![Page 73: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/73.jpg)
Pre-operative neurophysiological grade
Bland JDP: Do nerve conduction studies predict the outcome of carpal tunnel decompression? Muscle & Nerve 24: 935-940, 2001.
![Page 74: Diagnosis and Treatment of Carpal Tunnel Syndrome](https://reader031.vdocuments.site/reader031/viewer/2022020703/61fb2d212e268c58cd5b0e69/html5/thumbnails/74.jpg)
Indications electro diagnostic evaluation and/or surgery
Persistent numbnessSevere painWeakness – opposition, clumsy pinchThenar atrophyFailure of conservative tx