الرئيسية
أحدث الصور
من طرف Carpal Tunnel Syndrome (CTS) R.
Carpal tunnel syndrome is the compression of median nerve at the level of the carpal tunnel.
What are the common causes of CTS?
Any factor that increases the intercarpal pressure, which may be:
Decrease in tunnel size as caused by trauma; dislocation or fracture.
Increase in tunnel contents secondary to tenosynovitis, thickening of the transverse carpal ligament,…etc.
Increase in the intercarpal pressure caused by repetitive posture, movements and upper limbs weightbearing activities e.g. simultaneous wrist and finger flexion, repetitive wrist flexion-extension, keyboard typing, crutch walking and the use of wheelchair.
What complaints we expect to hear from our patients?
Numbness and/or pain along the distribution of median nerve in the hand.
Weakness of the muscles supplied by the median nerve especially the thenar muscles.
Occasional, burning shoulder pain may be felt.
What findings we should look for, when examining our patients?
Inspection of skin pseudomotor changes.
Atrophy of thenar muscles
Altered or diminished sensation in the thumb, index, long and radial aspect of ring finger.
Positive Tinel's sign.
Positive Phalen's test.
Decreased grip strength.
Increased median sensory and/or motor distal latency.
Abnormal x-ray findings especially in cases of trauma or diseases such as arthritis.
Physiotherapy for unoperated cases
1. Splint your patient's hand by a volar neutral wrist splint. It is to be used continuously day and night for 4-6 weeks with gradual weaning of the splint over the subsequent 4 weeks.
Instruct your patient to avoid wrist and hand postures that increase the intercarpal pressure, these include:
Gripping or pinching objects while flexing the wrist.
Gripping a tool by ulnarly deviating the hand.
Performing repetitive wrist flexion-extension movements.
Control inflammation through ice packs, tendon glideing exercises performed 5 times each, 5 times daily, and elevated activities.
You can use different modalities that help in controlling inflammation and/or reducing pain such as::
High voltage galvanic stimulation.
TENS.
Contrast bath: cool water for 30 sec. alternatively with warm water for 30 sec, all for 15-30 min.
Iontophoresis: 3 mA using 1 cm of lidocaine with epinephrine and 1 cm of dexamethasone for 20 min.
Infra-red Laser with frequency of 2500 Hz, applied over 5 points; one at the middle of wrist flexion crease, the second 1cm below, the third 2 cm below, the fourth is 1cm above and radially over the thenar muscles and the last point is 2cm above and radially. Laser is applied for 120 sec. over each point.
Phonophoresis: 1watt, continuous mode for 5- 15 min. over the area of carpal tunnel using diethylamine Salicylate (Reparil gel for example)
Physiotherapy following decompression surgery
For the first 3 weeks:
1. Allow protected use of the hand, by a volar cast worn for one week followed by a thermoplastic splint.
2. Control edema by encouraging overhead hand elevation and by applying retrograde massage.
3. Maintain ROM by applying tendon glide exercises; 10 repetitions, 3 times daily in addition to shoulder ROM exercises in all directions.
From 3 to 8 weeks
1. Control edema by encouraging elevated hand activities such as elevated fisting exercises repeated 10 times per hour and retrograde massage.
2. Try to model surgical scar by applying Elastomers and gentle friction massage over the scar.
3. To minimize pain from painful neuromas, teach your patient the desensitization program. This program consists of 3 phases. The first phase involves holding objects of different textures, the second involves holding objects of different shapes and the last involves the use of vibrator of different frequencies. Always start with what the patient can bear hardly then progress as the patient improves.
4. Increase strength and functional use of hand: isometric and isotonic exercises for the wrist and hand can be initiated by the 8th week (N.B: never overexercise your patient).
5. Restore ROM by applying nerve gliding exercises, tendon gliding exercises and passive thumb stretching (3 times per day, each 10 repetitions).
From 8-12 weeks
Start preparing your patient to return to his job by initiating work hardening. Initially light tasks can be performed before starting work simulation exercises. A special attention should be paid to modify work environment especially in work-related cases. Abundant use of ergonomically designed handles should be considered as well as routine during-work preventive exercise regimen.
Can we prevent CTS?!
We can minimize the risk of CTS by altering the way a person performs repetitive activities. For example, replacing old tools with ergonomically designed new ones.
Rest Periods and Avoiding Repetition. Advise a predisposed subject to begin his work with a short warm-up period, take frequent break periods, and avoid overexertion of the hand and finger muscles whenever possible..
Good Posture. Good posture is extremely important in preventing CTS, particularly for typists and computer users. A keyboard operator should sit with the spine against the back of the chair with the shoulders relaxed, the elbows along the sides of the body, and wrists straight. The feet should be firmly on the floor or on a footrest. Typing materials should be at eye level to minimize neck flexion. Chairs should be adjustable for height, with a supportive backrest.
Techniques and Tools for Reducing Force.
Teach your patient how to keep his wrist as neutral as possible during performing his job tasks. Also, teach him the importance of performing job adjustment to minimize stresses over his wrist and fingers. For example, advise a Keyboard operator to adjust the tension of the keys so that depressing the keyboard does not cause fatigue and to keep his hand and wrist in a relaxed position to avoid excessive force on the keyboard. Wrist rests, which fit under most keyboards, can help keep the wrists and fingers in a comfortable position. Recommend keeping the mouse as close to the keyboard and the computer users body as possible to reduce shoulder muscle movement and to hold the mouse lightly with the wrist and forearm relaxed.
Reducing Vibration. Protective equipment, such as shock absorbers, can reduce vibrations emitted from some tools. For example, tell a Bicyclist who ride frequently on rough roads to wear thick cycling gloves to lessen the shock transmitted to the hands and wrists.
Exercise
Hand and wrist exercises may help reduce the risk of developing CTS. Isometric and stretching exercises can strengthen the muscles in the wrists and hands, as well as the neck and shoulders, improving blood flow to these areas. Performing the following simple exercises for four to five minutes every hour (5-10 repetitions with holding 5 sec per each) may be helpful to your patient.
Wrists.
Wrist circles., and active finger flexion-extension exercises.
Active thumb palmar flexion and abduction.
Isometric and isotonic exercises for all wrist movements.
Wrist and finger flexors stretch with fingers first adducted then abducted.
Forearms
Teach your patient how to perform self-stretching of forearm flexor muscles.
Neck and Shoulders.
Self-stretching of trapezius, scaleni and sternocleidomastoid muscles from seated position.
Active shoulder shrugging, depression, protraction and retraction to minimize tense shoulder muscles.
General Exercise. A regular exercise regimen using a combination of aerobic and resistance training techniques strengthens the muscles in the shoulders, arms, and back, helps reduce weight, and improves overall health and well-being.
Carpal tunnel syndrome is the compression of median nerve at the level of the carpal tunnel.
What are the common causes of CTS?
Any factor that increases the intercarpal pressure, which may be:
Decrease in tunnel size as caused by trauma; dislocation or fracture.
Increase in tunnel contents secondary to tenosynovitis, thickening of the transverse carpal ligament,…etc.
Increase in the intercarpal pressure caused by repetitive posture, movements and upper limbs weightbearing activities e.g. simultaneous wrist and finger flexion, repetitive wrist flexion-extension, keyboard typing, crutch walking and the use of wheelchair.
What complaints we expect to hear from our patients?
Numbness and/or pain along the distribution of median nerve in the hand.
Weakness of the muscles supplied by the median nerve especially the thenar muscles.
Occasional, burning shoulder pain may be felt.
What findings we should look for, when examining our patients?
Inspection of skin pseudomotor changes.
Atrophy of thenar muscles
Altered or diminished sensation in the thumb, index, long and radial aspect of ring finger.
Positive Tinel's sign.
Positive Phalen's test.
Decreased grip strength.
Increased median sensory and/or motor distal latency.
Abnormal x-ray findings especially in cases of trauma or diseases such as arthritis.
Physiotherapy for unoperated cases
1. Splint your patient's hand by a volar neutral wrist splint. It is to be used continuously day and night for 4-6 weeks with gradual weaning of the splint over the subsequent 4 weeks.
Instruct your patient to avoid wrist and hand postures that increase the intercarpal pressure, these include:
Gripping or pinching objects while flexing the wrist.
Gripping a tool by ulnarly deviating the hand.
Performing repetitive wrist flexion-extension movements.
Control inflammation through ice packs, tendon glideing exercises performed 5 times each, 5 times daily, and elevated activities.
You can use different modalities that help in controlling inflammation and/or reducing pain such as::
High voltage galvanic stimulation.
TENS.
Contrast bath: cool water for 30 sec. alternatively with warm water for 30 sec, all for 15-30 min.
Iontophoresis: 3 mA using 1 cm of lidocaine with epinephrine and 1 cm of dexamethasone for 20 min.
Infra-red Laser with frequency of 2500 Hz, applied over 5 points; one at the middle of wrist flexion crease, the second 1cm below, the third 2 cm below, the fourth is 1cm above and radially over the thenar muscles and the last point is 2cm above and radially. Laser is applied for 120 sec. over each point.
Phonophoresis: 1watt, continuous mode for 5- 15 min. over the area of carpal tunnel using diethylamine Salicylate (Reparil gel for example)
Physiotherapy following decompression surgery
For the first 3 weeks:
1. Allow protected use of the hand, by a volar cast worn for one week followed by a thermoplastic splint.
2. Control edema by encouraging overhead hand elevation and by applying retrograde massage.
3. Maintain ROM by applying tendon glide exercises; 10 repetitions, 3 times daily in addition to shoulder ROM exercises in all directions.
From 3 to 8 weeks
1. Control edema by encouraging elevated hand activities such as elevated fisting exercises repeated 10 times per hour and retrograde massage.
2. Try to model surgical scar by applying Elastomers and gentle friction massage over the scar.
3. To minimize pain from painful neuromas, teach your patient the desensitization program. This program consists of 3 phases. The first phase involves holding objects of different textures, the second involves holding objects of different shapes and the last involves the use of vibrator of different frequencies. Always start with what the patient can bear hardly then progress as the patient improves.
4. Increase strength and functional use of hand: isometric and isotonic exercises for the wrist and hand can be initiated by the 8th week (N.B: never overexercise your patient).
5. Restore ROM by applying nerve gliding exercises, tendon gliding exercises and passive thumb stretching (3 times per day, each 10 repetitions).
From 8-12 weeks
Start preparing your patient to return to his job by initiating work hardening. Initially light tasks can be performed before starting work simulation exercises. A special attention should be paid to modify work environment especially in work-related cases. Abundant use of ergonomically designed handles should be considered as well as routine during-work preventive exercise regimen.
Can we prevent CTS?!
We can minimize the risk of CTS by altering the way a person performs repetitive activities. For example, replacing old tools with ergonomically designed new ones.
Rest Periods and Avoiding Repetition. Advise a predisposed subject to begin his work with a short warm-up period, take frequent break periods, and avoid overexertion of the hand and finger muscles whenever possible..
Good Posture. Good posture is extremely important in preventing CTS, particularly for typists and computer users. A keyboard operator should sit with the spine against the back of the chair with the shoulders relaxed, the elbows along the sides of the body, and wrists straight. The feet should be firmly on the floor or on a footrest. Typing materials should be at eye level to minimize neck flexion. Chairs should be adjustable for height, with a supportive backrest.
Techniques and Tools for Reducing Force.
Teach your patient how to keep his wrist as neutral as possible during performing his job tasks. Also, teach him the importance of performing job adjustment to minimize stresses over his wrist and fingers. For example, advise a Keyboard operator to adjust the tension of the keys so that depressing the keyboard does not cause fatigue and to keep his hand and wrist in a relaxed position to avoid excessive force on the keyboard. Wrist rests, which fit under most keyboards, can help keep the wrists and fingers in a comfortable position. Recommend keeping the mouse as close to the keyboard and the computer users body as possible to reduce shoulder muscle movement and to hold the mouse lightly with the wrist and forearm relaxed.
Reducing Vibration. Protective equipment, such as shock absorbers, can reduce vibrations emitted from some tools. For example, tell a Bicyclist who ride frequently on rough roads to wear thick cycling gloves to lessen the shock transmitted to the hands and wrists.
Exercise
Hand and wrist exercises may help reduce the risk of developing CTS. Isometric and stretching exercises can strengthen the muscles in the wrists and hands, as well as the neck and shoulders, improving blood flow to these areas. Performing the following simple exercises for four to five minutes every hour (5-10 repetitions with holding 5 sec per each) may be helpful to your patient.
Wrists.
Wrist circles., and active finger flexion-extension exercises.
Active thumb palmar flexion and abduction.
Isometric and isotonic exercises for all wrist movements.
Wrist and finger flexors stretch with fingers first adducted then abducted.
Forearms
Teach your patient how to perform self-stretching of forearm flexor muscles.
Neck and Shoulders.
Self-stretching of trapezius, scaleni and sternocleidomastoid muscles from seated position.
Active shoulder shrugging, depression, protraction and retraction to minimize tense shoulder muscles.
General Exercise. A regular exercise regimen using a combination of aerobic and resistance training techniques strengthens the muscles in the shoulders, arms, and back, helps reduce weight, and improves overall health and well-being.