Carpal tunnel syndrome is overuse syndrome or cumulative trauma due to Repetitive or sustained wrist movement or gripping activities.
CAUSES:
1. Decreases the space in carpal tunnel (carpal tunnel made up by carpal bones and carpal ligament at wrist level).
2. Enlarged content of tunnel could compress or restrict the mobility of the median nerve (median nerve supplies one of the muscles of the forearm and muscle of thumb and 1st & 2nd fingers).
3. Compression or Traction injury.
4. Fracture around the wrist.
5. Awkward wrist posture, compressive forces from sustained equipment usage, vibration against carpet tunnel could also lead to median nerve compression and trauma.
6. Osteoarthritis, Rheumatoid arthritis, Diabetes.
7. Pregnancy due to hormonal changes and water retention.
SYMPTOMS:
1. Increasing pain in hand with repetitive use.
2. Tightness in muscles of thumb and first two fingers (index and middle)
3. Irritability or sensory loss in median nerve distribution. (Refer image A.)
4. Decreased mobility in wrist, thumb and first two fingers (index and middle).
5. Weak hand grip.
6. Nocturnal numbness and pain that is relieved by flicking the wrist.
7. Progressive atrophy(reduction) in thenar eminence( bulged area of the palm near thumb).
MANAGEMENT:
A. Conservative Treatment
Patient with mild to moderate symptoms, we advise conservative treatment by minimizing or eliminating causative factors.
Includes:
1. Splint Protection: Splint the wrist in neutral position, so there is minimal pressure in the tunnel.
2. Activity modification: Modify activities to keep the wrist in Neutral position and to reduce forceful gripping.
3. Safety guidance
- Avoid handling hot, cold, sharp, or abrasive objects.
- Avoid sustained grasp; change the use of tools frequently.
- Redistribute hand pressure by building up the size of the handles.
- Wear protective gloves.
4. Mobility Techniques
a) Joint Mobilization
If there is restricted joint mobility, mobilize the carpal for increased carpal tunnel space. Which is done by an only certified physiotherapist.
b) Tendon Gliding Exercise (Refer image B.)
c) Median Nerve Mobilization (refer image C.)
Six positions for median nerve mobilization in wrist and hand are illustrated in image C. Sustain each position for 5 to 30 seconds without making symptoms worse. Four times per day.
d) Muscle Performance and coordination Exercise:
- Initially gentle isometric exercise
- Progress to strengthening and endurance exercises when symptoms are not increased with isometric exercise and full tendon and nerve gliding without symptoms or edema.
- Progress to speed, coordination, fine finger skill when symptoms are no longer provoked.
e) Functional independence
by teaching the patient how to monitor his or her hand for recurrence of symptoms and provoking factors and how to modify activities to decrease nerve injury. Usually sustained gripping, bending of the wrist, side bending of the wrist, pinching are most aggravating motion.
B. Surgical Decompression
if conservative measures do not relieve the nerve symptoms or the neurological symptoms are severe( persistent numbness, weakness, pain, decreased functional use of hand). Surgical Decompression involving the transaction of the transverse carpal ligament is performed to increase the volume of the carpal tunnel and relieve the compressive forces on the median nerve.
C. Post-Operative Management
The wrist may be immobilized 7 to 10 days postoperatively with the fingers free to move.
a) Maximum protection phase
- Wound management, control of swelling and pain.
- Active Tendon- gliding exercise (image B) and Nerve Gliding exercise (image C)
b) Moderate & Minimum Protection Phase
sutures are usually removed around the 10th to 12th postoperative day, & more active treatment is allowed.patient should be able to return to full activity by 6 to 12 weeks.
impairments may include residual weakness and sensory deficits, persistent edema, limited motion, hypersensitivity, and pain.
INTERVENTION:
1. Scar tissue mobilization: soft tissue mobilization to palmar fascia and scar.
2. Progressive Stretching and Joint, Tendon (image B), Nerve Mobilization (image C):
3. Muscle Performance Exercise & coordination Exercise: Same as above.
Four weeks after surgery and then progress to Grip and Pinch Exercise by six weeks.
4. Sensory stimulation and Discriminative Sensory Reeducation.
Symptoms usually subside within 1 to 6 months.