Carpal Tunnel Syndrome by Jon Tobey
Carpal Tunnel Syndrome by Jon Tobey
Carpal Tunnel Syndrome by Jon Tobey
Carpal Tunnel Syndrome byJon Tobey
Carpal tunnel syndrome is described by the sensory loss and motor weakness that occurs when the median nerve is compromised in the carpal tunnel. Carpal tunnel syndrome is usually cause by repeated movement over an extended period of time. This tends to cause an inflammation, which can affect the muscle, tendon, synovial sheaths and nerves. Also falling or a blow to the wrist, pregnancy, which causes hormonal changes and water retention, rheumatoid arthritis and osteoarthritis could also cause a decrease in the carpal tunnel space which could cause carpal tunnel syndrome.
"The carpal tunnel is a confined space between the carpal bones dorsally and the flexor retinaculum volary. The extrinsic finger flexor tendons and median nerve course through the tunnel." (Colby, Kisner. 441) Anything that causes a decrease of the space within the carpal tunnel or causes the contents of the tunnel to enlarge could compress or restrict the mobility of the median nerve causing a compression or traction injury and neurological symptoms of the wrist.
Symptoms of carpal tunnel syndrome include synovial thickness and scarring of tendon sheaths or irritation, inflammation and swelling as a result of repetitive wrist flexion, extension or gripping activities. Signs of the disorder include increasing pain in the hand or wrist, tightness in the adductor pollicis and extrinsic extensors of the thumb and digits two and three. Sensory loss in the median nerve distribution including the thumb, index and middle fingers and the radial aspect of the ring finger. (Nerys. 23-25) Possible decreased joint mobility in the wrist and metacarpalphalangeal joints (MCP) of the thumb and digits two and three.
If conservative non-operative measures do not relieve the nerve symptoms, most times surgical release of the transverse carpal ligament is performed to relieve the compressive forces on the median nerve. All scar tissue is also excised. The wrist is then immobilized for seven to ten days post-operatively with the wrist in slight extension and the fingers free to move.
Ten days after surgery the first phase rehabilitation of the wrist begins. This phase is called the maximum protection phase. During this phase the major goals are to rest and control edema. Begin active tendon and nerve gliding exercises along with other active exercises including active wrist extension and active radial and ulnar deviation.
The next and last phase is the moderate and minimum protection phase. During this phase techniques including scar tissue mobilization, progressive stretching and joint mobilization of the restricted tissue, strengthening exercises, dexterity exercises and sensory stimulation and discriminative sensory reeducation. The goal with progressive stretching and joint mobilization is lengthen the abductor pollicis brevis and opponens pollicis if restricted and to mobilize restricted tendons or nerve tissue. Strengthening exercises should begin four weeks after surgery with isometric exercises. Then the program should be progressed to grip and pinch exercises by six weeks. As soon as motor recovery occurs dexterity exercises should begin. These exercises including picking up small objects using pad to pad, tip to tip and pad to tip prehension patterns. Sensory stimulation and discriminative sensory reeducation is one of the last steps that will help desensitize and reprogram awareness as the nerve recovers. Exercises include using multiple textures for sensory stimulation. During this portion of the program the patient will progress form least irritating textures to maximum progress of most irritating textures. Also techniques including perception of slow vibration, moving touch, constant touch, rapid vibration and awareness of proximal and distal are necessary. The patient at times can use an exercise that they close their eyes as the therapist touches them with an eraser and the patient must identify where they have been touched. These are all techniques used in this phase in order to get the patient to return to full activity by six to twelve weeks. (Colby, Kisner 442-443)
There are several techniques used when the patient does not undergo surgery. These techniques include splinting, biomechanical analysis, joint mobilization, tendon gliding exercises, median nerve mobilization, gentle multiple angle muscle setting exercises and strengthening and endurance exercises. Splinting is used to keep the wrist in neutral position, so that there is minimal pressure and it provides rest to the tunnel. Biomechanical analysis is used to identify faulty wrist and upper upper extremity motions and decrease the use of faulty wrist motions. Joint Mobilization which is a manual therapy technique used to modulate pain and treat joint dysfunctions that limit range of motion of the tunnel. (Colby, Kisner 216) Tendon gliding exercises are used to develop mobility in the extrinsic tendons. Median nerve mobilization techniques are used to help with mobility of the wrist by using the six positions for median nerve mobilization in the wrist and hand and holding these positions for five to thirty seconds while the nerve begins to tingle. (Colby, Kisner 441) One study showed that performing median nerve gliding exercise, only 43% of the patients using these types of exercises underwent surgical release of the carpal tunnel compared to 71% in the control group. (Colby, Kisner 442) Gentle multiple angle muscle setting exercises are low intensity isometric exercises performed against little or no resistance. They are used to promote muscle relaxation and circulation while decreasing pain. (Colby, Kisner 82) The last techniques used are strengthening and endurance exercises. These techniques are used once symptoms are not increased with isometric exercises. Utilization of these exercises will help the patient return to functional activities.
Carpal Tunnel Syndrome Exercises
1) Cardiovascular activity has been shown to relieve symptoms of carpal tunnel syndrome. In one study when 30 sedentary people began working out three times a week for one hour, walking, rowing, cycling or doing aerobic dance, the pain, tightness and clumsiness in their hands decreased by 33% after 10 months. Study leader Peter Nathan, M.D. says that the decrease was probably related to "controlling weight and maintaining nerve health." (Shape, 94)
A) Treadmill for 30 minutes of duration two times a week. This exercise would be given in order to have the patient doing some aerobic work to keep up cardiovascular system, while also incorporating some impact training.
B) Recumbent bike for 30 minutes of duration two times a week. This exercise would be given as a non-impact exercise and seated so the patient could work on finger and wrist flexibility exercises at the same time. Both of these exercises will help improve cardiovascular endurance and also help control weight and maintain nerve health.
2) These exercises will help increase the joints range of motion or lengthen the muscle and its associated tendons. However they should not be performed when the joints are inflamed or painful.
A) Hand/Finger tendon glide. This is a range of motion exercise that will allow your hand and finger joints to move through their proper range of motion. To start have your fingers extended straight up. a) make a hook fist b) return to straight hand a) make a full fist c) return to straight hand a) make a straight fist d) return to straight hand then repeat. Hold positions for 5-10 seconds for 10 repetitions and 2 sets. (Harvards womens health watch, 2005, pg 2)
B) Wrist flexion/extension. This exercise will also keep the range of motion in your wrist and will work your flexor carpi ulnaris and flexor carpi radialis, extensor carpi ulnaris and extensor carpi radialis. To do this exercise you rest your forearm on a table or arm rest, with your hand over the edge and palm down (wrist extension). Move your hand up until a gentle stretch is felt, then return to starting position. Repeat the same motions with the palm up (wrist flexion). Two sets of 10 repetitions hold the extension and flexion for 5 seconds at top of movement. (Harvards womens health watch, 2005, pg 3)
C) The patient must also stretch the wrist extensor muscles (extensor carpi radialis and extensor carpi ulnaris) to increase wrist flexion. One technique used is when the patient is standing with the elbow extended, forearm pronated and the back of the hand against the wall with the fingers pointing down. Have the patient then slide the back of the hand up the wall. (Colby, Kisner, 409)
D) The wrist flexor muscles (flexor carpi radialis and flexor carpi ulnaris) must also be stretched in order to increase wrist extension. In order to stretch this area the patient should be standing with the elbow extended and the forearm supinated. Have the patient put the palm of their hand against the wall with the fingers pointing down, and then have them move their hand up the wall until a stretch sensation is felt in the wrist flexors. (Colby, Kisner, 409)
3) Resistive isometrics will strengthen the muscle without going through the full range of motion therefore there is little risk of stressing the joint and nearby structures. (Harvards womens health watch, 2005, pg 3)
A) Isometric wrist extension/flexion. Two sets of 10 repetitions. Hold the affected hand palm down (wrist extension, working the extensor carpi radialis and ulnaris) with the other hand on top. Try to raise the affected hand but don't allow it to move. In order to do wrist flexion( flexor carpi radialis and flexor carpi ulnaris) repeat the same exercises with the palm up. (Harvards womens health watch, 2005, pg 3)
B) Dumbbell pronation, three sets of fifteen to twenty repetitions. This exercise will be working the pronator teres and quadratus. The patient will hold a dumbbell unevenly to create an uneven resistive force. A bar with only a weight on one side would be best. The patient will then rest their forearm on a table while rotating the dumbbell from supination to pronation. Repeat with other arm. (Colby, Kisner, 412)
C) Dumbbell wrist flexion, three sets of fifteen to twenty repetitions. This exercise will be working the flexor carpi radialis and flexor carpi ulnaris, and would be applied to strengthen the medial epicondyle. This exercise is done seated using a light dumbbell with your arm on a table except for your wrist. With you palm up let the weight drop so that your wrist is in full extension and then curl your wrist up into wrist flexion. Repeat with other arm. (Colby, Kisner, 412)
D) Dumbbell wrist extension, three sets of fifteen to twenty repetitions. This exercise will be working the extensor carpi radialis and extensor carpi ulnaris, and would be applied to strengthen the lateral epicondyle. This exercise is done seated using a light dumbbell with your arm on a table except for your wrist. With you palm down let the weight drop so that your wrist is in full flexion and then curl your wrist up into wrist extension. Repeat with other arm. (Colby, Kisner, 412)
E) Dumbbell wrist abduction, three sets of 10 repetitions, hold at top of movement for three seconds. This will help improve flexor carpi radialis, extensor carpi radialis, flexor pollicus longus and extensor pollicus longus. With one hand over a bench with the wrist hanging off, put the wrist in a neutral position so the dumbbell is facing up and down. Then slowly abduct the wrist and return to starting position, and then repeat movement.
4) While trying to improve balance, proprioception and function one of the major priorities is that the patient uses methods in which they will desensitize the hypersensitive skin. This will help reprogram awareness as the nerve recovers. (Colby, Kisner, 443)
A) Using multiple textures for sensory stimulation (ex: cotton, rough material, sandpaper of various grades and Velcro). The patient will first begin to manipulate the least irritating texture for ten minutes. As their tolerance improves, they will progress to the next texture of slightly more irritating but tolerable stimulus. Maximum progress is when most irritating texture is tolerated. (Colby, Kisner, 443)
B) Pattern of recovery after nerve injury is pain, perception of slow vibration, moving and constant touch, rapid vibration and awareness from proximal to distal. Moving touch stimulus exercises can be used to reeducate. In this exercise a moving stimulus such as a pencil eraser is used to stroke over the area. The patient will first watch and then close their eyes and try to identify where the touch occurred. Progress from stroking to constant touch. (Colby, Kisner, 443)
C) Wall pushups with dynadisk. Two sets of 10 repetitions. This exercise will help improve balance and coordination in the wrists, while also working the upper body with a strength exercise. The patient will put two dynadisks on the wall, shoulder width apart, slightly under shoulder height. They will then begin to lower the body to the wall in a push up position. While maintaining balance in the wrists they will then begin to push off the disks back to the start position and then repeat.
5) In order to prevent future complications and reoccurrences, the patient must be informed to gradually resume the use of the hand while monitoring pain, swelling or dislocation. Any activities that provoke such complications should be avoided so that the wrist can full recover without being reaggravated. The patient should also be reminded about being aware of various exercises that could reprovoke the disorder. These exercises could include bicep curls, tricep extensions etc The patient should always keep their wrist in a neutral position rather than flexed or extended when involved in these exercises. The patient should also continue all of the flexibility exercises they were shown. But the most important issue is for them to be aware of their wrists and hands at all times and continue to progress rather than regress.
References
Colby, L.A. Kisner, C (2002) Therapeutic Exercise foundations and Techniques. F.A. Davis Co. Philadelphia.
Exercises for Aching Hands (2005, Nov.) Harvards Women's Health Watch. V. 13, Issue 3, pg 2-3. From Ebsco Host.
Fitness Fights Carpal Tunnel Syndrome. (2002, April) Shape V.21, Issue 8, pg 94. From Ebsco Host.
Nerys, W. (2007) 10 tips on carpal tunnel syndrome. Vol. 33 Issue 1, p23-25. http://web.ebscohost.com/ehost/detail?vid=4&hid=9&sid=805eb426-9a38-460c-a278-186bbe2de6a2@SRCSM2 From Ebsco Host
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