Carpal Tunnel Syndrome
Stacey Soda
ATHT 4960-Spring
’02
Rehab Techniques
Jason Bennett
Carpal Tunnel Syndrome
Carpal
tunnel syndrome (CTS) is a nerve entrapment disorder. It is caused be repetitive
motions of the wrist. This mainly includes
an overuse of wrist flexion. Median
nerve compression causes the symptoms of carpal tunnel syndrome.
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The carpal tunnel is
made up of the flexor retinaculum (transverse carpal ligament) as well
as carpal bones of the wrist. The transverse
carpal ligament is considered the anterior portion
(roof) of the carpal tunnel wall, while the carpal bones form the rest of
the tunnel. Sensory and motor impulses
are transmitted to the central nervous system by
the median, ulnar, and radial nerves of the hand.
However, only the median nerve travels through the carpal tunnel. Along with the median nerve, flexor tendons
go through the tunnel as well. Finger
flexion is caused by the flexor tendons, which connect
the arm muscles with the bones of the fingers (Ebben, 2001).
Biomechanical causes of
carpal tunnel syndrome include wrist extension, wrist flexion, as well as
ulnar deviation. 
Wrist extension is bending the wrist upward.
Wrist flexion is bending the wrist downward.
Ulnar deviation is bending the wrist towards the little finger.
The hand’s natural functional position causes a five to ten percent
wrist ulnar deviation.
The biomechanical cause
described in the Herzog-Moss Wrist Compression Mechanism is ulnar deviation.
The carpal bones involved are the triquetrum, hamate, and the pisiform,
which interact with the transverse carpal ligament.
The triquetrum is attached to the transverse carpal ligament, and it slides
up and down on the hamate. The pisiform
is on top of the triquetrum. This movement
alone causes a slight natural tension of the wrist. Ulnar deviation causes these three carpal bones
to telescope. This in turn causes the
transverse carpal ligament to shift downwards. The carpal tunnel cross-sectional size decreases.
When the tunnel decreases, it ends up squeezing the median nerve between
the flexor tendons and ligaments going to the fingers.
This motion in repetition may lead to carpal tunnel syndrome (Pinkham,
1988).
Compression
of the median nerve can cause many symptoms.
There is much controversy on whether some of the said causes really
do cause carpal tunnel syndrome. Symptoms
include pain, tingling, numbness, and either an increase or a decrease in
sensitivity. These symptoms are worse
at nighttime and the early morning (Falkenburg, 87). Early symptoms of CTS usually start off as painful tingling at night, either in one hand
or bilaterally. The fingers seem to
be swollen which causes a uselessness feeling of the fingers. The thumb, index, and ring fingers begin having
daytime tingling with an increase in symptoms. A person with carpal tunnel will begin to have
trouble gripping objects (Corbin, 2000). He
will then lose hand strength in the end because of thenar muscle atrophy.
This results in difficulty picking up objects.
Many
other factors are believed to cause carpal tunnel
syndrome. These include pregnancy,
diabetes, rheumatoid arthritis, and obesity.
Personal factors, age, degrees of force, and repetition of the upper
body movements are also causes of CTS (Ebben, 2001).
The
carpal tunnel pressure must be reduced in order to
reduce the pressure that is on the median nerve. One method is a conservative approach. The wrist and hand must rest in a neutral position,
and nonsteroidal anti-inflammatory drugs (NSAIDS) should be taken. The NSAIDs reduce the swelling and help to limit
median nerve entrapment (Corbin, 2000). During
the night, the wrist should be splinted in a neutral
position. Steroid injections underneath
the transverse carpal ligament may alleviate symptoms.
When at work or home, modify the activities which
caused the carpal tunnel syndrome.
Another method for reducing
carpal tunnel pressure is by surgery. Almost
fifty percent of the population who have carpal tunnel syndrome ends up needing
to have surgery. Two different types
of carpal tunnel release are Open CTR, and Endoscopic CTR. The surgery entails the reconstruction or removal
of the pressure source, which usually is by the release of the transverse
carpal ligament. This occurs by a small
incision to the transverse carpal ligament, and this in turn increases the
cross-sectional size of the carpal tunnel (Corbin, 2000). However, there is no guarantee of long-term
relief.
![[Carpal
Tunnel Surgery]](carpaltunnel_files/image012.jpg)
The rehabilitation goals
after carpal tunnel release initially are to regain active range of motion,
and then to restore muscular endurance and strength. Every rehab will be different
for each individual. There are four
phases of rehabilitation. The following
methods used to meet each phase’s objectives are designed
for a baseball pitcher who has had carpal tunnel release.
Phase I is the period of time immediately following the carpal tunnel release.
The wrist movement is restricted due to pain and swelling. 
A wrist immobilizer is applied
to prevent wrist extension and flexion. The prevention of outward and downward wrist
movements as well as inward movements of the thumb must occur with the immobilizer
(Falkenburg, 1987). The therapeutic
objectives of Phase I include teaching proper ambulation techniques as well
as maintaining an acceptable level of overall physical fitness. Pain-free ROM needs to be
maintained, and the amount of pain and swelling in the wrist should
be decreased. Another objective is
to minimize the loss of muscular strength and decrease the progression of
atrophy in the wrist. Rest is a major
factor in the treatment of carpal tunnel syndrome.
Ice application (ice packs or ice submersion) will help minimize pain
and swelling. Ice should be applied
two to three times a day for twenty minute sessions. Iontophoresis should be used
daily for sensory level stimulation with a treatment time of ten minutes (P.
Harvey, personal interview, 
A treadmill or a stationary
bike could be used two times a day for twenty minutes
each session if the sport’s aerobic training is not sport specific.
Yoga is effective for the reduction of pain as well, and it
also increases the grip strength (Nathan et al., 2001).
A one hour yoga program that is done two times a week shows a
decrease in pain and an increase in grip strength (Garfinkel et al., 1998).
Progression to Phase II
includes sufficient reduction of the local symptoms and sufficient tissue
healing. This is
measured by a circumferential tape measure as well as how the athlete
rates his pain level. Removal of the
wrist immobilizer must also occur to progress to the next phase. The wrist immobilizer is to be worn day and night for the first two weeks. After two weeks, the stitches are removed, but a brace is still to be worn at night.
Phase
II of the rehabilitation process is the period when more vigorous therapeutic
exercises should be initiated. Weight
bearing needs to be established and normal gait patterns need to be restored. Joint range-of-motion,
flexibility, proprioception, muscular strength, and muscular endurance must
also be restored to that of the normal wrist. 
A level of overall fitness needs to be maintained and developed.
The goal of ROM and flexibility needs
to be ninety percent compared to the other wrist. Active-assisted wrist extension stretching consists
of the person stretching the involved wrist using the uninvolved hand into
terminal extension. Three sets of ten
should be done with each stretch held for three to
five seconds (Prentice, 1994).
Tendon gliding and median
nerve gliding exercises provide active flexibility. The shoulders and the neck need to be in a neutral
position, and the elbow should be in supination and flexed ninety degrees.
There are five positions in which to place the fingers during the tendon
gliding exercises. These positions are straight, hook, fist, tabletop, and straight fist. The median nerve is mobilized
in the median nerve gliding exercises. There are six positions to this exercise.
Position one is to have the wrist in neutral
position, and have the thumb and fingers in flexion.
The second position is to have the wrist in neutral position with the
thumb and fingers in extension. The wrist and fingers are to be extended with the thumb in a neutral position for position
three. The wrist, fingers, and thumb
are to be extended for position four. In position five, the forearm is to be in supination.
Last of all, the opposite hand applies a gentle stretch to the thumb
in position six. 
Each position of both the tendon gliding and
the median nerve gliding exercises should be held
for five seconds, and there should be five sets of five repetitions. This continues for four weeks (Akalin et al.,
2002).
The goal of muscular strength should be ninety
percent compared to the normal wrist. This
can be done by using Theraputty twice daily for two
minutes at each session. This is
done five times a week, and as it gets easier for the athlete, the
time should be increased. There are different consistencies. When the athlete is ready to progress, a firmer
Theraputty should be used. The Theraputty provides grip-strengthening exercises.
The athlete should extend his fingers in it, and pull the putty apart.
Once the athlete has mastered this, a spring hand gripper should be used. The
pitcher needs to practice three sets of ten repetitions of D1 and D2 diagonals
for the shoulder five times a week because the shoulder needs to be worked as well for proprioception (P. Harvey, personal interview,
For progression to Phase
III, the athlete should have sufficient reduction of local symptoms and sufficient
wound healing to resume partial practice or conditioning activities.
A goniometer can measure if the athlete has met ninety percent ROM
and flexibility. Manual muscle test grip tests
may measure ninety percent strength. Eighty percent of muscular
endurance should be measured by number of sets and repetitions the athlete
is able to perform. Ninety percent
physical fitness can be measured by stationary bike
time. The athlete needs to have adequate
bracing for protection against repetitive wrist movement. Also, the athlete should
have a satisfactory level of motivation and confidence.
Phase
III occurs when the athlete can resume participation in part or all of the
normal activity. Therapeutic objectives
of this phase include restoring the athlete’s confidence to resume safe participation,
and continuing optimal development of overall physical fitness. Optimal restoration of flexibility, joint range-of-motion,
muscular strength and endurance must be continued.
Also, normal patterns of motor activity (balance,
coordination, gait patterns) must be re-established.
During phase III, there is a pain free range of motion.
Ultrasound is used as well as warm whirlpool
every other day for fifteen-minute sessions each. The intensity of the ultrasound depends on the
athlete. Progressive resistance exercises
are performed, and there is still active/ active-assisted
flexibility. The goal for the ROM and
flexibility is one hundred percent. The stretches from Phase II should be continued as well as PNF stretching. The goal of muscular strength is one hundred
percent. During Phase III, sport-specific
exercises are incorporated.
The throwing phases of motion should be incorporated
starting in reverse. These would
be accomplished in three sets of ten repetitions, five times a week.
Also, releasing baseballs would be included
in this phase using a theraband. Drill a hole through the baseball, tie it with
a theraband, and then attach the theraband to a post. The pitching motion can be
performed starting with less resistive therabands for three sets of
ten repetitions. As the pitcher progresses,
more resistive therabands may be used, and the repetitions can be increased
in the sets. The goal of overall physical
fitness is also one hundred percent. As
much conditioning with the team that the baseball
player can tolerate is allowed. The
goal for confidence level to proceed to the final stage is one hundred percent. In order to progress to Phase IV, these goals
must have been achieved. Two ways to measure if the goals have been achieved is to use a goniometer and to perform manual
muscle testing. The athlete must be
able to pitch correctly. Also, he must be willing to return to participation. A physician’s release must
be obtained as well in order to proceed to Phase IV.
Phase
IV is the period of time when complete rehabilitation has been achieved. This occurs 4-6 months after surgery (P. Harvey,
personal interview,
With
athletes, it is difficult to alter their tasks to help the rehabilitation
and prevention of carpal tunnel syndrome.
For instance, a baseball pitcher goes through the same motions daily.
Rest of the wrist is needed to get better. A
splint should be worn as much as possible to help
with the continuation of Phase IV in order to better the athlete.
Athletes are not the only
ones that need to be cautious. The
method of performing tasks should be altered while at work or at home in order
to encompass less force. Also, a more neutral wrist position during activity must be
performed. For people with repetitive
tasks, a correct working height should be used. Proper chair height, proper keyboard height,
and an eye-level screen are to be involved.
Improved keyboards show the biomechanical balance between arms and
hands by allowing proper positioning. The
angle of the left hand keys go inward instead of outward. The old design caused ulnar deviation of the
left hand (Pinkham, 1988).
There
are many other ways to help reduce wrist flexion and have less force. Manufacturing is considered
to have the highest rate per worker of CTS cases involving absenteeism. Handheld tools (vibrating equipment) for such
jobs as factory work should be redesigned to allow
more of a neutral wrist position (Corbin, 2000). When grasping objects, grip with the palms down
and grasp with the entire hand instead of only fingers.
Most
of the information that can be obtained about carpal
tunnel syndrome is controversial and unclear.
Some articles state that a person should do a conservative method to
CTS rather than surgery because the symptoms will come back in a couple of
years after surgery. However, surgery
seems to eliminate the symptoms during that time.
There is conflicting research on the change of muscle strength and
dexterity after surgery. The articles
say which symptoms cause carpal tunnel, however, there is no definite proof.
Continuous research needs to be performed before the best method of treating carpal tunnel
will be found.
Bibliography
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Corbin,
D.E. (2000). Carpal tunnel syndrome
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Ebben, J.M. (2001). Carpal tunnel syndrome. It’s not just
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A., Katz, W.A., Allan, D.A., Reshetar, R., & Schumacher, H.R. (1998). Yoga-based
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