The following is the physical therapy management of Carpal Tunnel Syndrome.
Summary of the Condition
According to the Cochrane review, “Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome”, the major problems that a patient diagnosed with CTS presents with include the following:
- pain in the wrist and hand which can radiate to the forearm
- paraesthesiae of the thumb, index, middle and radial half of the ring finger
- thenar muscle weakness (advanced stages of median nerve compression)1
Guide to Physical Therapy Practice2
Pattern 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Localized Inflammation; 2-4 months, 6-24 visits.
Pattern 5F: Impaired Peripheral Nerve Integrity and Muscle Performance Associated With Peripheral Nerve Injury; 4-8 months, 12-56 visits.
When using The Guide to assist in the plan of care for this patient, one must remember that everything that is suggested in The Guide may not be applicable to the individual patient. Therefore, these recommendations are only given as a general guide to practice; however, a plan of care which is tailored to the individual patient is best depending on their presenting symptomology and how long they have had CTS.
For example, for pattern 4E, the Guide states the following: “Over the course of 2 to 4 months, patient/client will demonstrate optimal joint mobility, motor function, muscle performance, and range of motion and the highest level of functioning in home, work (job/school/play), community, and leisure environments”. The expected range of number of visits per episode of care is 6 to 24. This range indicates the number of PT visits required to achieve the goals that have been set. It is anticipated that 80% of patients who are classified into this pattern will achieve their goals in 6-24 visits during a single continuous episode of care.
Therapeutic Exercise Interventions may include but are not limited to the following:2
- Aerobic capacity/endurance conditioning or reconditioning
- aquatic programs
- gait and locomotor training
- increased workload over time
- walking and wheelchair propulsion programs
- Balance, coordination, and agility training
- developmental activities training
- motor function (motor control and motor learning) training or retraining
- neuromuscular education or reeducation
- perceptual training
- posture awareness training
- standardized, programmatic, complementary exercise approaches
- task-specific performance training
- Body mechanics and postural stabilization
- body mechanics training
- posture awareness training
- postural control training
- postural stabilization activities
- Flexibility exercises
- muscle lengthening
- range of motion
- stretching
- Gait and locomotion training
- developmental activities training
- gait training
- implement and device training
- perceptual training
- standardized, programmatic, complementary exercise approaches
- wheelchair training
- Relaxation
- breathing strategies
- movement strategies
- relaxation techniques
- standardized, programmatic, complementary exercise approaches
- Strength, power, and endurance training for head, neck, limb, pelvic-floor, trunk, and ventilatory muscles
- active assistive, active, and resistive exercises (including concentric, dynamic/isotonic, eccentric, isokinetic, isometric, and plyometric)
- aquatic programs
- standardized, programmatic, complementary exercise approaches
- task-specific performance training
Manual Therapy Techniques:2
- Manual traction
- Massage
- connective tissue massage
- therapeutic massage
- Mobilization/manipulation
- soft tissue
- spinal and peripheral joints
- Passive range of motion
Electrical Modalities:2
- Electrotherapeutic delivery of medications
- iontophoresis
- Electrical stimulation
- electrical muscle stimulation (EMS)
- functional electrical stimulation (FES)
- high voltage pulsed current (HVPC)
- neuromuscular electrical stimulation (NMES)
- transcutaneous electrical nerve stimulation (TENS)
Mechanical Modalities:2
- compression therapies
- taping
- mechanical motion devices
- continuous passive motion (CPM)
Physical Agents:2
- Athermal agents
- pulsed electromagnetic fields
Cryotherapy:2
- cold packs
- ice massage
- vapocoolant spray
Hydrotherapy:2
- whirlpool tanks
- contrast bath
- pools
Light Agents:2
- infrared
- laser
Sound Agents:2
- phonophoresis
- ultrasound
Thermotherapy:2
- dry heat
- hot packs
- paraffin baths
Anticipated goals and expected outcomes may include but not limited to:2
- Joint swelling, inflammation, or restriction is reduced
- Pain is decreased
- Soft tissue swelling, inflammation, or restriction is reduced
- Gait, locomotion, and balance are improved
- Joint integrity and mobility are improved
- Muscle performance (strength, power, and endurance) is increased
- Range of motion is improved.
- Weight-bearing status improves
- Impact on functional limitations
- Ability to perform physical actions, tasks, or activities related to self-care, home management, work (job/school/play), community, and leisure is improved
- Safety is improved
Management of CTS
According to the Cochrane review of “Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome”, oral steroids, splinting, ultrasound, and yoga are beneficial at relieving carpal tunnel syndrome short-term; however, other non-surgical methods have not been proven to be successful.1
Pain Relief
- Splinting (see above for more information)
- RICE to decrease pain & edema3
- Modalities such as ice, heat, ultrasound, or electrical stimulation to decrease pain and inflammation.3 See section on Modality Use below for the current evidence regarding modality use and CTS.
Decreasing Swelling
- Active/passive ROM, RICE to decrease pain & edema, modalities such as ice, heat, ultrasound, or electrical stimulation to decrease pain and inflammation.4
Increasing Strength
Improving ROM
- Nerve gliding exercises to restore mobility of the median nerve through the carpal tunnel.3
Functional Activities
- Gripping exercises using a hand grip dynamometer, putty, or balls may be beneficial at restoring mobility and strength in functional activities. The PT should tailor the rehab program specifically to the patient’s occupational needs.1
- Pinching activities are also practiced with keys or picking up small pegs to improve finger dexterity.3
- Eccentric wrist strengthening exercises by adding occupation specific tasks such as lifting or carrying objects up to 40lbs. is commonly added to the rehab program to progress the patient and set them up for success.3
- Patient Education regarding ergonomics is imperative especially since majority of CTS patients develop the nerve entrapment due to overuse, repetitive activities such as typing or manipulating small tools such as dental work.5
Patient Education-Ergonomics
- Posture: maintain a good sitting posture as pictured above with a supported lumbar curve and relaxed arms. Sit with your buttocks as far back in the chair as possible, feet flat on the floor or on a footrest. Your knees should be bent about 90 degrees so they are at the same level or slightly above your hips. Shoulders and arms should be relaxed with arms positioned close to your sides (elbows bent about 90 degrees)6
- Office set-up: ensure a good posture by setting up the office for success. This means making sure that the computer is directly in front of you and items frequently used are within an arm’s reach.6,
- Worker technique: avoid pounding the keyboard, using your wrists to move the mouse, or gripping the mouse tightly which increases the demands on the hand and wrist. Use ergonomic computer accessories, such as document holders and head sets to avoid awkward neck postures. Also, use of a wrist pad on the keyboard or under your wrist near the mouse may reduces stress on the wrist while working on the computer.6
- Work Habits: avoid sitting for extended periods of time without changing position; get up and stretch as frequently as possible, preferably every 20-60 minutes. Take a short walk to enhance circulation and promote blood flow to fatigued muscles.7
- Be aware of early warning signs of CTS, such as weakness of your grip, numbness, and discomfort or pain in the arms, hands, wrists or shoulders.7
Home Exercise/Modality Use1
- Providers should offer instruction in a HEP of therapeutic exercises to improve flexibility, mobility, strength, and proper work techniques.
- To improve flexibility & mobility- Stretches:
- Stretch flexors and extensors to improve ROM and prevent recurrence of nerve compression: hold stretch for 15-30 seconds, 2 sets, 3x/day everyday
- To stretch the flexors: Straighten your arm and pull your hand back with your other hand so your fingers are pointing up & hold.
- To stretch the extensors: same as above with hand pointing downward.
- To improve strength- Progressive resisted isometrics within pain free ROM with wrist in neutral position. Then progress to strengthening the long finger flexors: Rest back of forearm on a flat surface for support, palm should be facing up, and curl a 1-5lb. dumbbell. To strengthen the extensors: same as above with palm facing downward.
Evidence on Modality Use:
Physical modalities play a secondary role in the treatment of CTS and should not be the sole treatment. There is a lack of consensus regarding the effectiveness of this treatment and further research may be beneficial.3 Ultrasound (US) and electrical stimulation (estim) are commonly used in hand therapy to facilitate recovery after nerve and tendon injuries. Therapeutic US can be delivered at a superficial or a deeper level. Thus, US can have a heating or a mechanical effect with the goal of heating and/or healing tissue. The sound waves cause molecules to vibrate, heat up, and penetrate the skin.8,9 Generally, one can follow these guidelines to determine which US frequency is appropriate when deciding to target superficial or deep structures:8
- Superficial: 1-2 cm; freq: 3 MHz
- Deep: 5 cm; freq: 1 MHz
There is evidence in the Journal of Hand Therapy which supports use of low-dosage continuous wave and pulsed ultrasound (PUS) for carpal tunnel syndrome and tendonitis.4 Low intensity US (< 0.5 W/cm^sup 2^) with continuous wave or pulsed mode “likely produces its therapeutic effects by microstreaming, which causes changes in cell permeability and thus facilitates a healing response”. Higher intensities in the continuous mode elevates tissue temperature, which may reduce pain and alter tissue viscoelasticity. These changes in tissue extensibility may improve mobility in contracted tissues. Furthermore, this technique can be used in conjunction with stretches and passive range of motion activities to improve range of motion.4
Another study that examined the effects of PUS at 1 MHz and continuous ultrasound at 3 MHz found that subjects in the continuous US group had a mean symptom duration of 84 months but also most likely had more severe CTS than subjects in the PUS group whose mean symptom duration was eight months.3 However, it is important to keep in mind that continuous ultrasound poses a risk of overheating. A study seeking to assess the efficacy of US treatment for mild to moderate idiopathic CTS found that PUS elicited greater improvements in subjective complaints, hand grip and finger pinch strength, and nerve conduction velocity than sham ultrasound treatment. Also, these subjective improvements were sustained at the 6 month follow-up. In this study the US was applied for 20 sessions at 1 MHz frequency, 1.0 W/cm2 intensity, pulsed mode 1 : 4, for 15 minutes per session.10
Yoga-based Interventions
To determine the effectiveness of a yoga-based regimen for relieving symptoms of carpal tunnel syndrome. Subjects received yoga-based interventions (11 yoga postures) designed to improve strength, mobility, and balance of each joint in the upper body. Additionally, relaxation exercises were practiced twice weekly for 8 weeks. Patients in the control group were offered a wrist splint to supplement their current treatment. After 8 weeks, improvements were seen in grip strength, pain intensity, and Phalen’s sign. Statistically significant findings were present for the yoga-intervention group for grip strength (increased from 162 to 187 mmHg) and pain intensity (pain decreased from 5.0 to 2.9 mm). However, changes in grip strength and pain intensity were not significant for control subjects. Additionally, the yoga group significantly improved in Phalen’s sign, reporting less symptoms during the test (see CTS page for description of this test). Overall, yoga-based interventions were found to be more effective than just wrist splinting alone in relieving symptoms of carpal tunnel syndrome.11
The following are 10 common yoga positions used to treat symptoms of CTS:12
The goals of these positions is to improve posture, promote relaxation to reduce pain, and to enhance mobility.
- Pose 1: Urdhva Hastasana (arms straight overhead)
- Raise your arms above your head, keeping them as straight as possible with your palms facing in. Pull your shoulder blades down. Try to squeeze your shoulder blades together and press the bottom tips of them against your back, lifting your chest. Breathe.
- Pose 2: Garudasana (eagle arms)
- Cross your right arm over your left at the elbow. Keeping your palms facing out, draw the left hand toward your face and entwine the right arm around the left. Soften your neck by lowering your chin. Draw the inner shoulder blades down and apart. Breathe deeply. Change sides and repeat.
- Pose 3: Ardha Ghomukhasana
- Take your left arm out to the side, palm facing back. Place the back of your right wrist against your spine. Roll your right shoulder back, sticking your chest out. Press the wrist into your spine to help activate the back muscles and pin the right shoulder blade to your back ribs, expanding your chest. Repeat with your right arm.
- Pose 4: Bharadvajasana in a chair (twist)
- Using a stable chair without arms, sit sideways. Place a four-inch yoga block (or towel roll) between your knees. The block will stabilize your pelvis and low back. Inhale and raise your arms up. Exhale and turn your navel and ribs toward the chair back. Hold on to the back of the chair to enhance stretch. Begin the twist from your navel and progress upward, turning with each exhalation. As you lift your chest high, drop your shoulders down and pin your shoulder blades to your ribs. Repeat each side twice.
- Pose 5: Maricyasana in a chair (open twist)
- Place your mid-buttock against one side of the chair. Open your legs to a right angle. Raise your spine up with your shoulders rolled back. Draw your right arm back and place your hand to the outside edge of the chair that is behind you. Place the back of your left hand inside your left knee. Inhale and raise your chest and pin your shoulder blades to your back ribs. Exhale and turn your top chest any amount. Breath slow and deep. Repeat each side twice.
- Pose 6: Maricyasana III in a chair (twist)
- Sit with your feet square on the floor. Place a block or towel roll between your knees. Raise your right arm, turn from your navel, and place your elbow outside your left knee. Inhale and lengthen your spine and draw your shoulder blades toward your waist. As you exhale, press your right armpit forward to turn your chest from the bottom up. Roll your left side back. Keep your neck long and neutral. Breathe. Repeat each side twice.
- Pose 7: Sideways Arm Stretch at the wall
- Stand one foot away from the wall. Walk your right hand up. Lift your chest and turn your shoulder back and down. Slowly walk your hand back. Keep turning your shoulder and extending into your fingers. Stretch your front chest. Breathe. Repeat each side twice. Note: If you feel tingling in your fingers, back off 10 percent, turn and lengthen your arm.
- Pose 8: Urdhva Hastasana at the wall
- Facing the wall, stand back 12 inches. Walk your hands up the wall, wrapping the outside of your arms toward your face and your inner arms back. Raise up on your toes to walk your hands further up. Attach your hands to an imaginary hook and slowly lower your feet to the floor, allowing your chest and side body to hang and stretch. Note: If your inner arm is hurting, separate your hands and turn your outer arm toward the wall even more.
- Pose 9: Baddhanguliyasana
- Interlace your fingers in front of you, palms facing out. Extend the web of your fingers into each other, then roll your shoulders back and down as you reach out with your palms. Breathe. Change the interlace of your fingers.
- Pose 10: Reverse Wrist Flexion
- Place the back of your palm on the chair beside you, fingers pointing back. Turn your upper arms and shoulders back, broadening and lifting your chest while pinning your shoulder blades to your ribs. Stretch one wrist at a time or both together.
Additional web-based sources:
http://sheddonphysio.blogspot.com/
http://www.osha.gov/SLTC/ergonomics/
http://www.umm.edu/patiented/articles/what_nonsurgical_treatments_carpal_tunnel_syndrome_000034_8.htm
http://physicaltherapy.about.com/od/flexibilityexercises/a/CTSexercise.htm
http://www.livestrong.com/article/22236-carpal-tunnel-prevention-exercises/
