Carpal tunnel syndrome is an entrapment neuropathy caused by compression of the median nerve as it travels through the wrist’s carpal tunnel. It is the most common peripheral nerve entrapment neuropathy worldwide. Carpal tunnel is the name given to the passage in the wrist through which median nerve runs to end in hand. Early symptoms include pain, numbness and paresthesia’s.
Causes: Carpal tunnel syndrome results from increased carpal tunnel pressure and subsequent compression of the median nerve. The most common causes of carpal tunnel syndrome include genetic predisposition, history of repetitive wrist movements such as typing, or machine work as well as obesity, autoimmune disorders such as rheumatoid arthritis, and pregnancy.
History and clinical presentation: Patients often report numbness, tingling, and pain that increase at night. Weakness, clumsiness, and temperature changes also are common complaints. The thumb, digits 2 and 3, and the radial half (towards thumb) of digit 4 are typically affected. Patients with carpal tunnel syndrome often will have a positive “flick sign”, meaning that symptoms improve when they flick their hand and wrist. Patients often find some relief with ice, rest if provoked by repetitive activity, and night splints.
· Electroneuromyography (ENMG)
· Electromyogram (EMG)
· Phalen’s test
· Tinel’s sign
· Durkan’s carpal compression test
· Scratch collapse test
· Hand elevation test
Medical management: Non-surgical treatment comprises of;
· Oral steroids
· Corticosteroid injections
· Vitamin B6
· Splinting/ hand brace.
All of these have limited to moderate evidence of effectiveness. Surgical treatment seems to be more effective than splinting and NSAIDS. Two main methods to decompress the median nerve by surgery are;
· Open carpal tunnel release (OCTR)
· Endoscopic carpal tunnel release (ECTR)
Physical therapy management: Patients with mild to moderate symptoms do not need to be immediately operated but can be effectively treated in a primary care environment.
Physical therapy typically consists of;
· Modification of activities and workplace
· Patient education
· Carpal bone and nerve mobilization
· Electromagnetic field therapy
It is important for a physiotherapist to pay attention to the cause of CTS. Physical therapist should give advice in task modification like taking sufficient rest and variation of movements.
Patients may benefit from physiotherapy-based treatment with goals of CTS symptom reduction and functional gains, provided that:
Their symptoms are intermittent and not rapidly worsening or if their CTS etiology is highly suggestive of the possibility of remission as an example of pregnancy-related CTS
Patients are informed about the lack of high-quality evidence for the effectiveness and safety of therapeutic modalities used by physiotherapists,
· Kolby and Kisner, therapeutic exercises, Ed.7th
· The comprehensive manual of therapeutic exercises by Elizabeth Bryan 2018
· Image Cleveland Clinic