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Non-Operative Management of Carpal Tunnel Syndrome

We have looked at Carpal Tunnel Syndrome (CTS) off-and-on in the past. Mostly about the condition itself. So the question that follows is what can we do about it – particularly if we want to avoid surgery? Depending on the severity of CTS, patients would be managed either conservatively or operatively. Conservative management of mild forms of CTS, include physiotherapy, which usually yield good results especially if the injury is recent and is due to awkward wrist postures and repetitive motions of the wrist in the workplace. Physiotherapy intervention is guided by the objective assessment and directed to the causative factors with rehabilitation lasting typically about 6 weeks to 4 months. Considerations include:

1. Splinting – Splint wrist in neutral to minimise pressure in the tunnel and to provide rest from the aggravating activity
    
2. Joint mobilisation – If there is restricted joint mobility, mobilise carpals for increased  carpal tunnel space.
    
3. Bio-mechanical analysis- identify faulty wrist or upper extremity motions. Adapt the environment if possible to reduce the need for faulty motion. Strengthen and increase endurance in stabilising muscles.
    
4. Tendon gliding  and median nerve mobilisation exercises – A study by Rozmaryn et al (1998) has shown a significant improvement in symptoms in patients treated conservatively with the tendon and median nerve gliding exercises. Only 43% of the patients in the experimental group who had the nerve mobilisation exercises underwent subsequent surgical release of the carpal tunnel, compared to 71% in the control group.
   • Tendon gliding exercise
     
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     Teach patient tendon gliding exercises to develop mobility in the extrinsic tendons. Such exercises should be performed gently to prevent increased swelling. One of such flexor tendon gliding exercise consists of 5 finger positions. Start off from neutral (straight hand) to hook fist position, then proceed to a full fist, followed by a straight fist and then thumb flexion. (see figure 1)
      
   • Median Nerve Mobilisation
     
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     Start off with Picture 1 (see figure  2) and progress to each successive position until the median nerve symptoms just begin to be provoked (i.e. tingling, but not to the extent of numbness). Stop at this position, as it is the maximum that the mobilisation will go. Sustain position for 5-30 seconds without making the symptoms worse. Alternate between this position and the preceding one. When the patient can be moved into the last position without symptoms, he or she can progress to the next mobilisation position and repeat the routine. This routine should be done 3-4 times daily as long the symptoms are not exacerbated.
      
5. Patient education- Teach the patient to monitor his or her hand for recurrence of symptoms and the aggravating factors. Once the patient understands the mechanism of injury, he or she would then modify activities to decrease nerve injury. Usually sustained wrist flexion, ulnar deviation, and repetitive wrist flexion and extension combined with gripping and pinching are the provoking movements.
    
6. Strengthening and endurance exercises- Initially, only gentle muscle setting exercises are the only resistive exerercises done. It is important that these exercises do not provoke symptoms.  Subsequently, dynamic strenghtneing and endurance exercises with isometrics will be added without increasing the symptoms.

Overall, the physiotherapy programme endeavours to educate the patient and increase his or her awareness of ‘high-risk’ wrist postures especially while working and to stabilise the wrist through means of strengthening, thus minimising the re-occurence of CTS in future.

References:

1. Rozmaryn, LM et al. Nerve and tendon gliding exercises and the conservative management of carpal tunnel syndrome. J Hand Ther 11:171, 1998.

Skier’s thumb? Gamekeeper’s thumb?

The ulnar collateral ligament is a strong, fibrous band that maintains stability on the inside border at the base of the thumb. The ligament prevents excessive thumb movement away from the hand.

Source: Orthopod
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• Pain and tenderness over the base of the thumb
• Swelling and or bruising over base of the thumb
• Pain with movement of the affected thumb and difficulty gripping objects
• Instability or catching of the thumb on movement

• Severity/grade of the injury
• How long ago injury occurred
• Patient age
• Physical demands of the patient
• Likely adherence of patient to protocols

If only a partial rupture has occurred patients are either placed in a mild cast or wrist splint (known as thumb spica) for 4 to 6 weeks.

Hand Infections

When discussing about sports injury, we tend to focus on the big traumatic stuff like fractures, broken bones, dislocations, torn ligaments or massive swellings. Minor injuries are often brushed off especially with the more physical contact sports. After all, isn't discipline and perseverance part of the game?

As a result we tend to overlook hand infections, particularly lacerations (cuts and grazes) and for the more contact sports, bite wounds are not uncommon.

Lacerations

Cuts and grazes to the hands and fingers are a common occurrence in sports as a result of accidental contact with equipment, playing surfaces and between players or participants.

All cuts and grazes have the potential to become infected and should therefore be taken seriously.

Standard practice should be wash and clean all cuts and grazes hygienically with antiseptic solution monitored carefully for a number of days for any signs of infection.

If an infection develops the following signs symptoms may be present:

• severe , throbbing pain
• fever
• movement of fingers reduced with pain
• swelling and redness in the hand

If two or more of the above signs and symptoms are present then the risk of an infection is high and you should immediately report to the nearest doctor or hospital.

Bite Wounds

Skin of the hand broken by human teeth is a particularly dangerous wound. Human saliva contains such high levels of bacteria that these injuries should always be presumed to be contaminated. Skin is broken either from a punch to the mouth or a bite wound.

It is highly recommended that a course of a broad spectrum anti-biotic be administered by a doctor immediately and the wound not covered over or closed.

Why taken lacerations and bite wounds seriously?

Because due to the continuity of tendons of the hands into the wrist and forearms, infections can spread rapidly if not treated. Consequences can be highly destructive and hand infections frequently require hospital admissions for more specific anti-biotic therapy and or surgical intervention. In serious cases the tissue can become necrotic and die.

So please do take these sometimes rather innocuous and minor wounds seriously and seek medical treatment immediately if required. 
 

Wii Right, Wrist-Wise

Wii Gamers often complain about wrist injuries. Here are some exercises and holding technique that Wii gamers can follow to better protect themselves from Repetitive Strain Injuries (RSI).

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