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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

      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

      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.

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