carpal tunel syndrome

Brief anatomy

The carpal tunnel is an anatomical compartment located at the base of the wrist. Nine flexor tendons and the median nerve pass through the carpal tunnel that is surrounded on three sides by the carpal bones that form an arch. The nerve and the tendons provide function, feeling, and movement to some of the fingers. The finger and wrist flexor muscles including their tendons originate in the forearm at the medial epicondyle of the elbow joint and attach to the Metaphalangeal (MP), Proximal Interphalangeal (PIP), and Distal Interphalangeal bones of the fingers and thumb (BSI). The carpal tunnel is approximately as wide as the thumb and its boundary lies at the distal wrist skin crease and extends distally into the palm for approximately 2 cm.

The median nerve can be compressed by a decrease in the size of the canal, an increase in the size of the contents (such as the swelling of lubrication tissue around the flexor tendons), or both Simply flexing the wrist to 90 degrees will decrease the size of the canal

condition related toCTS

(1) obesty

(2) pregnancy

(3)  hypothyriodism

(4)arthritis

(5) diabetes

symptoms

People with carpal tunnel syndrome initially feel numbness and tingling of the hand in the distribution of the median nerve (the thumb, index, middle, and part of the fourth fingers). These sensations are often more pronounced at night and can awaken people from sleep
signs
atrophy of the thenar eminence, weakness of the flexor pollicis brevis, opponens pollicis, abductor pollicis brevis, as well as sensory loss in the distribution of the median nerve distal to the transverse carpal ligament

daignosis

Physicians can use specific tests to try to produce the symptoms of carpal tunnel syndrome. In the Tinel test, the doctor taps on or presses on the median nerve in the patient's wrist. The test is positive when tingling in the fingers or a resultant shock-like sensation occurs. The Phalen, or wrist-flexion, test involves having the patient hold his or her forearms upright by pointing the fingers down and pressing the backs of the hands together. The presence of carpal tunnel syndrome is suggested if one or more symptoms, such as tingling or increasing numbness, is felt in the fingers within 1 minute. Doctors may also ask patients to try to make a movement that brings on symptoms.
Often it is necessary to confirm the diagnosis by use of electrodiagnostic tests. In a nerve conduction study, electrodes are placed on the hand and wrist. Small electric shocks are applied and the speed with which nerves transmit impulses is measured. In electromyography, a fine needle is inserted into a muscle; electrical activity viewed on a screen can determine the severity of damage to the median nerve. Ultrasound imaging can show impaired movement of the median nerve. Magnetic resonance imaging (MRI) can show the anatomy of the wrist but to date has not been especially useful in diagnosing carpal tunnel syndrome.

treatment

Mild symptoms usually can be treated with home care. The sooner you start treatment, the better your chances of stopping symptoms and preventing long-term damage to the nerve.
You can do a few things at home to help your hand and wrist feel better:

• Stop activities that cause numbness and pain. Rest your wrist longer between activities.
• Ice your wrist for 10 to 15 minutes 1 or 2 times an hour. Try taking nonsteroidal anti-inflammatory drugs (NSAIDs) to relieve pain and reduce swelling.
• Wear a wrist splint at night to keep your wrist in a neutral position. This takes pressure off your median nerve. Your wrist is in a neutral position when it is straight or only slightly bent. Holding a glass of water is an example of your wrist in a neutral position.

Nonsurgical Treatment

If diagnosed and treated early, carpal tunnel syndrome can be relieved without surgery. In cases where the diagnosis is uncertain or the condition is mild to moderate, your doctor will always try simple treatment measures first.

(1)Bracing or splinting. A brace or splint worn at night keeps the wrist in a neutral position. This prevents the nightly irritation to the median nerve that occurs when wrists are curled during sleep. Splints can also be worn during activities that aggravate symptoms.
(2)Medications. Simple medications can help relieve pain. These medications include anti-inflammatory drugs (NSAIDs), such as ibuprofen.
(3)Activity changes. Changing patterns of hand use to avoid positions and activities that aggravate the symptoms may be helpful. If work requirements cause symptoms, changing or modifying jobs may slow or stop progression of the disease(4)Steroid injections. A corticosteroid injection will often provide relief, but symptoms may come back.

Surgical Treatment

Surgery may be considered if you do not gain relief from nonsurgical treatments. The decision whether to have surgery is based mostly on the severity of your symptoms.

• In more severe cases, surgery is considered sooner because other nonsurgical treatment options are unlikely to help.
• In very severe, long-standing cases with constant numbness and wasting of your thumb muscles, surgery may be recommended to prevent irreversible damage

Physiotherapy and occupational therapy

Typical physiotherapy exercise for carpal tunnel syndrome.

One review of the evidence for possible symptom reduction found good evidence  recommendations) for splinting, ultrasound, nerve gliding exercises, carpal bone mobilization, magnetic therapy, and yoga for people with carpal tunnel syndrome However, a recent evidence based guideline produced by the American Academy of Orthopedic Surgeons assigned lower grades to most of these treatments.

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A n k l e E x e rc i s e s

If you have no improvement after one week, contact your physician.

This patient handout was produced by the Camino Medical Group Department of Orthopedics for the purpose of better assisting

our patients with their recovery. It is important that you follow the directions your physician has prescribed in order to benefit from

the rehabilitation process.

T H E   A L P H A B E T S  

Exercise 1

1.     While seated with the edge of the heel on the floor,

draw the entire alphabet one letter at a time by

moving the injured ankle and using the great toe as

the “pen”.

2.     Do two sets of (A-Z), two to three times a day.

D S H I E L D   W I P E R 

Exercise 2

1.     Sit with the foot flat on the floor and facing straight

ahead.

2.     Rotate the affected foot to mimic a windshield wiper

blade: Pivot the foot outward and touch the inside

edge of the foot to the floor (A)

3.     Rotate it inward and touch the outside of the foot to

the floor (B).

4.     Do two sets of 10 to 15

repetitions, two to three

times a day.

S I N G L E   L E G   S TA N D                   

p a r t i a l   w e i g h t - b e a r i n g 

Exercise 4

1.     Stand while placing one

hand on a table.

2.     Shift some of the weight to

the injured foot for 15

seconds.

3.     Increase the time spent on

the injured foot by 15

seconds until you can stand

for 45 seconds.

4.     Gradually increase the

amount of weight supported

by the injured foot until full

body weight is used.

5.     Do two sets of 10 to 15   

repetitions, two to three

times a day.

E V E R S I O N   A N D   I N V E R S I O N   I S O M E T R I C S 

Exercise 5

Eversion

1.     (A) Stand and place the outside of the injured foot

against a table leg or door jamb.

2.     Push outward with the foot for 2 to 3 seconds.

3.     Do two sets of 10 to 15 repetitions, two to three times a

day.

 

E X E R C I S E   B A N D - E V E R S I O N   A N D   I N V E R S I O N 

Exercise 6

Eversion

1.     Sit with the involved leg straight.

2.     Tie a loop in an elastic exercise band(Theraband*) and attach the other

end to a heavy object such as a table leg.

3.     Place the loop around the ball of the foot (A).

4.     Rotate (evert) the foot away from the table leg and return to the starting

position (1 repetition).

5.     Do not rotate the leg to do the exercise.

6.     Do two sets of 10 to 15 repetitions, two to three times a day.

Inversion

1.     (B) Reverse the position of the exercise band.

2.     Rotate (invert) the foot inward, away from the table leg.

3.     Do two sets of 10 to 15 repetitions, two to three times a day.

G A S T R O C N E M I U S   S T R E T C H 

Exercise 7

1.     Place the injured foot behind the uninjured foot and

keep the back knee straight, with the heel firmly

planted on the floor.

2.     Lean forward against a wall so that you feel a stretch

in the calf farthest from the wall.

3.     Hold for 30 seconds.

4.     Do two sets of 10 to 15 repetitions, two to three times

a day.

E U S   S T R E T C H 

Exercise 8

1.     Stand with the injured foot in front of the other foot.

2.     Bend the knee of the back foot and lower your body

toward the floor without letting the back heel rise off

the floor.

3.     You should feel the stretch in the lower calf of the

back leg.

4.     Do two sets of 10 to 15 repetitions, two to three times

a day

S I N G L E   L E G   S TA N D   S TA N D I N G 

C A L F   R A I S E   ( f u l l   w e i g h t - b e a r i n g ) 

Exercise 9

Single-leg stand

1.     Stand with the injured foot

on the floor and the other

leg bent at the knee and off

the floor (as shown for the

standing calf raise).

2.     Maintain full weight on

injured leg for 30 seconds.

3.     Do two sets of 10 to 15   

repetitions, two to three

times a day.

Standing Calf Raise

1.     Raise up on the ball of the

injured foot

2.     Return the heel to the floor.

3.     Weight is supported only on

the injured side.

4.     Do two sets of 10 to 15 repetitions, two to three times

a day.

S I N G L E   L E G   S TA N D   W I T H   A 

T O W E L 

Exercise 10

1.     Roll a towel into a strip 4

inches wide, 1 to 2 inches

high, and 12 to 18 inches

long.

2.     Stand with the injured ankle

on the towel as for the     

single-leg stand (exercise 4).

3.     Hold for 30 seconds.

4.     Do two sets of 10 to 15   

repetitions, two to three

times a day.

L AT E R A L   S T E P  

Exercise 11

1.     Place a rolled towel on the ground and stand with

both feet to one side of the towel (A).

2.     Step over the towel with the injured ankle (B) and

remain on one foot (C).

3.     Reverse the process and step over the towel in the

opposite direction.

4.     Increase speed as pain will allow.

5.     Do two sets of 10 to 15 repetitions, two to three

times a day.

L AT E R A L   B O U N D 

Exercise 12

1.     Place a rolled towel on the ground and stand with

both feet to one side of the towel (same as Lateral

Step starting position).

2.     Hop over the towel and land on the right foot.

3.     Then, hop back over the towel and land on the left

foot.

4.     Gradually increase speed and height of bound as

comfort allows.

4.     Do two sets of 10 to 15 repetitions, two to three

times a day.

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Cervical spondylosis

It is degeneration of the spin from wear and tear , it is spinal arthritis

It becomes increasingly more common as people age. More than 85% of people over age 60 are affected.

Predisposing factors:

    a-Genetics – if your family has a history of neck pain

    b-Smoking – clearly linked to increased neck pain

    c-Occupation – jobs with lots of neck motion and overhead work

    d-Mental health issues – depression/anxiety

    e-Injuries/trauma – car wreck or on-the-job injury

.Diagnosis

1-X-rays

These pictures are traditionally ordered as a first step in imaging the spine. X-rays will show aging changes, like loss of disk height or bone spurs.

2-Magnetic resonance imaging (MRI)

This study can create better images of soft tissues, such as muscles, disks, nerves, and the spinal cord.

3-Computed tomography (CT) scans

This specialized x-ray study allows careful evaluation of the bone and spinal canal.

4-Myelography

This specific x-ray study involves injecting dye or contrast material into the spinal canal. It allows for careful evaluation of the spinal canal and nerve roots.

5-Electromyography (EMG)

6-Nerve conduction studies and electromyography may be performed by another doctor to look for nerve damage or pinching.

7-Neck flexibility assessment. Cervical spondylosis limits the range of motion in your neck. To observe this effect, your doctor may have you tilt your head toward each of your shoulders and rotate your neck from side to side.

Clinical picture:

Problemes result from compression on the spinal cord or nerve root or both

If the spinal cord is compressed, a change in walking is usually the first sign. Leg movements may become jerky (spastic), and walking becomes unsteady. Sensation may be decreased in the feet and hands. The neck may be painful and become less flexible. Reflexes may be increased, sometimes causing muscle spasms, particularly in the legs. Coughing, sneezing, and other movements of the neck may worsen symptoms. Sometimes the hands are affected more than the legs and feet. If severe, compression may impair bladder and bowel function.

If spinal nerve roots are compressed, the neck is usually painful, and the pain often radiates to the head, shoulders, or arms. Muscles in one or both arms may become weak and waste away, making the arms limp. Reflexes in the arms may be decreased

Treatment:

1-Analgesics:

    Paracetamol at full strength is often sufficient. For an adult this is two 500 mg tablets, four times a day.

    Anti-inflammatory painkillers. Some people find that these work better than paracetamol. They can be used alone or in combination with paracetamol. They include ibuprofen which you can buy at pharmacies or get on prescription. Other types such as diclofenac or naproxen need a prescription. Some people with stomach ulcers, asthma, high blood pressure, kidney failure, or heart failure may not be able to take anti-inflammatory painkillers.

    A stronger painkiller such as codeine is an option if anti-inflammatories do not suit or do not work well. Codeine is often taken in addition to paracetamol. Constipation is a common side-effect from codeine. To prevent constipation, have lots to drink and eat foods with plenty of fibre.

    A low dose tricyclic antidepressant, such as amitriptyline, is sometimes used for chronic (persistent) neck pain. The dose of amitriptyline used for pain is 10-30 mg at night. At higher doses, tricyclic antidepressants are used to treat depression. However, at lower doses they have been found to help relieve certain types of pain including neck pain.

2-Role of physiotherapy:

Your physical therapist may give you passive treatments such as:

    Deep Tissue Massage: This technique targets spasms and chronic muscle tension that perhaps builds up through daily life stress. You could also have spasms or muscle tension because of strains or sprains. The therapist uses direct pressure and friction to try to release the tension in your soft tissues )ligaments, tendons, muscles.)

    Hot and Cold Therapies: Your physical therapist will alternate between hot and cold therapies. By using heat, the physical therapist seeks to get more blood to the target area because an increased blood flow brings more oxygen and nutrients to that area. Blood is also needed to remove waste byproducts created by muscle spasms, and it also helps healing.Cold therapy, also called cryotherapy, slows circulation, helping to reduce inflammation, muscle spasms, and pain. You may have a cold pack placed upon the target area, or even be given an ice massage. Another cryotherapy option is a spray called fluorometh

    ane that cools the tissues. After cold therapy, your therapist may work with you to stretch the affected muscles.

    Electrical stimulation: This can be performed within the clinic and if extremely successful, a TENS unit can be issued to a patient for home use. E-stim stimulates your muscles through variable (but safe) intensities of electrical current. It helps reduce muscle spasms, and it may increase your body’s production of endorphins, your natural pain killers. It may also drive out inflammation, bring in healing properties, relax, and re-educate the muscles involved. The e-stim unit in the clinic is of a professional standard; the equipment is relatively large. However, a smaller machine for at “at home” use is also available. Electrical stimulation is a helpful therapy.

, your therapist will teach you various exercises to improve your flexibility, strength, core stability, and range of motion (how easily your joints move). Your physical therapy program is individualized, taking into consideration your health and history. Because your PT program is so individualized, we can’t say what should and shouldn’t be in your plan; again, your physical therapist will decide that. But we can generally say that you may learn about body mechanics—how to move your body so that you don’t increase your pain. You’ll learn how to avoid positions that exacerbate your pain. You may also learn about correcting your posture and how to use good ergonomics at work.

Wearing a neck brace (cervical collar) off and on throughout the day to help limit neck motion and reduce nerve irritation

3-Surgical treatment:

.Anterior approach is an incision in the front of the neck and moves aside the windpipe (trachea) and swallowing tube (esophagus) to expose the cervical spine. Your surgeon can then remove a herniated disk or bone spurs, depending on the underlying problem. Sometimes, with disk removal, your surgeon will fill the gap With agraft of bone or implant.

.Posterior approach Your surgeon may opt to remove or rearrange bone from the back of your neck, especially if several portions of the channel that houses the cord have narrowed. The operation, called a laminectomy, removes the back part of the bone over the spinal canal through an incision in the back of your neck.

Complication of surgry:

It may include infection, a tear in the membrane that covers the spinal cord at the site of the surgery, bleeding, a blood clot in a leg vein and neurological deterioration. In addition, the surgery may not eliminate all the problems associated with your condition.

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