Protocol: Carpal Tunnel Syndrome
Carpal Tunnel Syndrome often involves two problem areas: the wrist itself, and stresses at the neck. Median nerve compression within the carpal tunnel may be primary, or secondary to (or aggravated by) compression within the scaleni at the neck. Compression at the scaleni can upset blood flow and other functions in the median nerve along its entire length to the carpal tunnel. Posture stresses at the neck and shoulder girdle can also increase neuro receptor irritability distally at the wrist and hand, increasing CTS symptoms.
Local CTS wrist problems are addressed with anti-inflammatory modalities: iontophoresis of dexamethasone into the CT, microcurrent stimulation, LLLT, Neuroprobe acupuncture point stim. Mobilization techniques may open and reduce mechanical compression.
Excessive tension with flexor muscles-tendons due to overuse or pain will perpetuate carpal tunnel compression. Trigger point Strain-Counterstrain (SCS) and other trigger point treatment can reduce this, as can certain active exercises that inhibit hypertonicity. Tendon-gliding exercises can reduce adhesions that may form among compressed tendons. Specific tendon massage techniques can reduce swelling and adhesions.
Neck issues relate to reducing thoracic outlet compression (not thoracic outlet syndrome in the classic sense, but simply a degree of thoracic outlet compression). Tight scaleni, abnormal shoulder girdle and upper thoracic spine postures can compress the brachial plexus. Excess neurological stimulation due to posture stresses, muscular trigger points and spasms, constant low grade nociceptor (pain) stimulation can all increase neuro irritability distally, particularly at structures passing through a stressed carpal tunnel. These add to CTS thresholds.
Proximal stresses are managed per our neck pain protocol: manual therapy mobilizations such as muscle energy technique, craniosacral technique, mechanical link mobilizations, strain-counterstrain, traction… all assisted by electro-modalities such as microcurrent or Neuroprobe acupuncture point stimulation and posture re-training. Any contributory stresses at the TMJ must also be addressed.
PROTOCOL: Carpal Tunnel Syndrome
NOTE: Addresses local structure and function of the carpal tunnel and its neurovascular bundle …plus considers any degree thoracic outlet compression as a possible source of median nerve double-crush… plus assumes pain and trigger points in cervical region can also increase pain and neuro effects distally. CTS often part of wider set of upper quarter dysfunctions.
1. Splinting as indicated, initially at night.
2. Pain control modalities: microcurrent, Neuroprobe acu-puncture point stim, ice-heat modalities
3. Electric stim for effusion and inflammation control: Iontophoresis, Microcurrent, TNS, LLLT
4. Neck pain control per neck pain protocol
5. Rest-activity patterns; Work stress intervention
1. Dexamethasone iontophoresis; LLLT
2. Microcurrent E-stim at carpal tunnel to Erb’s Point at neck.
3. Joint and soft tissue mobilization; myofascial release (MFR), strain-counterstrain (SCS), at upper
extremity and at neck-thoracic outlet.
4. Carpal tunnel tendon gliding exercises and sensory-motor re-education exercises
5. Forearm muscle groups strengthening exercises:
Antagonist inhibitory method versus agonist strengthening
6. Trigger point myotherapy proximally and distally; TheraCane at home
7. Neck-shoulder-thoracic outlet mobility, flexibility, relaxation, posture re-training
8. TMJ stress reduction (see that protocol)
9. Job and ADL ergonomic modifications
10. Neurology, Occupational Therapist, Certified Hand Therapist referrals
REHABILITATION AND PREVENTION:
1. CUMULATIVE TRAUMA SCHOOL training class
2. Ergonomic modifications and preventive exercises for work and ADL
3. Upper body reconditioning plan
4. Refer to neck pain protocol. Refer to tendinitis protocol
Patient Education: “SmartCare CTS Guide”; “Personal Ergonomics Guide”, “Living with CTD”
GOALS: Reduce carpal tunnel compression and inflammation. Reduce flexor hypertonicity
Reduce double crush effects and trigger referrals from neck or thoracic outlet.
Correct posture, strength, flexibility, muscle tonicity. Correct ergonomic stresses. Prevent recurrence.
Visit One: Upper quarter evaluation; patient education re. findings and treatment plan
Acute pain control: microcurrent (CT to brachial plexus), Neuroprobe
Splinting as indicated: night and-or work
Work demands modification
Home exercises re. remedial wrist and neck ROM and flexibility
Visit Two: Dexamethasone iontophoresis
Microcurrent (carpal tunnel to brachial plexus), Neuroprobe acu-point stim
Proximal care: address cervical, upper thoracic, thoracic outlet, TMJ
Upgrade home exercises: extensor digitorum exercises to inhibit flexor tone
Visit Three: Repeat visit two procedures
Wrist mobilization; localized MFR; tendon gliding; transverse friction massage
Trigger point myotherapy at forearm and proximally
Upgrade home exercises: gripper for agonist strengthening
Visit Four: Repeat visit three procedures
Thoracic and ribs manual therapy; mobilization, MFR, visceral techniques
Upgrade home exercises: neck stabilization, thoracic strength and stability
Visit five: EMG biofeedback relaxation training at SCM, scaleni, traps and wrist flexors
Referral to specialist MD, Hand Therapist, OT, DO, DC, LMT