RESOLVING CARPAL TUNNEL SYNDROME – PART 2
In part one of this two part article about Resolving Carpal Tunnel Syndrome (CTS), I discussed surgical verses non-surgical approaches that can be used, symptoms, basic anatomy, and physical examination processes.
In part two, I will discuss recommended manual therapy options and supporting exercises. I will provide you with video demonstrations about recommended treatments and exercises that we often provide, to our patients, and review the pros/cons of splints and taping.
MANUAL THERAPY FOR CTS
If the case of CTS is not severe (no muscle atrophy, or significant sensory impairment) then conservative management (manual therapy) should be the first line of treatment. That being said, surgery should not be rule-out if functional changes are not achieved within a reasonable period time.
Fortunately, we have found that most cases of CTS do respond WELL to combinations of nerve mobilizing treatments and nerve gliding exercises. In addition to our nerve-mobilization soft tissue procedures, we also recommend including manual mobilization techniques of the carpal bones.
Here are three reasons we would recommend trying manual therapy first before considering surgery.
Research has shown that patients receiving manual therapy exhibit greater improvements in their pain-pressure threshold compared to those who experience surgery. (16)
Research has shown that manual mobilization of the carpal bones increases dimensional changes in the carpal tunnel. (14). This has been shown to reduce the pressure on the median nerve.
Research has shown that after a period of one year, patients who had manual therapy, combined with exercise, had outcomes comparable to those of patients who had surgery. Additionally, the manual therapy patients experienced quicker improvements at the 1-month time period than surgical patients. (24)
In the following two videos, we will demonstrate some the procedures we frequently use at Kinetic Health to increase mobility of the Median nerve along its pathways. This process does not limit itself to only area of the Carpal Tunnel, but follows the entire pathway of the nerve median from the neck (cervical spine) to the hand.
MSR Nerve Release - Part 1 (Neck to Shoulder)
In this video we focus on releasing, the median nerve from its origin at the neck into the shoulder (cervical plexus to the neurovascular sleeve) using Motion Specific Release procedures.
MSR Median Nerve Release
In this video we will focus on releasing the median nerve using Motion Specific Release procedures to address typical median nerve entrapment syndromes such as Carpal Tunnel Syndrome (CTS), Pronator Teres Syndrome, and Anterior Interosseus Nerve Syndrome.
EXERCISES FOR CTS
CTS is often associated with low aerobic fitness, increased body mass, and lymphatic edema, so specific exercises should also address a wide range of problems. Several factors must be considered when prescribing exercises for CTS. Select exercises that:
Address compression on the median nerve.
Aid in improving nerve gliding.
Correct postural issues and improve strength.
Nerve flossing exercises have been shown to decrease pressure on compressed or tethered nerves. (17, 18) The following nerve flossing video is an example of the type of exercises we typically prescribe to our CTS patients. (Perform some of these exercises four or five times per day.)
Median Nerve Flossing Exercises
If you have median nerve entrapment (Carpal Tunnel or some other related nerve entrapment syndrome), then use the exercises in this video to floss, mobilize, and release this nerve from its surrounding tissues.
Tai Chi is a remarkable form of low impact exercise. The research on Tai Chi is substantial, and has shown that it: (25, 26, 27, 28, 29, 30, 31)
Improves balance and cardiovascular health.
Increases bone density.
Decreases stress (specifically cortisol).
Improves lymphatic drainage and much more.
Due to its many benefits Tai Chi is a great form of exercise to integrate into patient exercise routines. The following two videos demonstrate some of the possible Tai Chi related exercises you could integrate into your exercise prescriptions. The first video integrates Tai Chi into some conventional stretching exercise routines. The second is designed to loosen the shoulders and decrease edema.
A Different Computer Break - Releasing Wrist, Hand, and Arm Tension
I often combine these movements with our nerve flossing exercises to aid our patients in their recovery, and have found that they are able to achieve remarkable results.
Tai Chi Shoulder Release
In this modification of “Fair Lady Works at Shuttles” I show you an easy way to decrease the tension in both shoulders.
Note: In addition to these exercises, we would also prescribe appropriate strengthening, and proprioceptive exercise when we determine the patient is ready to do so.
BRACES & TAPING – WHEN TO USE THEM
Braces are used in some CTS cases to correct biomechanical alignment. Braces are most effective when they are custom made to provide three degrees of ulnar deviation, and two-degrees of wrist flexion (neutral position). (12).
CTS patients often have increased symptoms at night due to wrist-bending. The use of a night splint can provide considerable relief for many patients. Since they help to keep the wrist in a straight, neutral position. Just make sure that the splint is not too tight, since over tightening a brace can increase pressure on the carpal tunnel, causing a worsening of symptoms.
It is important to note that while braces/splints often help to decrease pain for the short term, they do NOT provide long-term relief or solution. Wearing a brace/splint can take pressure off the wrist when lifting or performing repetitive motion, but wearing it all the time could lead to increased joint stiffness and loss of muscle strength in the arm and wrist.
Taping can aid in improving stability of the ulnar-carpal joint. In addition, carpometacarpal radial taping can reduce swelling (edema), decrease pain and provide support. Taping can also act as a biofeedback device, reminding the patient to keep their wrist in a neutral position when typing or performing other repetitive actions. (11)
CONCLUSION – RESOLVING CARPAL TUNNEL SYNDROME
Carpal Tunnel Syndrome is NOT a condition that you can put aside in the hope that it will just go away! If the case of Carpal Tunnel Syndrome is not severe (no muscle atrophy, or significant sensory impairment) then conservative management (manual therapy + exercise) is often successful in addressing this condition.
In my clinical opinion, manual therapy should always be your first choice in addressing this condition. That being said, certain cases of CTS may require surgery, so always keep that option open.
DR. BRIAN ABELSON DC.
Dr. Abelson believes in running an Evidence Based Practice (EBP). EBP's strive to adhere to the best research evidence available, while combining their clinical expertise with the specific values of each patient.
Dr. Abelson is the developer of Motion Specific Release (MSR) Treatment Systems. His clinical practice in is located in Calgary, Alberta (Kinetic Health). He has recently authored his 10th publication which will be available later this year.
Make an appointment with our incredible team at Kinetic Health in NW Calgary. Just scan the QR code with your phone camera and click the link, or call Kinetic Health at 403-241-3772 to make an appointment today!
Occupation and carpal tunnel syndrome., Stapleton MJ. Anz Journal of Surgery. 2006 Jun;76(6):494–496.
Nonfatal occupational injuries and illnesses requiring days away from work, 2010., US Bureau of Labor and Statistics, US Department of Labor, 2011. USDL report number: 11-1612.
Carpal tunnel syndrome., LeBlanc KE, Cestia W. Am Fam Physician 2011;83(8):952-8.
Therapist’s management of carpal tunnel syndrome: a practical approach., Evans R., Skirvin T, Osterman AL, Fedorczyk JM (Eds). Rehabilitation of hand and upper extremity, 6th edition. Philadelphia, Penn: Elsevier Mosby; 2011. pp. 666-777.
Basic Science of Nerve Compression., Jacoby SM, Eichenbaum MD, Osterman AL., Skirvin T, Osterman AL, Fedorczyk JM (Eds). Rehabilitation of the Hand and Upper Extremity, 6th edition. Philadelphia, Penn: Elsevier Mosby; 2011. pp. 649-65.
Sensory Re-education., Rosen B, Lundborg G. Skirvin T, Osterman AL, Fedorczyk JM (Eds). Rehabilitation of hand and upper extremity, 6th edition. Philadelphia, Penn: Elsevier Mosby; 2011. pp. 634-45.
Minor peripheral nerve injuries: an underestimated source of pain., Greening J, Lynn B. Manual Ther. 1998;3(4);187-94.
Nerve Entrapment Syndromes: James S Harrop, MD, Hanna, MD, Dachling Pang, MD, FRCS(C), Kamran Sah- rakar, MD, http://emedicine.medscape.com/article/249784-overview
Splinting for carpal tunnel syndrome., Page MJ, Massy-Westropp N, O’Connor D, Pitt V. The Cochrane Collaboration. Cochrane Database of Systematic Reviews. Chichester, UK: John Wiley & Sons Ltd; 2012.
Carpal tunnel syndrome: surgeon’s management., Amadio PC. Skirvin T, Osterman AL, Fedorczyk JM (Eds). Rehabilitation of hand and upper extremity, 6th edition. Philadelphia, Penn: Elsevier Mosby; 2011. pp. 657-65.
Elastic Taping (Kinesio Taping Method)., Coopee R. Skirvin T, Osterman AL, Fedorczyk JM (Eds). Rehabilitation of hand and upper extremity, 6th edition. Philadelphia, Penn: Elsevier Mosby; 2011. pp. 1529-38.
Therapist’s management of carpal tunnel syndrome: a practical approach., Skirvin T, Osterman AL, Fedorczyk JM (Eds). Rehabilitation of hand and upper extremity, 6th edition. Philadelphia, Penn: Elsevier Mosby; 2011. pp. 666-777.
Electrodiagnosis of carpal tunnel syndrome., Robinson LR. Phys Med Rehabil Clin N Am. 2007 Nov. 18(4):733-46, vi.
Dimensional changes of the carpal tunnel and the median nerve during manual mobilization of the carpal bones. Bueno-Gracia E, Ruiz-de-Escudero-Zapico A, Malo-Urriés M, Shacklock M, Estébanez-de-Miguel E, Fanlo-Mazas P, Caudevilla-Polo S, Jiménez-Del-Barrio S. Musculoskelet Sci Pract. 2018 Aug;36:12-16.
The value added by electrodiagnostic testing in the diagnosis of carpal tunnel syndrome., Graham B. J Bone Joint Surg 2008; 90:2587-2593.
Effectiveness of Manual Therapy Versus Surgery in Pain Processing due to Carpal Tunnel Syndrome: A Randomized Clinical Trial, Fernández-de-la-Peñas C, Cleland J, Palacios-Ceña M et al. European Journal of Pain 2017; 21: 1266-1276.
Different nerve gliding exercises induce different magnitudes of median nerve longitudinal excursion: An in vivo study using dynamic ultrasound imaging., Coppieters MW, Hough AD & Dilley A. J Orthop Sports Phys Ther 2009; 39: 164-171.
Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome. O’Connor D, Marshall S, Massy-Westropp N. The Cochrane Database of Systematic Reviews 2003; 1: CD003219.
False-Positive Rates for Nerve Conduction Studies and Ultrasound in Patients Without Clinical Signs and Symptoms of Carpal Tunnel Syndrome, John R Fowler, Kevin Bryne, Tiffany Pan, Robert J Goitz, J Hand Surg Am. 2019 Mar;44(3):181-185. doi: 10.1016/j.jhsa.2018.11.010. Epub 2019 Jan 8.
Carpal tunnel syndrome - Part I (anatomy, physiology, etiology and diagnosis)., Chammas M, Boretto J, Burmann LM, Ramos RM, Dos Santos Neto FC, Silva JB. Rev Bras Ortop. 2014 Sep-Oct. 49 (5):429-36.
Diagnosis of carpal tunnel syndrome. Ultrasound versus electromyography., Lee D, van Holsbeeck MT, Janevski PK, et al. Radiol Clin North Am. 1999 Jul. 37(4):859-72.
Carpal tunnel syndrome and its relation to occupation: a systematic literature review., Palmer KT, Harris EC, Coggon D. Occup Med (Lond). 2007 Jan. 57(1):57-66.
Carpal tunnel syndrome as an occupational disease., Kao SY. J Am Board Fam Pract. 2003 Nov-Dec. 16(6):533-42.
Carpal Tunnel Syndrome: Physical Therapy or Surgery? Journal of Orthopaedic & Sports Physical Therapy, February 28, 2017 Volume 47 Issue3 Pages162-162 https://www.jospt.org/doi/full/10.2519/jospt.2017.0503
“Interventions for Preventing Falls in Older People Living in the Community,” Cochrane Database of Systematic Reviews 15, no. 2 (2010): CD007146, L. D. Gillespie et al.,
Effect of Tai Chi Exercise on Proprioception of Ankle and Knee Joints in Old People, British Journal of Sports Medicine 38 (2004): 50–54.
Long Term Tai Chi Exercise Improves Physical Performance among People with Peripheral Neuropathy, L. Li and B. Manor, American Journal of Chinese Medicine 38, no. 3 (2010): 449–59.
J. W. Hung et al., “Effect of 12-Week Tai Chi Chuan Exercise on Peripheral Nerve Modulation in Patients with Type 2 Diabetes Mellitus,” Journal of Rehabilitation Medicine 41, no. 11 (2009): 924–29.
The Effects of Tai Chi on Bone Mineral Density in Postmenopausal Women: A Systematic Review, P. M. Wayne et al., Archives of Physical Medicine and Rehabilitation 88, no. 5 (May 2007): 673–80
Tai Chi Exercise for Treatment of Pain and Disability in People with Persistent Low Back Pain: A Randomized Controlled Trial, Arthritis Care and Research 3, no. 11 (2011): 1576–83.
Tai Chi Exercise for Patients with Cardiovascular Conditions and Risk Factors: A Systematic Review, G. Y. Yeh, C. C. Wang, P. M. Wayne, R. Phillips, Journal of Cardiopulmonary Rehabilitation and Prevention 29, no. 3 (2009): 152–60
Median nerve compression neuropathy by the lacertus fibrosus: report of three cases., Swiggett R, Ruby LK. J Hand Surg Am. 1986 Sep. 11 (5):700-3.
The controversial arcade of Struthers., Siqueira MG, Martins RS. Surg Neurol. 2005. 64 Suppl 1:S1:17-20; discussion S1:20-1.
Supracondylar process and supratrochlear foramen of the humerus: a case report and a review of the literature., Varlam H, St Antohe D, Chistol RO. Morphologie. 2005 Sep. 89 (286):121-5.
Variations of the pronator teres muscle: predispositional role to median nerve entrapment., Nebot-Cegarra J, Perez-Berruezo J, Reina de la Torre F. Arch Anat Histol Embryol. 1991-1992. 74:35-45.
Anatomy, function, and pathophysiology of peripheral nerves and nerve compression., Lundborg G, Dahlin LB. Hand Clin. 1996 May. 12 (2):185-93.
Anatomic observations in carpal tunnel syndrome as they relate to the tethered median nerve stress test.,LaBan MM, MacKenzie JR, Zemenick GA. Arch Phys Med Rehabil. 1989 Jan. 70 (1):44-6.
Manual Therapy Versus Surgery for Carpal Tunnel Syndrome: 4-Year Follow-Up from a Randomized Controlled Trial, Fernández-de-las-Peñas C, Arias-Buría J, Cleland J et al., Physical Therapy 2020; 100: 1987-1996.