Elbow/ Wrist/ Hand/ TMJ Flashcards
CTS prevalence
8% nationally Twice as likely for women (10% vs. 5%) More common in those > 50 yo Incidence is increasing More common in the working population.
Etiology of CTS
- Elevated CTS pressure (etiology of this unknown)
- Disruption in intraneural blood flow
- Enlargement of the flexor tendon synovial sheaths (more of a fibrous hypertrophy than acute inflammation)
Clinical Course of CTS
- Successful response to nonsurgical intervention unknown. There is a fairly high rate of patients who progress to surgery. PTs should closely monitor progress.
- Factors that may influence nonsurgical results: Severity of nighttime sxs, + Phalens, thenar wasting, prior nonsurgical intervention.
- Acute and chronic. Acute is unusual. Chronic: Usually starts with sxs at night, progresses to sxs during the day, clumsiness, grip weakness.
Classification of CTS severity
Mild: Intermittent sxs
Moderate: More constant sxs
Severe: Thenar atrophy
Intrinsic risk factors for CTS
- Strongest intrinsic risk factors: Obesity, age, female.
- Other intrinsic factors: DM, OA, other MSK disorders, estrogen replacement, CV disease, hypothyroid, family hx, lack of PA, wrist ratio >.70, wrist-palm ratio >.4, wide hand, short stature.
Occupational risk factors for CTS
- Forceful hand exertions = strongest risk factor
- Weaker associations: High psychological demand + low decision authority, vibration, prolonged off neutral wrist positioning, repetitive work.
Computer users do not have an increased risk of CTS when compared to the general population or industrial workers.
Use of imaging for CTS
Guidelines recommend against routine use of MRI or ultrasound.
CTS exam guidelines
A: Monofilment testing (3.22 for normal)
B: Katz hand diagram, Phalen test, Tinel sign, carpal compression
B: 3 of the following: Age >45, shaking hands, sensory loss in thumb, wrist-ratio >0.7, CTQ > 2
D: ULTT, scratch collapse test, vibration sense
Katz hand diagram
(1) classic CTS: symptoms in at least 2 of 3 fingers
completely innervated by the median nerve (thumb, index, or middle fingers) but no symptoms in the palm or dorsal hand;
(2) probable CTS: same as classic except palmar symptoms allowed, unless only on ulnar side of the hand;
(3) possible CTS: symptoms in at least one of either the thumb, index, or middle fingers
(4) unlikely CTS: no symptoms in any of
these fingers.
CTS strength measures
A: Do not use lateral pinch strength
B: Do not use grip strength for short term change
C: Can use grip strength to compare to norms.
CTS: Education regarding ergonomics
C: Can educate patients that mouse use further increases carpal tunnel pressure (all designs). Can recommend using arrow keys, touch screens, alternating mouse hand, use of keyboards with reduced strike force.
CTS: Orthoses
B: Neutral positioned wrist orthosis worn at night for short-term relief and functional improvement
C: Can recommend increases wear to during the day if night time doesn’t work.
C: Add joint mobilizations to orthosis use
C: Should recommend orthosis to pregnant women with CTS.
CTS: Superficial heat and diathermy
C: short-term symptom relief
CTS: IFC
C: Can try it for short term relief
CTS: Low level laser therapy
B: Should not use
CTS: ultrasound
C: Should not use thermal ultrasound
D: Conflicting evidence for nonthermal ultrasound
CTS: Ionto/phonophoresis
B: Should not use ionto
C: May use phono but should consider other interventions.
CTS: Manual therapy
C: May use MT directed at c/s and UE
D: Conflicting use of neurodynamic mobilizations
CTS: Therapeutic exercise
C: May use combined orthotic/stretching program for pts who don’t have thenar atrophy and have normal 2PD
