hand pain/ sensory deficits- Carpal Tunnel CPG Flashcards
What diagnostic test should you do with a suspected carpal tunnel patient?
A evidence
Semmes- Weinstein Monofilament Testing (SMWT)- 2.83 or 3.22 for threshold of normal light touch and static 2PD (2 point discrimination) on middle finger
For mod- severe- use 3.22 to any radial finger for threshold for normal
What tests and measures can you administer for those suspected to have CTS
B evidence
Katz Hand diagram, Phalen test, Tinels sign, and carpal compression test
What other subjective and objective measures should you document for patients with CTS
- Age ( > 45 years)
- Whether shaking hands relieves their symptoms
- Sensory loss of the thumb
- Wrist ratio index ( >.67)
- Boston Carpal Tunnel Questionarre and Symptom Severity Scale (CTQ-SSS)- > 1.9
Presence of 3 or more findings = acceptable diagnostic accuracy
What recommendation can be made about UL Neurodynamic tests? Scratch- collapse test? Tests of vibration?
Conflicting evidence- therefore no recommendation can be made
What are the outcome measures recommended for CTS? What if the patient is electing for non- surgical management?
B evidence
- CTQ- SSS- only one recommended for non surgical management
- CTQ- FS (Carpal tunnel questionnaire- functional scale)
- DASH (Disability of the Arm and Shoulder)
What physical performance measures are recommended for those with CTS? Surgery versus non- surgery?
C evidence
Surgery: DMPUT- Dellon- Modified Moberg Pick up Test
Non- surgery: PPB (Purdue Peg board)
Others: Jebsen Taylor Hand Function Test, Nine- Hold Peg Test
What recommendations are made about lateral pinch?
A evidence
Should NOT be used
What recommendations can be made for assessing grip strength following CTS?
B evidence
Should NOT be used when assessing short term <3 mo.
What recommendation can be made about grip strength and 3 point or tip pinch strength in suspected CTS? Post surgery?
C evidence- Can be used in suspected patients
D evidence- conflicting evidence following surgery
What recommendations are made regarding provocation testing for those with non- surgical/ surgical managed CTS?
C- NOT to use vibration/ threshold tests for non- surgical patients, Phalens test for surgical patients
D- conflicted evidence for 2 point discrimination and threshold testing for surgical patients
What recommendations can be made about assistive technology for patients with CTS
C evidence-
Alternative strategies- use of arrows, touch screens, alternating mouse hand, keyboards with reduced strike force
What orthosis recommendation can be made for CTS
B evidence
Neutral wrist position- worn at night for short term relief
C evidence
Can adjust wear time including day time, symptomatic, or full- time use when night- only is ineffective
can also add MCP joint immobilization to modify wrist position if no relief
Can be used for pregnant patients
What Biophysical Agents SHOULD/ CAN you use for CTS?
C evidence
- Trial of superficial heat for short- term relief
- Microwave shortwave diathermy- mild to moderate idiopathic CTS
- Trial of IFC for short- term relief- without pacemakers for mild to moderate CTS
- Phonophoresis with non- surgical management
What biophysical agents should NOT be used for CTS?
B evidence:
- Iontophoresis- for mild/ moderate CTS
- Low level Laser Therapy- or other non- laser light therapy
- Magnets
C evidence:
4. Thermal Ultrasound- for mild/ moderate CTS
What recommendation can be made about non- thermal U/S?
Conflicting evidence- no recommendation can be made
What recommendation is made for manual therapy for CTS?
C evidence
cervical spine and upper extremity
D evidence
Neurodynamic mobilization- conflicting evidence
What recommendations are made regarding therex for CTS?
C evidence
Combined orthotic/ stretching program for those with mild/ moderate CTS without thenar artopthy and normal 2PD
What is the prevalence for men versus women for CTS?
Women 2X more than men
What forms the carpal tunnel?
Carpal bones and the transverse carpal ligament
What tendons pass thru the carpal tunnel?
(4) FDS- Flexor digitorum superficialis
(4) FDP- Flexor digitorum profundus
Single tendon from FPL- Flexor Pollicus longus
What is the most superficial structure in the carpal tunnel?
Median nerve
What do the sensory branches do the median nerve innervate?
Thumb, index finger, middle, and radial half of the ring fingers
What motor branches do the median nerve innervate?
the first and 2nd lumbrical muscles
Opponens pollicus
ABP- abductor pollicus brevis
Superficial portion of the flexor pollicus brevis
What nerve innervates the thenar eminence/ carpal tunnel?
Palmar cutaneous branch- branches off median nerve 5cm proximal to wrist
What nerve innervates the area of the scaphoid tubercle?
Lower antebrachial cutaneous
What is the blood supply to the median nerve
Radial and ulnar arteries
Other than the classic signs, what are some of the pathoanatomical features seen with CTS?
Can see pain, proximal to shoulder, elevated carpal tunnel pressure, ischemic nerve changes, and compression from adjacent structures
What are some factors that lead to poor outcomes for non- surgical management?
Longer symptom duration, + phalen test, thenar eminence muscle wasting
What are the best predictors for success for non- surgical management of CTS?
Shorter symptom duration ( < 1 year)
Lower severity of night- time symptoms
What is the leading cause of Acute CTS? Other causes?
Distal radius fractures
Spontaneous bleeding, thrombosis, dislocation of metacarpal base, infection, pregnancy, fracture
What intrinsic risk factors have the strongest link to CTS?
Obesity, age, female sex
Risk increases linearly with MRI and doubles with BMI > 30 kg/m, and in those > 50 y/o
Female sex increases by 1.5-4X
What are some other intrinsic risk factors associated with CTS but to a lesser extent?
DM, OA, musculoskeletal disorders, estrogen replacement therapy, CV disease risk factors, hypothryoidism, family h/o CTS, lack of activity, wrist ratio > .70, wrist palm ratio > .39, short wide hand, short stature
What are some conflicting risk factors with CTS?
RA, smoking, alcohol abuse, oral contraceptive use, menopause, parity, hysterectomy, or oophorectomy q
What occupational risk factor had the strongest association with CTS?
Forceful hand exertions
Weaker associations with high psychological demand paired with low decision authority, vibration, prolonged off neutral wrist position, repetitive work
Computer users- not at increased risk
What are some differential diagnostics for CTS?
Cervical radiculopathy, TOS, diabetic/ polyneuropathy, other median neuropathies- like pronator teres syndrome, ulnar and radial tunnel syndrome, ALS, MS
