Surgical Considerations for the UE - Carpal Tunnel Syndrome Flashcards
When is surgery indicated?
If conservative treatment fails over time over a reasonable time frame (2 to 3 months), dependent on:
- Response from PT
-Ergonomics
- Patient participation requirements
- Effectiveness of other treatment (Meds, injections, biologics)
- Worsening of neurological symptoms
What are the 2 different techniques used for Carpal Tunnel Release?
- Open technique
- Endoscopic Technique
When doing the Subjective on a Post-Op patient, what important information should we gather?
- We must do a Red/Yellow flag screening
- We must understand the full scope ot the surgeon
-Such as restrictions (of AROM, grasping, and lifting) and the parameters of wearing the removable brace and a night splint - We must ask if they will be working while rehabbing
- And must ask what level of activity they need to get back to
We can not get the info from the patient, then we must reach out to the surgeon so we can treat the patient safely
What are the Primary and Secondary Tissues affected by the Surgery?
- Primary: Median Nerve
- Secondary: Surrounding tissues disrupted by surgeon to access the primary tissue
What would take place in the Physical Examination, what do you expect to see?
- Integumentary Exam
-We would see redess, swelling and possible some ecchymosis around the incision. We must look for necrosis, excessive tenderness or endema, increased heat and drainage (which can indicate infection or delayed healing)
-Before and after each treatment session - Neurological Exam
-May find sensation deficits based on severity of prior Sx
-Get the baseline for dermatomes and myotomes based on affected levels (test like light touch, 2-point discrimination, and dermatome testing should be done) - Cervical AROM/PROM
-All directions will be limited due to pain and/or fear - Palpation
-Tenderness to palpate (TTP) of forearm flexors and muscles of the hand. Muscle guarding after surgery is a large contributor to the pts muscle pain - Resisted Testing (if allowed)
-This would give an idea of their muscle activation ability
-If MMT is performed, it would be submaximal
-May be performed on muscles proximal to surgical site
What are the Prognostic Factors?
- Natural Hx:
-The bodies ability to heal itself over time - Primary tissue healing times
-Nerve, can take up to 4 months to fully resolve - Return to activty/sport timeline
-Highly variable based on patient’s activities and participation
What is Phase 1? What is the timeline, primary pain mechanism and Goals?
Phase 1 - Protected Motion
- From weeks 0-3
- Pt’s will be in the acute stage and inflammatory phase
- Primary pain mechanism is either nocicptive from the trauma or peripheral neuropathic due to the irritation during surgery
- Goals: Aims to protect the surgical site, limit end-ranges of motion and control pain and swelling
What is Phase 2? What is the timeline, primary pain mechanism and Goals?
Phase 2 - Progressive Loading/Strengthening
- From weeks 3-6
- Pt’s will be in the subacute stage and proliferative phase
- The Primary Pain mechanism will be the same as phase 1 but should be at a decreased severity and irritability allowing for more activity in rehab
- Goal: To increase all wrist motions in a pain-free manner, begin wrist strengthening exercises and return to all ADLs pain free
What is Phase 3? What is the timeline, primary pain mechanism and Goals?
Phase 3 - Functional, Sensorimotor and Sport Specific training
- From 6-16 weeks
- Pt’s will be in the chronic stage and remodeling phase
- Goals: To further increase strength in the functional manner and return the patient to all their normal activites
What are the Precautions of Phase 1?
- Limit end-range wrist motions
- Splint wearing during the day and night
- Progress ADLs as tolerated
- Focus on improving ergonomics
What interventions take place in Phase 1?
What are the criterias to progress to Phase 2?
- Manual Therapy
-Gentle STM - Gentle ROM
-Flexion and Extension - Genle Isometrics for hand and forearm musculature
- Education on pain management and proper ergonomics
The criterias to progress to phase 2 are:
- Independent with ADLs and well-controlled pain symptoms
What are the Precautions of Phase 2?
- Progress mobility into end-ranges
- Increase A/PROM to full
- Normalize movement patterns
- Increase endurance
- Progressive strengthening
What interventions take place in Phase 2?
- Manual Therapy
-STM to hand and forearm musculature
-Gentle Neurodynamics - Continue to progress A/PROM of the wrist
- Hand, wrist and forearm strengthening
- Introduce functional activies
- Education on activity modification to avoid provoking or aggravaing Sx
What are the Precations of Phase 3?
- Normalize strength and mobility
- Create a long-term HEP
- Return to all functional activities
What interventions take place in Phase 3?
- Manual Therapy (if necessary)
- Progressive hand, forearm, and scapular strengthening exercises
- Increase conditioning to match activity and participation requirements
- Exercises that mimic their activities and demands
- Education in long-term management