NAME :- Joshi Hetvi Birenkumar (2019-2024)

TOPIC :- Pilot Study on Carpal Tunnel Syndrome Subject.

COLLEGE :- Gokul Physiotherapy College

WORK PLACE :-

1. GMERS Medical College & Hospital, Dharpur

[Patan].

2. Mavjat Multispecialty Hospital, Palanpur.

3. Dr. Joshi Medico Gym Palanpur.

TITLE :-

Effectiveness of manual therapy to decrease pain, numbness, tingling, paraesthesia and improve
functional ability in arpal tunnel syndrome subject.

AIM :-

To study effectiveness of manual therapy to decrease pain, numbness tingling, paraesthesia and
improve functional ability in carpal tunnel syndrome subject.

NEED OF STUDY :-

Researches have found that manual therapy to decrease pain, numbness, tingling, paraesthesia &
improve functional ability, carpal tunnel syndrome subject so greater benefits can be achieved at
large scale.

INTRODUCTION :-

Carpal tunnel syndrome (CTS) is condition due to compression of the median nerve as it travels
through the wrist at the carpal tunnel.(4)

The median nerve is susceptible to pressure as it courses through the tunnel with the extrinsic
finger flex or tendon on their way into the hand.(5)

Carpal tunnel syndrome is characterized by sensory loss and motor weakness that occur when the
median neve is compromised in the carpal tunnel.(5)

Carpal tunnel syndrome is the overcrowded fibro osseous canal formed between three carpal
bones (scaphoid, trapezoid, hamate) and the transverse carpal ligament.(1)

Carpal Tunnel Syndrome Classification(7) :-

Mild Only sensory conduction is affected, numbness and tingling at night,

no weakness, diagnosis is used by medical history, physical findings
are not present.

Moderate Both sensory and motor are affected, symptoms will appear
throughout the day, provocative test are positive

Severe Both sensory mother and needle finding in EMG. Weakness and
atrophy.
Cause and Etiology(2) :-

§ Rheumatoid Arthritis
§ Malunited Colles Fracture
§ Ganglion in the carpal region
§ Osteoarthritis of the Carpal bones
§ Hematoma
§ Growth Hormone abnormalities
§ Gout
§ Tumours
§ Idiopathic
§ Connective Tissue Disorders

Risk Factor(8) :-

§ Dislocation or subluxation of the carpas.

§ Fracture or skewed consolidation of the distal radius.
§ Acromegaly.
§ Cysts or tumours within the tunnel.
§ Pregnancy.
§ Menopause.
§ Obesity.
§ Kidney Failure.
§ Hypothyroidism.
§ Use of oral contraceptives.
§ Congestive Heart Failure.
§ Diabities.
§ Alcoholism.
§ Vitamin deficiency or toxicity.
§ Exposure to toxins.

Clinical Features(2) :-

• Pain.
Stage 1 • Discomfort in hand.
• Morning stiffness in hand.

• Tingling and Numbness.

Stage 2 • Pain.
• Paraesthesia

• Clumsiness in the hand.

Stage 3
• Impairment of digital function.

• Sensory loss.
Stage 4
• Wasting of the thenar eminence
Symptoms(1):-

§ Swelling.
§ Cold.
§ Dry and shiny skin.
§ Burning.
§ Aching.
§ Warmth
§ Carpal Tunnel Syndrome typically produce pain, Numbness and tingling in the thumb, index
finger, middle finger, and lateral half of the ring finger.
§ Hand weakness and difficulty with fine motor task may also occur as the condition worsens.

Investigations(2) :-

§ NCS (Nerve Condition Studies)

§ EMG (Electromyography)
§ Imaging Studies = X-Ray
MRI (Magnetic Resonance Imaging)

§ Provocative Test(9) :-

1. Phalen’s Test :-

• Procedures :-

The patients is asked to actively wrists maximally and hold this position for 1 minutes by pushing
the patient’s wrist together.

• Interpretation :-

During the performance patients feel tingling in the thumb, index finger, middle finger and lateral
half of the ring finger and is indicative of Carpal Tunnel Syndrome caused by pressure on the
median nerve.
2. Reverse Phalen’s (prayer) Test :-

• Procedures :-

Wrist as well as the fingers are hold in the position extreme extension.

• Interpretation :-

The symptoms of tingling, numbness, discomfort, begin to appear by 1 minutes.

3. Carpal Compression Test / Modified Reverse Phalen’s Test :-

(Durkan Carpal Compassion Test)
(Pressure Provocation Test)
(Durkan Test)

• Procedures :-

Carpal Compression test or applying fim pressure to the palm over the nerve for up to 30 seconds
to elicit symptoms has also been proposed.

• Interpretation :-

The pain and the paraesthesia in the median nerve distribution within 30 seconds. Additional
Investigation should be performed.
4. Tinel’s Sign/Median nerve percussion test :-

• Procedures :-

Performed by lightly tapping the skin over carpal tunnel at the wrist .

• Interpretation :-

Pain, parathesis of the median-innervated fingers with percussion over the median nerve.

Hypothesis :-

§ Null Hypothesis Ho :-

There is no statistical significant difference in the effectiveness of manual therapy to decrease

pain, numbness, tingling, parathesis, and improve functional ability in carpal tunnal syndrome
subject.

§ Alternative Hypothesis H1 :-

There is statistical significant difference in the effectiveness of manual therapy to decrease pain,
numbness, tingling, parathesis, and improve functional ability in carpal tunnal syndrome subject.

Methodology :-

§ Method of collecting data :-

Ø Types of case study :- Pilot Case Study.

Ø Sample Size :- 10 cases.
Ø Age Criteria :- 22-55 Year Old. F:M = 2:1
Ø Duration :- 1 Months .
Ø Study Populations :- Subject having problem of carpal tunnel syndrome.
Ø Study Setting :- Physiotherapy OPD.
Selection criteria :-

§ Inclusion criteria :-
Ø Subject between 22-55 years of Age.
Ø Female more then male who have carpal tunnel syndrome.
Ø Hormonal changes after pregnancy.
Ø Weakness of thumb abduction and thenar muscle.
Ø Malunited colles fracture.
Ø Difficulty in activity of daily living .

§ Exclusion criteria
Ø Subject more than 60 years of age.
Ø Subject with kidney disease, diabets Mellitus.
Ø Growth hormone abnormalities.
Ø Surgery for carpal tunnel syndrome on contralateral hand inpreceding 2 months.
Ø Drug or alcohol abuse.

Outcome Measures(9) :-

1. Carpal tunnel symptom severity scale.

2. Carpal tunnel functional status scale.

Reliability
Levine et al : Test- retest reliability: researchers
measured scores on the SSS and FSS 2 days
apart and calculated pearson correlation
coefficients: SSS was 0.91 FSS was 0.93
(excellent)
Internal consistency: SSS Chronbach alpha
0.89, FSS Chronbach alpha 0.91
Katz et al: Internal consistency: SSS
Chronbach alpha for the non work comp group
was 0.89, work comp group 0.89
FSS Chronbach alpha for the non work comp
group was 0.88, work comp group 0.89
Validity
Levine et al. noted the absence of a universally
accepted measurement for gauging the severity
of symptoms or hand functionality. To address
this, they evaluated the validity of traditional
objective measures like grip and pinch strength,
median nerve sensory conduction, two-point
discrimination, and Semmes Weinstein
monofilament testing in patients with CTS.
However, they discovered only moderate to
weak correlations, as these measures did not
always capture the disability highlighted by the
Symptom Severity Scale (SSS) and Functional
Status Scale (FSS). Additionally, they found
that patient satisfaction correlated positively
with improvements in SSS and FSS scores,
indicating the relevance of subjective
experiences in assessing CTS outcomes.
Tools Used :-

Dairy & Pen Chair TENS

Ultrasound Pillow Massage Ball

Dumb-bell LASER Rubber Bands

Data Collection Procedure :-

1. Ten subjects, aged between 22 and 55, afflicted with Carpal Tunnel Syndrome, were selected
through a random process.

2. I meticulously adhered to specific inclusion criteria in selecting these ten subjects.

3. Following selection, a thorough examination was conducted, leading to the diagnosis of carpal
tunnel syndrome in each subject.

4. Assessments were meticulously conducted utilizing a variety of scales and specialized tests.

5. A comprehensive treatment regimen spanning four weeks was meticulously explained to each
subject.

6. During the inaugural week, a regimen encompassing Ultrasound (US), Transcutaneous

Electrical Nerve Stimulation (TENS), and Laser therapy was administered once daily.

7. Subsequently, in the second week, manual therapy sessions were scheduled twice daily.

8. The third week focused on the implementation of strengthening exercises, conducted twice
daily.

9. The fourth and final week incorporated range of motion exercises, performed 2 to 3 times
daily.

10. Upon the conclusion of the four-week period, subjects underwent reassessment, with their
responses meticulously recorded.

Treatment :-

Medical Management :-
• NASIDS :- To relief the pain.
• Steroid Injections :- The site of the injection is 1cm
• Cortisone :- To Reduce Swellings.

Surgical Management :-
• Endoscopic
• Open surgery
Physiotherapy Management :-

I. General Management(1,2)

Ø Electrotherphy(11) :-

i. LASER Therapy :-

LASER therapy (Light Amplification by Stimulated Emission of Radition) is found effective in

relieving pain. Laser by reducing swelling and enhancing the healing process. On superficial
median, nerve conduction velocity by a low intensity laser.
Energy density of 4J/cm2 is usually sufficient.
Time :- 7 to 10 minutes.

ii. TENS:-

TENS[Transcutaneous Electrical Nerve Stimulation] over the palmar aspect of wrist.

TENS therapy an effective of pain relief -20 sessions of TENS
Frequency :- 1-5 HZ.
Pulse Width :- 100 and 500ms.
Intensity :- 30MA or more.
Time :- 8 to 10 minutes.

iii. Ultrasound (US) :-

20 Sessions of ultrasound treatment.

1 MHz, 1.0 w/cm2
Pulse mode - 1:4
Time - 8 minutes
Application – Over Lapping Circle

Ø Splints(2):-

That blocks movements at the wrist is adequate to avoid compression stretch to carpal tunnel
syndrome. Splinting In a neutral position at night has effective implication in form of pain relief.
Limiting the end range positions that Increase Carpal Tunnel Pressures and promoting adequate
blood circulation along with consequent subsidence of edema.
Ø Exercise(5) :-

I. Joint Mobilization :- Specific carpal mobilizations: stabilization of the proximal bone and
volar guide of the distal bone. stabilization of the lunate with the index fingers and volar
glide to the capitate with the thumbs to increase extension.

II. Tendon-gliding exercise :-

There are five Positions in which the fingers move during tendon gliding exercises.

i. Straight hand :- Waist in neutral Position waist and fingers in full extension then moving to
full wrist and finger flexion and then reversing the motion. (Figure A)

i. Hook(claw) Fist Position :- Flexing the distal interphalangeal joint (DIP) and proximal
inter phalangeal Joint (PIP) while maintaining meta carpal phalanges (MCP) extension.
Gliding occurs between the profundus and superficialis tendons and between the profundus
tendon and the bone. (Figure B)

ii. Full Fist :- Flexing all the metacarpal phalangeal (MCP) and interphalangel(IP) joints
simultaneously. (Figure C)

iii. Table-Top :- Straight fist position by flexing the proximal interphalangeal(PIP) joint.
(Figure D)

iv. Straight Fist(sublimes fist):- Distal interphalangeal(DIP) joints in extension. Gliding of the

superficialis tendon occurs with respect to the flexor sheath and bone. (Figure E).
III. Median Nerve Mobilization :-

Six Positions for median nerve mobilization in the hand. That position for 5 to 30 seconds without
making the symptoms worse. Moved into position with out symptoms progress to the next stretch
position and repeat the mobilization routine 3 or 4 time per day.

i. Wrist neutral with fingers and thumb flexed. (Figure A)

ii. Wrist neutral with fingers and thumb extended. (Figure B)
iii. Wrist and fingers extended, thumb neutral. (Figure C)
iv. Wrist, fingers, and thumb extended. (Figure D)
v. Wrist, fingers, and thumb extended and forearm supinated. (Figure E)
vi. Wrist, fingers, and thumb extended, forearm supinated, and thumb stretched into extension.
(Figure F)
Advance Management(6) :-
Ø Manual Therapy :-

PHASE 1

GOOD FOR :-
• Alleviating nerve pain in the wrist and hand.
• Relieving muscle tension.
• Warm-up for phase 2 and 3 exercises.

GUIDELINES :-
• Perform every day.
• Tools: small massage ball, foam roller.
• Add phase 2 when you have no pain at rest and no more than mild pain (3/10) with the
exercises

Ø SOFT TISSUE MOBILIZATIONS :-

• Spend 1–2 minutes on each area.
• Perform in any order on both sides.
• Stop on tender points for 10–20 seconds

i. PECTORAL MOBILIZATION :-
Position a small massage ball between a doorframe or rack and your pectoral muscles near the
front of your shoulder. Place that arm behind your back and add dynamic movement by reaching
overhead to further mobilize the muscles.
ii. WRIST FEXOR MOBILIZATION :-
Lay your arm out straight on a bench or table with your palm facing up. Press the ball into your
forearm flexor muscles (where the bottom of your forearm connects to your elbow) and massage
around the area. Add dynamic movement by extending your wrist while applying steady pressure
with the ball.

iii. MOBILITY EXERCISES :-

Ø Do 3 sets of 10–15 reps.
Ø Pause at end range for 2–3 seconds.

Median Nerve Slider Mobility 1 :-

Start with your arm out to your side with your shoulder at 90 degrees, your elbow and wrist bent,
and your head titled away from your elevated arm. In one fluid motion, straighten your elbow,
extend your wrist, and move your head toward your arm. Go back and forth between these
positions to mobilize the median nerve.
Median Nerve Slider Mobility 2
Position your shoulder and elbow at 90-degree angles with your palm facing forward. Splay your
fingers and thumb, then bring them together to mobilize the median nerve.

PHASE 2
GOOD FOR :-
• Alleviating nerve pain in the wrist and hand.
• Improving wrist range of motion.
• Warm-up for phase 3 exercises

GUIDELINES :-
• Perform every day
• Add phase 3 when you can do the exercises with no more than mild pain (3/10)

i. PECTORAL STRETCH :-
Position your forearm against a doorframe or rack with your shoulder at about 90 degrees. Step
forward until you feel a stretch in your chest region. Move your arm slightly higher to stretch the
upper fibers of your pectoral muscles. Perform 3 reps with 30- to 60-second holds.
ii. WRIST FLEXOR STRETCH :-
Straighten your arm out in front of your body with your palm facing up. Form a grip around your
palm with your opposite hand, then pull down until you feel a stretch on the bottom of your
forearm. Perform 3 reps with 30- to 60-second holds.

iii. WRIST FLEXION AND EXTENSION MOBILITY :-

With your arm supported on a table and your palm facing down, flex and extend your wrist as far
as you can, pausing for 2–3 seconds in both flexion and extension. Do 3 sets of 10–15 reps.

PHASE 3
GOOD FOR:-
• Strengthening the wrist, hand, forearm, and neck muscles.
• Preventing hand and wrist nerve pain.

GUIDELINES:-
• Perform 3 or 4 days a week.
• Do 3 sets of 10–15 reps.
• Push sets to fatigue.
• Tools: dumbbell, grip strengthener, finger exerciser, resistance band
i. WRIST FLEXOR CURL :-
Support your arm on a table so that your palm is facing up and only your hand is hanging over the
edge. Holding a dumbbell, slowly extend your wrist, then flex (curl toward your body).
Momentarily pause in the top position before transitioning to the next rep.

ii. SUPINATOR AND PRONATOR CURL :-

With your arm supported, hold one end of the dumbbell and rotate through pronation and
supination. Keep your elbow on the table, isolate the movement through your wrist and forearm,
and focus on slowly rotating from a palm-up to a palm-down position.

iii. GRIP STRENGTHENER :-

Use a grip strengthening device (resistance hand gripper, finger exerciser, or grip ring) to improve
forearm and hand strength. You can use any tool that provides resistance while closing your hand
and perform power grip and pinches grip.
 GRIP STRENGTHENER

[A. Hook Grip. B. Cylinder Grip. C. Chuck Or Three-fingered Grip. D. Lateral or Key Pinch
E. Tip Pinch. F. Fist Grip. G. Spherical Grip.]

iv. RESISTED FINGER EXTENSOR :-

Place your fingers in the holes of a finger extensor resistance exerciser, then splay and extend your
fingers and thumb.

v Conclusion:

The results indicate that the treatment for subjects with Carpal Tunnel Syndrome is effective in
decreasing pain, numbness, tingling, paraesthesia, and improving functional ability. However,
manual therapy along with conventional physical therapy proves to be more effective in the
management of Carpal Tunnel Syndrome.
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edition, page no.-341).

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