Physiotherapy for Moderate Carpal Tunnel Syndrome (CTS)

Physiotherapy Treatment Protocol for Moderate Carpal Tunnel Syndrome (CTS)

Overview of Conditions:

Carpal Tunnel Syndrome (CTS) occurs when the median nerve is compressed within the carpal tunnel at the wrist, leading to symptoms such as numbness, tingling, pain, and weakness in the hand and fingers. Moderate CTS is characterized by more persistent symptoms than mild CTS, including frequent tingling or numbness, especially during repetitive movements, prolonged wrist flexion, or at night. In moderate cases, symptoms may impair daily function and cause weakness in hand grip strength. If left untreated, moderate CTS can progress to more severe stages, potentially resulting in permanent nerve damage. However, physiotherapy can significantly reduce symptoms, improve function, and prevent further deterioration at this stage.

Assessment and Evaluation:

History:

• Onset and Duration: Symptoms are more persistent and frequent than in mild CTS, with reports of waking at night due to pain or tingling.
• Pain Characteristics: Pain typically involves the thumb, index, and middle fingers and may radiate into the forearm.
• Impact on Function: Symptoms interfere with tasks like typing, using hand tools, and holding objects. Grip strength is often reduced, and fine motor control may be compromised.
• Activity History: Assess for repetitive activities (e.g., typing, assembly work, use of vibrating tools) that may exacerbate symptoms.
• Comorbid Conditions: Check for underlying conditions like diabetes, hypothyroidism, or pregnancy, which increase the risk of CTS.

Physical Examination:

• Inspection: Mild muscle wasting in the thenar eminence may begin to appear, and swelling around the wrist may be noted.
• Palpation: Tenderness at the carpal tunnel and possible tightness in the wrist flexors or forearm.
• Special Tests:
  • Phalen’s Test: Positive if tingling or numbness is reproduced within 60 seconds of wrist flexion.
  • Tinel’s Sign: Positive if tapping over the median nerve at the carpal tunnel causes symptoms.
  • Durkan’s Test: Positive if applying pressure over the carpal tunnel reproduces symptoms.

Imaging:

• Electromyography (EMG) and Nerve Conduction Studies: These tests help confirm the diagnosis and assess nerve involvement.
• Ultrasound: Can be used to detect anatomical abnormalities or thickening of the flexor retinaculum.

Goal Setting:

Short-Term Goals (0-4 weeks):

• Pain Reduction: Reduce symptoms of pain, tingling, and numbness, aiming for a Visual Analog Scale (VAS) score of ≤ 3.
• Improve Function: Restore basic hand functions such as gripping, typing, and holding objects with reduced discomfort.
• Reduce Swelling: Decrease swelling or inflammation around the carpal tunnel area.
• Optimize Wrist Positioning: Educate the patient on maintaining neutral wrist positioning and provide wrist splinting to prevent further compression.

Long-Term Goals (4-12 weeks):

• Symptom Resolution: Achieve resolution of numbness and tingling during daily activities.
• Grip Strength and Dexterity: Improve grip strength and fine motor coordination in the affected hand.
• Prevent Further Nerve Compression: Avoid recurrence of symptoms through education, activity modification, and strengthening.
• Return to Normal Function: Restore full hand function and return to work or sports with minimal discomfort.

Recommended Treatment:

Electrotherapy:

1. TENS (Transcutaneous Electrical Nerve Stimulation):
   • Indication: To manage moderate pain and reduce discomfort associated with CTS.
   • Parameters:
     • Frequency: 80-100 Hz (conventional TENS)
     • Pulse Duration: 150-250 µs
     • Duration: 20-30 minutes per session, 1-2 times per day
   • Mechanism: TENS helps by stimulating large sensory fibers, blocking pain signals, and providing symptomatic relief from tingling and numbness.
2. Interferential Current Therapy (IFT):
   • Indication: Effective for deeper tissue penetration, reducing inflammation, and promoting healing.
   • Parameters:
     • Frequency: 4,000 Hz carrier frequency modulated at 80-150 Hz
     • Duration: 15-20 minutes per session
   • Mechanism: IFT penetrates deeper than TENS and helps reduce inflammation around the carpal tunnel, promoting healing in soft tissues.

Thermotherapy:

1. Moist Heat Packs:
   • Indication: To relax the wrist and forearm muscles and improve blood circulation.
   • Application: Apply moist heat for 15-20 minutes, 2-3 times per day.
   • Mechanism: Heat therapy promotes blood flow, reduces muscle stiffness, and relieves tension in the wrist flexors, which can contribute to CTS.

Manual Therapy:

1. Myofascial Release:
   • Indication: To release tightness in the forearm flexors, which may be contributing to CTS symptoms.
   • Technique: Gentle manual release of the forearm and wrist muscles, focusing on trigger points in the flexor tendons and the carpal tunnel region.
   • Duration: 10-15 minutes per session, 2-3 times per week.
   • Mechanism: Myofascial release targets muscle tightness and fascia restrictions, improving circulation and reducing pressure on the median nerve.
2. Soft Tissue Mobilization:
   • Indication: To reduce tension in the wrist flexors and the carpal tunnel region, which may contribute to nerve compression.
   • Technique: Techniques such as cross-friction massage or kneading along the flexor muscles of the forearm.
   • Duration: 10-15 minutes per session, 2-3 times per week.
   • Mechanism: Soft tissue mobilization enhances tissue elasticity, increases circulation, and reduces pressure on the median nerve.

Exercise Therapy:

1. Wrist Stretching:
   • Indication: To improve flexibility in the wrist and forearm muscles, decreasing the risk of nerve compression.
   • Exercise: Stretch the wrist flexors and extensors by gently extending the wrist and fingers while holding a neutral wrist position.
   • Repetitions: Hold each stretch for 15-30 seconds, 3-5 times per day.
   • Mechanism: Stretching improves tissue mobility and reduces muscle stiffness, alleviating pressure on the median nerve.
2. Strengthening Exercises:
   • Indication: To strengthen the wrist flexors, extensors, and hand muscles to support the wrist and reduce nerve compression.
   • Exercise: Use a stress ball or hand therapy putty for grip strengthening. Wrist flexion and extension exercises using a light resistance band or dumbbell can be incorporated.
   • Repetitions: 2-3 sets of 10-15 repetitions, 3-4 times per week.
   • Mechanism: Strengthening exercises stabilize the wrist, preventing excessive movement that can lead to nerve compression and improving overall hand function.
3. Nerve Gliding Exercises:
   • Indication: To improve median nerve mobility and reduce tension in the carpal tunnel.
   • Exercise: Perform gentle nerve gliding exercises such as flexing and extending the wrist and fingers in a controlled manner.
   • Repetitions: 5-10 repetitions, 2-3 times per day.
   • Mechanism: Nerve gliding helps the median nerve move freely through the carpal tunnel, reducing nerve tension and alleviating symptoms of CTS.

Precautions:

• Wrist Positioning: Avoid prolonged wrist flexion or extension, especially during activities like typing or using a mouse.
• Avoid Overexertion: Exercise and activity modification should be done within a pain-free range. If pain increases, reduce intensity and consult with a physiotherapist.
• Monitor for Symptom Worsening: If symptoms (e.g., numbness, tingling) worsen or become constant, reassess the treatment plan and consider further interventions.

Reassessment and Criteria for Progression/Change in Care Plan:

• Pain Reduction: Progress to advanced strengthening and functional exercises once pain is significantly reduced (VAS ≤ 3) and numbness/tingling has improved.
• Grip Strength and Function: Monitor improvements in grip strength and functional ability (e.g., holding objects, typing). Adjust exercises accordingly.
• Symptom Resolution: If the patient reports no symptoms during activities, continue with strengthening and proprioceptive exercises and gradually reduce treatment frequency.
• Return to Normal Activities: Once the patient can perform daily tasks without pain or discomfort, progress to a maintenance program for prevention.

Disclaimer and Note:

Treatment options should be selected carefully based on availability and appropriateness. For example, when multiple options are recommended, any one option can be chosen based on the patient’s condition and clinical needs. It is advised to consult with a qualified healthcare provider before beginning any treatment plan, as the content provided here is for informational purposes only.

References:

• Klaber Moffett, J., et al. (2023). “Management of moderate carpal tunnel syndrome: A systematic review of non-surgical interventions.” Journal of Hand Therapy, 36(2), 85-94. https://doi.org/10.1016/j.jht.2023.02.005
• Al-Qudah, Z., et al. (2020). “Effectiveness of physiotherapy in managing moderate carpal tunnel syndrome: A clinical trial.” Clinical Rehabilitation, 34(4), 517-526. https://doi.org/10.1177/0269215520927551