Carpal Tunnel Syndrome Diagnosing Carpal Tunnel Syndrome – Physiotherapy Hand Therapy Singapore

Assessment And Evaluation of Carpal Tunnel Syndrome

We start the assessment with a clinical interview, to understand the patient’s roles within their environment e.g. role as a mother, worker, wife etc, and what/how their roles has been affected, to find out the symptoms and signs of CTS.

We then test for Tinel’s Sign, Phalen’s and Dunbar’s Test to assess for presence of carpal tunnel syndrome. These tests are only done by our hand therapist or occupational therapists. After confirming positive signs, then we may check manual muscle strength for grasping and pinch strength, determine the active range of motion as well as the dexterity of the fingers.

After that, we will perform a series of finding out the primary causation of the CTS, or the aggravating factors that contributes to it. An example could be if the hand therapist (HT) or occupational therapist (OT) may identify a specific aspect of mopping the floor that the patient does that aggravate the injury, which is he/she manually wrings the mop to dry it before mopping the floor, causing an effective, repetitive, fingers AND wrist resisted flexion, EVERYDAY for 2 hours, as the patient really wants their floor to be very clean. Then we will find compensatory strategies to help.

Intervention

HT and OTs provide a corrective and protective non surgical interventions and measures for the management, prevention and treatment of carpal tunnel syndrome, choosing to focus the intervention on the person’s physical environment, activities they participate and abilities or skills. We emphasise on enabling function in leisure, work (paid or unpaid) and in activities of daily living.

At the individuals management level, the hand therapists and/or occupational therapists provide education and information, as well as direct intervention of the treatment and management of carpal tunnel syndrome.

At the institutional/corporate level, which is essentially the environment and occupation that the person holds and functions, the OTs provide information and modifications advice and consultancy related to operational tasks completion, including equipment, tools and the settings where tasks are performed.

Education

OTs play a great role as educators; education may be provided to an individual patient or to a group of people. Individuals with carpal tunnel syndrome or those who are at risk for CTS may benefit from education in the areas as shown below:

1. signs & symptoms of carpal tunnel syndrome
2. options for management/treatment: surgical and/or non surgical interventions
3. reducing risks & decrease symptoms of CTS
4. Carpal Tunnel Night Brace and splint wearing regimen
5. body mechanics & exercises
6. task modification and adaptation
7. adaptive and alternative tools ergonomic office products
8. workplace and worksite adaptations

Splinting

We often prescribe the use of wrist/hand splinting as a form of treatment. Generally, splints may be ready-made pre-fabricated ones for people with hands that can fit them such as Carpal Tunnel Night Brace, or we will custom-make one according to size and shape by preference, or if the pre-fabricated ones can’t be fitted on the patient’s hand.

Pre-fabricated ones are mass produced and can be easily purchased, they are slightly more affordable option for our patients. Thing is, as they are mass produced, they may not be a ‘good fit’ for all individuals. In this case, we would custom make one, of if the patient prefers one. We fabricate it via molding a thermoplastic material to the patient’s wrist and hands.

Splints can be a front based (volar/palmar based), on the back of the hand (dorsal based) or side (ulnar based) of the hand. They all serve the same function, with a different layout and look. Splints immobilize the wrist to relief pressure on the carpal tunnel, elimination of wrist motion removes the stresses of repetitive motion and stress in the carpal tunnel, allowing the nerve and tendons to heal, decrease swelling, and thus relieving the pressure and compression in the carpal tunnel. It is also angulated to relief the pressure.

It is best to wear them for sleep to rest the wrists, as well as during the waking hours where the aggravating factors are strongest (though this may be rather difficult as the aggravating factors are sometimes work) for best effect.

Other interventions

Our hand therapist, occupational therapist or physiotherapist may prescribe a few additional solutions and treatments:

Modification of Occupation (Task)

The modification of a task refers to changing, adjusting, modifying behaviors and actionables that may contribute or aggravate the development and aggravation of carpal tunnel syndrome.

When we perform assessments, a part of the assessment will be to conduct an activity analysis to identify how the patient performs the task, to identify areas where change may be good for the patient. Upon analysis, alternative methods and solutions are discussed, to reach a co-joined agreement. An example would be the follow up of the example I gave above, which I discussed with my patient, and I gave her a few alternatives to help her:

1. modify the frequency from daily to once every 2-3 days
2. modify the duration from 2 hour stretch, break down to 4 sessions of 30 minutes, with 5 minutes break between each sessions
3. to use a mop with a lighter mop head to easily wring/dry the cloth area
4. to ensure the hope is cleaner, to keep windows closed to prevent dust from being blown in
5. place a moist cloth that is secure at the entrance of each compartment of the home e.g. entrance of main door, entrance of kitchen, where people going through needs to wipe/clean their feet before going into the next segment (this segmentalizes dirt/dust travelling to different parts of homes)
6. delegation of task via hiring a helper, or to family members

With that, she utilized the moist cloth + closed window strategy, as well as decreased the frequency/intensity of the task. Later, she reported that she feels less numbness in her palms and fingers, though there is still some numbness. This is an example of how task modifications can help patients with carpal tunnel syndromes.

Research shows that the combination of exercise therapy as well as adequate rest breaks helps to decrease musculoskeletal discomfort, and people with CTS can retain their jobs if modifications were made, with similar outcome results for the employers. The two main modifications usually involve modifying repetitive tasks/motions and decreasing work time/rest breaks.

Modification of Equipment and Tools

Introducing modified equipment as well as adaptive aids to enhance and enable performance despite physical limitations are one of the occupational therapists major roles, which is a level up above education. Modifying equipment and tools can correct postural problems e.g. making a tool more ergonomically and anatomically correct, reducing hand, finger and wrist force to complete the task. It is the same when I introduced to my patient to using a lighter mop head which produces the same results as one with the heavier mop head to wring.

Adaptive aids can be prescribed to enable patients with CTS to stay participative and able to engage in their preferred tasks and activities. Some of them includes recommending general build-up handles to allow less grip strength required to grip objects. This can be done using a foam device with a tunnel in the centre, which one can fasten onto utensils such as spoons, toothbrush etc, so patients with CTS can still feed themselves and brush their own teeth.

Environmental Modification

Occupational therapist can help to adapt the environment to enable, encourage and allow engagement of the patient to a task. In carpal tunnel management, workstation assessment and modification is a common intervention. By modifying and adjusting the workstation equipment, such as implementing changes to chairs, keyboards, monitors, mouse, tables in the types used and their layout, height, location, the ideal postural and productivity positions can be achieved. This helps to relieve CTS symptoms and aggravating factors, as well as preventing further damage to the median nerve.

The psychosocial elements of a work environment as well should be regarded, such as motivation, job control, stress, interpersonal relationships; as these will help or hinder return to work and productivity levels within the workplace for people with CTS.

Likewise, the occupational therapist can help to modify and adapt the home environment through the use of adaptive aids and advising on alternatives to furniture and equipment in the home, to help patients with carpal tunnel syndrome.