Carpal Tunnel Syndrome Definition:
Carpal tunnel syndrome is the compression of the median nerve in the carpal flexor space, underneath the transverse carpal ligament. It is often associated with patients who perform repetitive motions at the wrist, causing flexor tenosynovitis and swelling at the wrist. Carpal tunnel syndrome occurs most commonly between the ages of 30 and 60 and is more common in women than men. It is thought that there is a higher prevalence in women, because women typically have smaller wrists than men.
Mechanism of Injury:
- Typically an overuse injury caused by excessive repetitive motion of the hand, wrist, and arm (e.g. painting, typing on a keyboard, recreational activities such as racquetball, playing musical instruments, and sewing).
- Compression of the median nerve can also come from excessive synovial fluid because of multiple causes: Pregnancy due to secondary fluid retention, Renal dysfunction, Acromegaly, Gout, Myxedema, Amyotrophy, Trauma, Infection, and Collagen disorders. (PRAGMATIC)
- Bone fractures and arthritis near the wrist or hand are more acute and traumatic causes.
- CTS Predictor rule: Age of 45 or older, patient reports shaking hands relieves symptoms, wrist ratio index >.67, reduced median sensory field of the first digit, and Symptom Severity Scale score >1.9.
Signs and Symptoms:
- Intermittent pain, especially during the night, due to fluid retention and fluid pooling.
- Numbness/Tingling in the median nerve distribution, which includes the radial three and a half digits on the palmar side; index, middle and ring finger on dorsal surface of the hand.
- Muscle weakness, especially grip strength and sometimes thumb opposition.
- Decreased sensation.
- Patient is constantly shaking out hands for pain and numbness relief.
- Signs of carpal tunnel can be observed using Tinel’s Test, in which the median nerve is tapped at the wrist, which can cause pain from the wrist into the hand. Phalen’s test is also performed by holding full flexion of the wrist for 30-60 seconds, which will elicit numbness or tingling.
- Final diagnosis can be made by performing a nerve conduction test monitoring the median nerve conduction velocity.
Treatment: Modalities/Pain Control:
- Symptoms can be subdued with various forms of activity modification.
- NSAIDS for everyday pain control. Diuretics are sometimes prescribed for those that may have fluid retention issues. Local steroidal injections/oral steroids seem to be temporarily effective, but may produce side effects. Vitamin B6 supplementation, which is suggested to act as a diuretic, has not shown significant results.
-Ultrasound and low level laser treatment have shown significant improvements in condition, though ultrasound typically shows better results than laser treatment.
- Overall, 50% of cases eventually require surgery as a last resort. The surgery procedure simply involves releasing the transverse carpal ligament that surrounds the median nerve and carpal flexor tendons. Surgery is typically successful in resolving the problem, depending upon condition severity and chronicity.
Manual Therapy: Soft tissue massage, SASTM (Sound Assisted Soft Tissue Mobilization), and Graston techniques have shown success in mild to moderate CTS cases.
Assistive Devices:
-A Neutrally positioned splint may be worn for most of the day. Splinting has been proven to significantly improve symptoms by keeping the hand in a neutral position, allowing optimal diameter of the carpal tunnel.
-Hot and cold wrist wraps may also be used.
-Advising more ergonomic positions and devices can also be included in this category. Oftentimes more ergonomic workplace devices are suggested to office workers (keyboard, gel pad, armrests). http://orthotape.com/images/products/Default/wrist/Exoform_Carpal_Tunnel_Wrist_lg.JPG
Education:
- Advise the patient not to sleep on their wrists, or with their hand underneath a pillow, as this will cause unwanted pressure upon the wrist.
- Review the positions that may have caused the condition to come about (keyboard height).
- A home or workplace visit may help the therapist recognize causatory factors. The therapist may also suggest workplace and recreational activity modifications.
Exercise: There doesn’t seem to be a direct relationship between exercise and CTS success. Oftentimes, wrist flexor strength is addressed too early due to poor grip strength, and performing wrist flexor exercises can make the problem worse. Exercise is typically administered later in the healing process.
Possible exercises include: ROM exercises, median nerve glides, gentle stretching of shoulder, forearm, wrist and hands. Isometric exercises such as making a fist, and fanning the fingers.
HEP:Dr. Housang Seradge prescribed and created the following HEP for people performing repetitive wrist activities. This exercise sequence should be performed once every hour of repetitive activity. One study showed a 67% success rate of mild/moderate CTS cases when adhering to this exercise program (18-34% success reported nationally).
· Extend and stretch both fingers and wrist as if they were in a handstand position. Hold for five seconds;
· Straighten both wrists and relax fingers;
· Make a tight fist with both hands;
· Bend both wrists down with the hands still in a fist. Hold for five seconds;
· Straighten both wrists and relax fingers for five seconds;
· Hang arms loosely at sides and shake them for five seconds;
· Repeat steps 1 through 6, 10 times. http://www.eatonhand.com/hw/ctexercise.htm
Burke, Jeanmarie & Buchberger, Dale J & Carey-Loghmani, M Terry & Dougherty, Paul E & Greco, Douglas S & Dishman, J Donald. (2007). A pilot study comparing two manual therapy interventions for carpal tunnel syndrome. Journal of manipulative and physiological therapeutics.
D.B. Piazzini, I. Aprile, P.E. Ferrara, C. Bertolini, P. Tonali, L. Maggi, A. Rabini, S. Piantelli, & L. Padua. (2007). A systematic review of conservative treatment of carpal tunnel syndrome. Clinical Rehabilitation, 21(4), 299-314. O'Sullivan, Susan B., and Thomas J. Schmitz. Physical Rehabilitation: Assessment and Treatment. Philadelphia: F.A. Davis, 1988. Print.
Seradge, Houshang & Parker, Win & Baer, Carrie & Mayfield, Kim & Schall, Laura. (2002). Conservative treatment of carpal tunnel syndrome: an outcome study of adjunct exercises. The Journal of the Oklahoma State Medical Association, 95.
Definition A break in the distal radius with or without ulnar involvement. The fracture usually occurs about 1 inch from the radiocarpal joint.
MOI Fall on out-stretched hand (FOOSH). The fall can be low-energy (i.e. tripping over something) or high impact (i.e. falling off a skateboard). Bimodal age distribution- occurs in very young & elderly. Common in females due to higher prevalence of osteoporosis and/or lower bone mineral density.
Signs/Symptoms A “dinner-fork” deformity, pain, swelling, bruising, tenderness, diminished pulse, decreased mobility and crepitus (if the fractured bones are approximating). However, do not test for crepitus as this can greatly worsen the condition.
After immobilization, expect deficiencies in ROM & grip strength, and stiffness in hand and fingers. Also can be accompanied by shoulder or neck pain if patient was casted or held arm out of normal positioning.
Diagnostic: X-ray
Possible Physician Interventions Casting or splinting (most common) External fixation- better anatomical results/bone alignment. Wrist bridging- distal pins in 2nd MC. Nonbridging- distal pins in distal radial bone fragment. Internal fixation- for anatomical reduction, allows for earlier mobilization & ROM. Wiring (percutaneous pins)- used with external fixation or alone for greater stabilization. Contraindicated in those with osteoporosis or severely comminuted fractures. Bone substitutes- for patients with osteoporosis. *Treatment type can vary by age & condition.
Therapeutic Exercise Focus should be on wrist & hand ROM & strengthening. If the patient was casted above the elbow, therapy could be indicated for the elbow joint as well. Prehensile hand function- grip strength & precision. Wrist- flexion, extension, ulnar & radial deviation. Elbow- flexion, extension, pronation & supination.
Patient Education Proper diet, EXERCISE, & vitamins to build bone mineral density & to prevent falls. Bones respond best to loading; encourage WB exercises once bone is healed and able to tolerate resistance.
Manual Therapy Distal Radioulnar Joint: pronation & supination Superior Radiounlnar Joint: pronation & supination. Radiocarpal Joint: distraction, volar glide for extension, dorsal glide for flexion, radial glide for ulnar deviation & ulnar glide for radial deviation. Thumb CMC: distration, ulnar, radial, dorsal, & ventral glides. CMC's 2-5: distraction for mobility, volar glide for flexion, dorsal glide for extension. Thumb MCP: distraction, volar, & dorsal glides. MCP's 2-5: distraction for mobility, volar glide for flexion, dorsal glide for extension, radial glide for abduction, & ulnar glide for adduction. Grades I-2 for pain (1-2 bouts for 20-30 seconds) Grades 3-4 for resistance (3-5 bouts for 45-60 seconds) Transverse friction massage for scar tissue (for those who were treated by internal fixation). Assistive Device: not indicated
Home Instruction Elevation for edema, pain control, comfort while sleeping.
ROM: wrist flexion, extension, ulnar & radial deviations. Flexion & extension of the fingers (open/close the fingers on the hand). Pronation & supination of the forearm.
Strength/endurance: Tennis ball squeezes, pronation/supination holding objects of varied weight, four-way theraband for flexion, extension, radial & ulnar deviations.
Household items/ADLs that can help with therapy: silly putty or play-doh (flatten and squish), tennis ball, soup can or hammer for pronation/supination, stirring/cooking, sewing, & folding laundry.
Pain Control Paraffin bath for pain in the chronic phase. Review contraindications prior to treatment. Cryotherapy is helpful initially to help control pain & swelling. Cryotherapy & thermotherapy for use during therapy to assist in achieving ROM. OTC medications
References
Atkins, R., Duckworth, T., & Kanis, J. (1990) Features of Algodystrophy after Colles’ Fracture. Journal of Bone & Joint Surgery. British Volume. Jan;72(1):105-10
Bialocerkowski, A. (2001). A home program is as effective as in-rooms treatment in the management of distal radius fracture. Australian Journal of Physiotherapy. Vol 27.
Blakeney, William. (2010) Stabilization and treatment of Colles’ fractures in elderly patients. Clinical Interventions in Aging. Nov. 18; 5:337-44.
Gould. Barbara & Dyer, R. (2011). Pathophysiology for the Health Professions. 4th ed. Saunders Elsevier: St. Louis, Missouri.
Kay, S., McMahon, M., & Stiller, K. (2008). An advice and exercise program has some benefits over natural recovery after distal radius fracture: a randomised trial. Australian Journal of Physiotherapy. 54(4); 253-9.
Loudon, J, Swift, M. & Bell, S. (2008) The Clinical Orthopedic Assessment Guide (2nd ed). Champaign, IL: Human Kinetics.
Definition:
Ulnar neuropathy occurs when there is damage to the ulnar nerve. The ulnar nerve is an extension of the medial cord of the brachial plexus and innervates muscles of the hand and forearm. It also provides sensation for the 4th (medial) and 5th digits of the hand4. Damage to the nerve destroys the nerve’s myelin sheath which slows or prevents nerve signaling2.
Signs & Symptoms:
-abnormal sensation of the 5th digit and/or part of the 4th digit
-tingling or burning sensation
-weakness of the hand
-pain in the hand or elbow
-loss of coordination of the fingers
-numbness or decreased sensation
-decreased hand grip
-claw-like deformity
-Wartenberg’s sign abduction of 5th digit (http://www.youtube.com/watch?v=K7EmeSGqEp4)
-positive Tinel’s sign at elbow- paresthesias in ulnar portion of hand4 (http://www.youtube.com/watch?v=T1oFeckmaGQ)
Mechanism of Injury:
Entrapment- can occur in several areas but the two most common are the cubital tunnel in the elbow or in guyon’s canal in the wrist4.
Trauma- a direct blow to the inside of your elbow7
Sleeping with a bent elbow7
Compression- leaning on your elbow or wrist extension for long periods of time7
Diabetes
Deformities
Tumors
Risk factors include:
Age: a prospective study showed that increased age is highly correlated with a greater tendency for ulnar neuropathy5.
Arthritis of the elbow
Repetitive or prolonged activities that require the elbow to be flexed or bent7.
Treatment:
Ulnar neuropathy is generally treated conservatively at first. If the condition does not improve, or if the nerve is highly compressed, surgery may be an option7. Different surgical options include cubital tunnel release, ulnar nerve anterior transposition and medial epicondylectomy7. Therapeutic Exercise:
Therapists can use nerve glides which can promote smoother movements of the nerve within the tunnel and to reduce adhesions and other possible causes of compression4. An example of an ulnar nerve glide sequence: http://www.youtube.com/watch?v=YV6N3kCy0fE
Increasing the range of motion and strength of the wrist and hand are also very important. This should be done with caution as you do not want to cause more irritation to the nerve. Examples include:
-Cervical range of motion exercises (rotation, flexion, extension and side bending) hold each for 10 seconds
-elbow and wrist range of motion (hold each for 10 seconds)
-shoulder depression (hold for 10 seconds and repeat 10 times)
-finger adduction- place objects between each finger and squeeze together for 10 seconds and repeat 5 times
-finger flexion-squeeze a rubber ball and hold for 10 seconds and repeat 10 times.
Education:
Educate the patient about how their ulnar nerve may have been compressed or injured. Tell the patient to avoid sleeping with their elbow bent at night. A night splint can be worn to ensure7. Also encourage them to avoid resting their elbow on hard surfaces. If that is unavoidable, have them place padding underneath their elbow.
Assistive Equipment:
The use of a night splint to avoid flexion and extension of the elbow at night has shown to be beneficial in clinical trials6. Cushions for the elbow and wrist can also be used to relieve pressure when resting on hard surfaces.
Manual Therapy:
I was unable to find research supporting the use of manual therapy for ulnar neuropathy.
Home Exercise Program:
The patient should continue the strengthening and range of motion exercises they were taught in therapy. Instruct them to perform the nerve glides at home but remind them to perform them in a slow and controlled manner to avoid irritation. The nerve glides should be repeated 15 times 3-4 times a day. Encourage them to perform stretches throughout the day in the opposite pattern of their work position and to maintain proper body mechanics.
Modalities/Pain Control:
NSAIDS- to reduce possible swelling around the nerve and provide pain control7
Steroid injections
References:
1.Caliandro P, La Torre G, Padua R, Giannini F, Padua L. Treatment for ulnar neuropathy at the elbow. Cochrane Database Syst Rev. Feb 16 2011;2:CD006839.
2.Dugdale, David C. "Ulnar Nerve Dysfunction: MedlinePlus Medical Encyclopedia." U.S National Library of Medicine. U.S. National Library of Medicine, 26 Sept. 2010. Web. 02 Mar. 2012. <http://www.nlm.nih.gov/medlineplus/ency/article/000789.htm>.
3.Dutton, M. (2004). Orthopaedic: Examination, evaluation, & intervention. New York, NY:McGraw-Hill.
Definition
Complex Regional Pain Syndrome (CRPS) is a relatively new term for what had been called causalgia, reflex sympathetic dystrophy, and reflex neurovascular dystrophy. Complex regional pain can fall into two different categories. The first type is a pain syndrome brought on by an event that is not limited to a single peripheral nerve (Dutton, 2004). The second type involves direct partial or complete injury to a nerve or one of its major branches. This page focuses on type 1.
Type 1 is caused by an abnormal reaction of the sympathetic nervous system following an injury (Dutton, 2004). CRPS typically will occur in a single extremity following trauma or surgery (Eijs et al., 2011). This will normally affect either an arm or a leg. The incidence of CRPS type I, is between 1 and 2% after a fracture, 2 to 5% after peripheral nerve injury and between 7 and 35% in prospective Colles’ Fractures. There also are a larger number of patients who have no known cause but still end up with CRPS Type I. This is not just limited to an upper extremity injury.
Mechanism of Injury
According to most of the sources that I reviewed there are certain injuries that have a more likely occurrence of CRPS, but it is somewhat ambiguous as to the known factors. As mentioned early, CRPS has a high incidence in people with distal extremity fractures. According to one article the trauma does not have to be a fracture but can be as simple as a minor sprain (Rho, Brewer, Lamer, & Peter, 2002). Once an injury occurs there is damage to the nerves. The nerves are then unable to properly control blood flow, feeling (sensations), and temperature of the affected area. Because the nerves are functioning incorrectly there can be problems with blood vessels, bones, muscles, nerves, and skin. The sympathetic nervous system normally affects the body by vasoconstricting blood vessels, increasing HR and force of contraction, and it activates sweat glands. Normally, this is a very beneficial mechanism that our body's use very day, however, in people CRPS they have an over active sympathetic nervous systems in some area of their body. This causes sweating and vasoconstriction of blood vessels in that area which in turn causes multiple signs and symptoms and the diagnosis of CRPS.
Signs and Symptoms
There are four different stages of CRPS. During all four stages pitting or non-pitting edema, will likely be present (Dutton, 2004). The first stage of CRPS may span a couple weeks or as long as a couple months. It is associated with persistent, burning pain, and edema. Other symptoms of this stage include increased sensation to touch, sweating, and increased nail and hair growth. The most important part about stage one is to try and get your patient moving (Stehno-Bittle, 2011). If the patient does not move their limb stiffness will increases with time, due to fibrosis and adhesions (Dutton, 2004). Stage two of CRPS can last several months. This stage presents with persistent pain and at this point stiffness begins to set in. The affected limb can be swollen, cool, and cyanotic. Due to the swelling and blood flow changes there is hair loss and cracked brittle nails. The third and final stage can last an unlimited amount of time. At this point there is atrophy of skin, subcutaneous tissue, and muscle (Stehno-Bittel, 2011). Once CRPS has progressed to stage three it rarely reversible and there are permanent changes in the extremity. There are typically tightened muscles and contractures, muscle wasting, and pain in the entire limb. There is some inconsistency as to whether there is a fourth stage or not. For those that believe there is a fourth stage it is characterized by two years post onset and at this point everything is irreversible.
CRPS can be diagnosed through X-rays, bone scans, and nerve conduction studies. However, these may not have positive findings until CRPS has progressed to the point of atrophy in the limb. Bone scans and X-rays will not show a change until there is atrophy in the bone
Treatment
There is not one clear intervention or exercise treatment that works best for CRPS. According to one source the best treatment plan requires a combined team effort. Most sources tend to agree that there is no cure for CRPS, however the disease can be slowed and hopefully the person can continue to live a normal life. CRPS is a disorder that can spontaneously resolve itself during any of the previously mentioned stages. It is more likely to resolve itself if it is caught in the first stage, as it progresses to bone and muscle tissue it is less likely to be reversed.
Therapeutic Exercise
The quicker a person is diagnosed with CRPS the better. This allows a person to begin therapy earlier. One source says that immobilization and overprotection of the limb is ineffective and that therapy exercise should be started immediately (Dutton, 2004). When using Ther Ex for CRPS the key is to try to avoid excess pain and not re-aggravate the injury with PT. The exercises should be progressed slowly, beginning with PROM and moving through AAROM, to AROM. ROM exercises should all be in a pain free range. Depending on the joint that is affected there should be some weight bearing exercises added to the exercise program (Dutton, 2004). By trying to incorporate weight bearing exercises and ROM exercise it helps a patient be able to go about their ADL’s. There have also been positive therapeutic effects for functional therapies and observing a mirror image of the unaffected limb (Patterson, 2011).
Patient Education
Patients need to be educated as to the fact that it is important to continue to move the joint or joints that are affected by the CRPS. However, with this movement remind them that it needs to be in a pain free ROM if possible. It also may be beneficial to explain what the diagnosis of CRPS means, the stages of CRPS, and why physical therapy and movement helps. It may also be beneficial to explain that with lack of movement there is atrophy and weakness that will occur.
Assistive Equipment
No assistive devices were found in research. Most of the research I reviewed wanted the patient to attempt to bear weight through the affected limb and use the affected limb as much as possible to avoid atrophy. By immobilizing the limb it can lead to demineralization, vasomotor changes, edema, and trophic changes (Dutton, 2004)
Manual Therapy
I was unable to find any supported evidence for passive accessory movements, but in most the sources I reviewed they talked about the benefit of passive physiologic movements. Most of the exercise related sources stated that passive range of motion is a very effective way to begin treatment to hopefully desensitize the limb. Once a patient can do PROM, they should be progressed to AROM as quickly as possible.
CRPS is very commonly caused by a fracture (Colle’s Fracture is very common), which means that PAM is contraindicated in a lot of these cases until the fracture has healed completely.
Home Instruction
Home instruction for CRPS is to elevate the affected limb as often as possible. The limb should also be mobilized several times during the course of the day. This should still be in a pain free ROM. Remind the patient to try to use the affected limb as much possible (within pain range) and not to over protect it. Exercises can be simple passive or active ROM activities. It can be very simple and include any degrees of freedom the joint may have. Depending on the stage a patient is in and how sensitive the patient is simple weight bearing exercises can be added.
Pain Control and Modalities
Pain control can be obtained through pain medicines, steroids, and blood pressure medicines. In some cases antidepressants can also help. For some patients these medicines do not work and there are more invasive procedures to try to help the pain. Some techniques include: injected medicine that numbs affected nerves/pain fibers around spinal cord, internal pain pump that directly delivers medicine to the spinal cord, and surgery that cuts the nerves to destroy the pain (unclear as to if it helps or hinders).
Modalities that we can use include TENS. A TENS unit may help in the desensitization process (helps decreases edema, sensitivity, and sympathetic response). The electrodes are placed over the peripheral nerve associated with the nerve injury (commonly median or ulnar nerves). During therapy using TENS may allow the patient to be able to perform AROM, where as without it they may not be able to stand the pain. The TENS unit works by blocking or interfering with the pain receptors through the gate theory.
In some cases of CRPS, desensitization programs are used. These programs begin by using very soft textured materials and rubbing them over the surface of the skin. As the nerves begin to acclimate to these materials a more abrasive material is used. The idea is to acclimate the patient to different materials such as socks, shirts, sheets, etc.
I found one source that said that ultrasound could be used to deliver heat and create vasodilation, but I was unable to find any solid evidence backing up the use of ultrasound to treat CRPS.
Eijs, F. V., Stanton-hicks, M., Zundert, J. V., Faber, C. G., Lubenow, T. R., Mekhail, N., Kleef, M. V., et al. (2011). EVIDENCE-BASED MEDICINE 16 . Complex Regional Pain Syndrome. Pain Practice, 11(1), 70-87.
Patterson, R. W., Li, Z., Smith, B. P., Smith, T. L., & Koman, L. A. (2011). Complex regional pain syndrome of the upper extremity. The Journal of hand surgery, 36(9), 1553-62. doi:10.1016/j.jhsa.2011.06.027
Definition: Triangular Fibrocartilage Complex (TFCC) is the articular disc between the triquetrum carpal and the distal ulna. Specifically the triangle’s base is attached to the medial edge of the ulnar notch of the radius. The triangle’s point/apex attaches to the lateral part of the ulnar styloid base. It cushions compressive forces and stabilizes the distal radioulnar joint. Both surfaces are smooth and concave to allow carpal gliding, especially during pronation and supination. Many ligaments and structures support the TFCC.
MOI:
Compression with forced ulnar deviation (ex. Swinging a bat or racket),
repetitive twisting with palmar rotation,
FOOSH,
blow to medial side of wrist,
direct pressure on hands (gymnastics),
using heavy tools
Sign/Symptoms:
Pain on ulnar side of wrist
clicking/grinding/crepitus
Weakness
Lunotriquetral interval tenderness
Decreased wrist ROM
Decreased grip strength
Diagnostics:
There are 2 classes of TFCC: traumatic and degenerative
TFCC Compression Test: reproduction of pain/clicking with ulnar deviation of wrist with forearm in neutral
Piano Key Sign: Depress distal ulna from dorsal to volar with the hand pronated; (+) if painful laxity in the affected wrist compared with the contralateral wrist
Ulnar Carpal Sag
MRI
Surgical Treatment:
Open Repair or Arthroscopic Repair only with traumatic types
Conservative Treatment:
NSAIDs
Immobilize in cast/splint
Avoid excess pronation because it puts ulnar head at risk for dorsal displacement
Physical Therapy to increase wrist ROM, strengthen surrounding structures, improve circulation
Modalities:
Cold pack or ice to control pain and edema. If there is a scar from surgery then ultrasound may break up adhesions. Paraffin bath may help in proliferative or remodeling stages of healing.
Ther Ex:wrist stretches, hand putty for fine motor techniques, PROM/AROM for wrist and digits, tendon glides (lumbrical grip, hook fist, full fist), isometrics (ex. 10 reps 4 times/day), isotonics if no edema is present, light ADLs with 5lb max
Manual Therapy: distraction for pain relief (1-2 bouts of 20-30 seconds), possible surgical scar management through massage but no specific evidence
Assistive Device:Splint with wrist in slight flexion and ulnar deviation
Education: Explain the anatomy of the triangular fibrocartilage complex; instruct patient to avoid ulnar deviation, excess pronation, and other mechanisms of injury. Modify activity and suggest ideas for safe wrist positions at work, in sports, etc. Make sure they are using an appropriate size racket/bat for sports
HEP: see Ther Ex, give only a few key exercises at a time that don’t involve equipment to increase patient compliance, NSAIDS and ice to relieve pain
Definition
DeQuervain’s Syndrome, also called DeQuervain’s Tenosynovitis, is an inflammation of the tendon sheath (synovium) surrounding the abductor pollicis longus and extensor pollicis brevis when the tendons become irritated. The swelling changes the shape (stenosis) of the first dorsal compartment of the wrist making it difficult for the tendons to move as they should.
Mechanism of Injury
DeQuervain’s Syndrome is most commonly caused by overuse of the APL and EPB tendons by repeated radial and ulnar deviation movements. Activities that may cause such overuse include painting, hammering, golf, typing, knitting, and so on. The overuse causes the extensor retinaculum to thicken and the fibro-osseus canal to narrow resulting in the tendons becoming entrapped and compressed. Other possible risk factors or reasons include an association with pregnancy and rheumatoid arthritis. It is most commonly found in middle-aged women.
Signs/Symptoms
Common signs and symptoms include:
Localized swelling and tenderness along the radial styloid process.
Pain and tenderness along the thumb side of the wrist radiating into the forearm and thumb.
Pain is more severe with ulnar deviation, thumb flexion, adduction, extension, and abduction.
The pain may be gradual or sudden.
Crepitus of tendons moving through extensor sheath.
Palpable thickening of extensor sheath and tendons distal to it.
Loss of thumb CMC abduction.
A catching or snapping sensation may be felt by the patient.
DeQuervain’s Syndrome is identified by a positive Finkelstein’s test. The Finkelstein test is performed by having the patient make a fist around their thumb and then, stabilizing the forearm, ulnarly deviate the wrist by applying the pressure to the second metcarpal. A positive test is indicated by pain along the region of the APL and EPB tendons.
This test may also be positive in Wartenburg’s syndrome, basilar thumb arhtrosis, or intersection syndrome.
Radiographs may also be done to help differentially diagnose from bony pathologies. Differential diagnosis may include arthritis of the first carpometacarpal joint, scaphoid fracture and nonunion, radiocarpal arthritis, Wartenburg’s syndrome (entrapment of superficial radial sensory nerve), and intersection syndrome (pain on posterior wrist caused by flexion and extension).
Treatment Strategy Modalities/Pain Control
The main pain control is to rest the area. Cryotherapy, iontophoresis, and phonophoresis may be used acutely. For chronic DeQuervain’s Syndrome, thermal modalities such as hot pack and thermal ultrasound can be helpful. NSAIDS may work for some less severe patients and corticosteroid injections may be used as a last resort before surgery if therapy does not help.
Manual Therapy
Manual therapy may include a number of different mobilizations and manipulations such as:
Mulligan’s mobilization techniques (radial glide of proximal carpal row and ulnar glide of trapezium)
Capitate manipulation
CMC joint mobilizations
Carpal bone mobilizations
Transverse friction massage over the first dorsal compartment and APL and EPB tendon may be performed.
Assistive Devices
A thumb spica splint will most often be used to limit the ROM for approximately 3-6 weeks and is to be worn all day. This splint is in 15 degrees wrist extension, thumb midway between palmar and radial abduction, and 10 degrees of thumb MP joint flexion. Splint should be made to where patient can still oppose thumb to the second and third phalanges in order to still be functional while wearing it.
Education
The patient should know to take rest from actions causing pain until the syndrome gets well enough to tolerate those movements again, which should be by the end of the splint use. In addition, the patient should understand the importance of appropriate body mechanics and the reasoning behind them.
Exercise
Stretching can include:
Opposition stretch
Touch the tip of the thumb to the tip of the little finger and hold for 6 seconds, repeat 10 times.
Wrist stretch
Flexion and extension with elbow straight holding for 15-30 seconds, repeat 3 times.
Strengthening/Endurance can include:
Wrist flexion
Hold weight with palm up and bend wrist upward, slowly lower back to starting position. Do 3 sets of 10.
Wrist extension
Hold weight with palm down and bend wrist upward, slowly lower back to starting position. Do 3 sets of 10.
Wrist radial deviation
Hold weight with thumb facing upward and bend wrist bringing thumb towards ceiling but keeping forearm still, slowly lower back to starting. Do 3 sets of 10.
Grip strength
Squeeze a ball of putty or rubber ball holding for 5 seconds. Do 3 sets of 10.
Finger spring
Place rubber band around ends of thumb and fingers and open fingers to stretch band. Do 3 sets of 10. Home Exercise Program
The home exercise program should closely resemble the above exercises. Household items such as a can of soup, a water bottle, or a hammer can replace the handweight if needed. Exercises should be performed once a day.
Some cases may need surgery if no improvement seen with therapy. This surgery includes cutting the tendinous sheath to allow for more room, but may involve complications.
Definition:
Carpal tunnel syndrome is the compression of the median nerve in the carpal flexor space, underneath the transverse carpal ligament. It is often associated with patients who perform repetitive motions at the wrist, causing flexor tenosynovitis and swelling at the wrist. Carpal tunnel syndrome occurs most commonly between the ages of 30 and 60 and is more common in women than men. It is thought that there is a higher prevalence in women, because women typically have smaller wrists than men.
Mechanism of Injury:
- Typically an overuse injury caused by excessive repetitive motion of the hand, wrist, and arm (e.g. painting, typing on a keyboard, recreational activities such as racquetball, playing musical instruments, and sewing).
- Compression of the median nerve can also come from excessive synovial fluid because of multiple causes: Pregnancy due to secondary fluid retention, Renal dysfunction, Acromegaly, Gout, Myxedema, Amyotrophy, Trauma, Infection, and Collagen disorders. (PRAGMATIC)
- Bone fractures and arthritis near the wrist or hand are more acute and traumatic causes.
- CTS Predictor rule: Age of 45 or older, patient reports shaking hands relieves symptoms, wrist ratio index >.67, reduced median sensory field of the first digit, and Symptom Severity Scale score >1.9.
Signs and Symptoms:
- Intermittent pain, especially during the night, due to fluid retention and fluid pooling.
- Numbness/Tingling in the median nerve distribution, which includes the radial three and a half digits on the palmar side; index, middle and ring finger on dorsal surface of the hand.
- Muscle weakness, especially grip strength and sometimes thumb opposition.
- Decreased sensation.
- Patient is constantly shaking out hands for pain and numbness relief.
- Signs of carpal tunnel can be observed using Tinel’s Test, in which the median nerve is tapped at the wrist, which can cause pain from the wrist into the hand. Phalen’s test is also performed by holding full flexion of the wrist for 30-60 seconds, which will elicit numbness or tingling.
- Final diagnosis can be made by performing a nerve conduction test monitoring the median nerve conduction velocity.
Treatment:
Modalities/Pain Control:
- Symptoms can be subdued with various forms of activity modification.
- NSAIDS for everyday pain control. Diuretics are sometimes prescribed for those that may have fluid retention issues. Local steroidal injections/oral steroids seem to be temporarily effective, but may produce side effects. Vitamin B6 supplementation, which is suggested to act as a diuretic, has not shown significant results.
-Ultrasound and low level laser treatment have shown significant improvements in condition, though ultrasound typically shows better results than laser treatment.
- Overall, 50% of cases eventually require surgery as a last resort. The surgery procedure simply involves releasing the transverse carpal ligament that surrounds the median nerve and carpal flexor tendons. Surgery is typically successful in resolving the problem, depending upon condition severity and chronicity.
Manual Therapy: Soft tissue massage, SASTM (Sound Assisted Soft Tissue Mobilization), and Graston techniques have shown success in mild to moderate CTS cases.
Assistive Devices:
-A Neutrally positioned splint may be worn for most of the day. Splinting has been proven to significantly improve symptoms by keeping the hand in a neutral position, allowing optimal diameter of the carpal tunnel.
-Hot and cold wrist wraps may also be used.
-Advising more ergonomic positions and devices can also be included in this category. Oftentimes more ergonomic workplace devices are suggested to office workers (keyboard, gel pad, armrests).
http://orthotape.com/images/products/Default/wrist/Exoform_Carpal_Tunnel_Wrist_lg.JPG
Education:
- Advise the patient not to sleep on their wrists, or with their hand underneath a pillow, as this will cause unwanted pressure upon the wrist.
- Review the positions that may have caused the condition to come about (keyboard height).
- A home or workplace visit may help the therapist recognize causatory factors. The therapist may also suggest workplace and recreational activity modifications.
Exercise: There doesn’t seem to be a direct relationship between exercise and CTS success. Oftentimes, wrist flexor strength is addressed too early due to poor grip strength, and performing wrist flexor exercises can make the problem worse. Exercise is typically administered later in the healing process.
Possible exercises include: ROM exercises, median nerve glides, gentle stretching of shoulder, forearm, wrist and hands. Isometric exercises such as making a fist, and fanning the fingers.
HEP: Dr. Housang Seradge prescribed and created the following HEP for people performing repetitive wrist activities. This exercise sequence should be performed once every hour of repetitive activity. One study showed a 67% success rate of mild/moderate CTS cases when adhering to this exercise program (18-34% success reported nationally).
· Extend and stretch both fingers and wrist as if they were in a handstand position. Hold for five seconds;
· Straighten both wrists and relax fingers;
· Make a tight fist with both hands;
· Bend both wrists down with the hands still in a fist. Hold for five seconds;
· Straighten both wrists and relax fingers for five seconds;
· Hang arms loosely at sides and shake them for five seconds;
· Repeat steps 1 through 6, 10 times.
http://www.eatonhand.com/hw/ctexercise.htm
REFERENCES:
"Carpel Tunnel Syndrome." Physiopedia. Ed. Kristen Sartore. Web. 14 Feb. 2012. <http://www.physio-pedia.com/index.php/Carpel_Tunnel_Syndrome>.
Bielefeld, Teri. "What You Need to Know about Carpal Tunnel Syndrome: A PT Perspective." APTA, 1996. Web. 14 Feb. 2012. <http://www.utmb.edu/rehab/Outpatient/Carpal.pdf>.
Burke, Jeanmarie & Buchberger, Dale J & Carey-Loghmani, M Terry & Dougherty, Paul E & Greco, Douglas S & Dishman, J Donald. (2007). A pilot study comparing two manual therapy interventions for carpal tunnel syndrome. Journal of manipulative and physiological therapeutics.
D.B. Piazzini, I. Aprile, P.E. Ferrara, C. Bertolini, P. Tonali, L. Maggi, A. Rabini, S. Piantelli, & L. Padua. (2007). A systematic review of conservative treatment of carpal tunnel syndrome. Clinical Rehabilitation, 21(4), 299-314.
O'Sullivan, Susan B., and Thomas J. Schmitz. Physical Rehabilitation: Assessment and Treatment. Philadelphia: F.A. Davis, 1988. Print.
Seradge, Houshang & Parker, Win & Baer, Carrie & Mayfield, Kim & Schall, Laura. (2002). Conservative treatment of carpal tunnel syndrome: an outcome study of adjunct exercises. The Journal of the Oklahoma State Medical Association, 95.
Seradge, Housang. "Carpal Tunnel Syndrome Exercises." E-Hand. Web. 14 Feb. 2012. <http://www.eatonhand.com/hw/ctexercise.htm>.
Zieve, David. "Carpal Tunnel Syndrome." PubMed Health. Web. 14 Feb. 2012. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001469/.
Colles Fracture
DefinitionA break in the distal radius with or without ulnar involvement. The fracture usually occurs about 1 inch from the radiocarpal joint.
MOI
Fall on out-stretched hand (FOOSH). The fall can be low-energy (i.e. tripping over something) or high impact (i.e. falling off a skateboard).
Bimodal age distribution- occurs in very young & elderly.
Common in females due to higher prevalence of osteoporosis and/or lower bone mineral density.
Signs/Symptoms
A “dinner-fork” deformity, pain, swelling, bruising, tenderness, diminished pulse, decreased mobility and crepitus (if the fractured bones are approximating). However, do not test for crepitus as this can greatly worsen the condition.
After immobilization, expect deficiencies in ROM & grip strength, and stiffness in hand and fingers. Also can be accompanied by shoulder or neck pain if patient was casted or held arm out of normal positioning.
Diagnostic: X-ray
Possible Physician Interventions
Casting or splinting (most common)
External fixation- better anatomical results/bone alignment.
Wrist bridging- distal pins in 2nd MC.
Nonbridging- distal pins in distal radial bone fragment.
Internal fixation- for anatomical reduction, allows for earlier mobilization & ROM.
Wiring (percutaneous pins)- used with external fixation or alone for greater stabilization. Contraindicated in those with osteoporosis or severely comminuted fractures.
Bone substitutes- for patients with osteoporosis.
*Treatment type can vary by age & condition.
Therapeutic Exercise
Focus should be on wrist & hand ROM & strengthening. If the patient was casted above the elbow, therapy could be indicated for the elbow joint as well.
Prehensile hand function- grip strength & precision.
Wrist- flexion, extension, ulnar & radial deviation.
Elbow- flexion, extension, pronation & supination.
Patient Education
Proper diet, EXERCISE, & vitamins to build bone mineral density & to prevent falls.
Bones respond best to loading; encourage WB exercises once bone is healed and able to tolerate resistance.
Manual Therapy
Distal Radioulnar Joint: pronation & supination
Superior Radiounlnar Joint: pronation & supination.
Radiocarpal Joint: distraction, volar glide for extension, dorsal glide for flexion, radial glide for ulnar deviation & ulnar glide for radial deviation.
Thumb CMC: distration, ulnar, radial, dorsal, & ventral glides. CMC's 2-5: distraction for mobility, volar glide for flexion, dorsal glide for extension.
Thumb MCP: distraction, volar, & dorsal glides. MCP's 2-5: distraction for mobility, volar glide for flexion, dorsal glide for extension, radial glide for abduction, & ulnar glide for adduction.
Grades I-2 for pain (1-2 bouts for 20-30 seconds)
Grades 3-4 for resistance (3-5 bouts for 45-60 seconds)
Transverse friction massage for scar tissue (for those who were treated by internal fixation).
Assistive Device: not indicated
Home Instruction
Elevation for edema, pain control, comfort while sleeping.
ROM: wrist flexion, extension, ulnar & radial deviations. Flexion & extension of the fingers (open/close the fingers on the hand). Pronation & supination of the forearm.
Stretching: wrist flexors and extensors, ulnar & radial deviations. Prayer stretch- palms facing.
Strength/endurance: Tennis ball squeezes, pronation/supination holding objects of varied weight, four-way theraband for flexion, extension, radial & ulnar deviations.
Household items/ADLs that can help with therapy: silly putty or play-doh (flatten and squish), tennis ball, soup can or hammer for pronation/supination, stirring/cooking, sewing, & folding laundry.
Pain Control
Paraffin bath for pain in the chronic phase. Review contraindications prior to treatment.
Cryotherapy is helpful initially to help control pain & swelling.
Cryotherapy & thermotherapy for use during therapy to assist in achieving ROM.
OTC medications
References
Ulnar Neuropathy
Definition:
Ulnar neuropathy occurs when there is damage to the ulnar nerve. The ulnar nerve is an extension of the medial cord of the brachial plexus and innervates muscles of the hand and forearm. It also provides sensation for the 4th (medial) and 5th digits of the hand4. Damage to the nerve destroys the nerve’s myelin sheath which slows or prevents nerve signaling2.
Signs & Symptoms:
-abnormal sensation of the 5th digit and/or part of the 4th digit
-tingling or burning sensation
-weakness of the hand
-pain in the hand or elbow
-loss of coordination of the fingers
-numbness or decreased sensation
-decreased hand grip
-claw-like deformity
-Wartenberg’s sign abduction of 5th digit (http://www.youtube.com/watch?v=K7EmeSGqEp4)
-positive Tinel’s sign at elbow- paresthesias in ulnar portion of hand4 (http://www.youtube.com/watch?v=T1oFeckmaGQ)
Mechanism of Injury:
Entrapment- can occur in several areas but the two most common are the cubital tunnel in the elbow or in guyon’s canal in the wrist4.
Trauma- a direct blow to the inside of your elbow7
Sleeping with a bent elbow7
Compression- leaning on your elbow or wrist extension for long periods of time7
Diabetes
Deformities
Tumors
Risk factors include:
Age: a prospective study showed that increased age is highly correlated with a greater tendency for ulnar neuropathy5.
Arthritis of the elbow
Repetitive or prolonged activities that require the elbow to be flexed or bent7.
Treatment:
Ulnar neuropathy is generally treated conservatively at first. If the condition does not improve, or if the nerve is highly compressed, surgery may be an option7. Different surgical options include cubital tunnel release, ulnar nerve anterior transposition and medial epicondylectomy7.
Therapeutic Exercise:
Therapists can use nerve glides which can promote smoother movements of the nerve within the tunnel and to reduce adhesions and other possible causes of compression4. An example of an ulnar nerve glide sequence: http://www.youtube.com/watch?v=YV6N3kCy0fE
Increasing the range of motion and strength of the wrist and hand are also very important. This should be done with caution as you do not want to cause more irritation to the nerve. Examples include:
-Cervical range of motion exercises (rotation, flexion, extension and side bending) hold each for 10 seconds
-elbow and wrist range of motion (hold each for 10 seconds)
-shoulder depression (hold for 10 seconds and repeat 10 times)
-finger adduction- place objects between each finger and squeeze together for 10 seconds and repeat 5 times
-finger flexion-squeeze a rubber ball and hold for 10 seconds and repeat 10 times.
http://www.ndortho.com/Pt_Advisor-WEB/Ulnar_Neuropathy.pdf
Education:
Educate the patient about how their ulnar nerve may have been compressed or injured. Tell the patient to avoid sleeping with their elbow bent at night. A night splint can be worn to ensure7. Also encourage them to avoid resting their elbow on hard surfaces. If that is unavoidable, have them place padding underneath their elbow.
Assistive Equipment:
The use of a night splint to avoid flexion and extension of the elbow at night has shown to be beneficial in clinical trials6. Cushions for the elbow and wrist can also be used to relieve pressure when resting on hard surfaces.
Manual Therapy:
I was unable to find research supporting the use of manual therapy for ulnar neuropathy.
Home Exercise Program:
The patient should continue the strengthening and range of motion exercises they were taught in therapy. Instruct them to perform the nerve glides at home but remind them to perform them in a slow and controlled manner to avoid irritation. The nerve glides should be repeated 15 times 3-4 times a day. Encourage them to perform stretches throughout the day in the opposite pattern of their work position and to maintain proper body mechanics.
Modalities/Pain Control:
NSAIDS- to reduce possible swelling around the nerve and provide pain control7
Steroid injections
References:
1.Caliandro P, La Torre G, Padua R, Giannini F, Padua L. Treatment for ulnar neuropathy at the elbow. Cochrane Database Syst Rev. Feb 16 2011;2:CD006839.
2.Dugdale, David C. "Ulnar Nerve Dysfunction: MedlinePlus Medical Encyclopedia." U.S National Library of Medicine. U.S. National Library of Medicine, 26 Sept. 2010. Web. 02 Mar. 2012. <http://www.nlm.nih.gov/medlineplus/ency/article/000789.htm>.
3.Dutton, M. (2004). Orthopaedic: Examination, evaluation, & intervention. New York, NY:McGraw-Hill.
4.Guardia, Charles F. "Ulnar Neuropathy." Medscape. 18 May 2011. Web. 2 Mar. 2012. <http://emedicine.medscape.com/article/1141515-overview>.
5.Ho S. Factors for Ulnar Neuropathy at the Elbow: A Prospective Study. Archives of Physical Medicine and Rehabilitation. 2006;87, Issue 11:e15-e16.
6.Seror P. Treatment of ulnar nerve palsy at the elbow with a night splint. J Bone Joint Surg Br. Mar 1993;75(2):322-7
7."Ulnar Nerve Entrapment at the Elbow (Cubital Tunnel Syndrome) - AAOS." AAOS. Web. 02 Mar. 2012. <http://orthoinfo.aaos.org/topic.cfm?topic=A00069>.
Complex Regional Pain Syndrome
Definition
Complex Regional Pain Syndrome (CRPS) is a relatively new term for what had been called causalgia, reflex sympathetic dystrophy, and reflex neurovascular dystrophy. Complex regional pain can fall into two different categories. The first type is a pain syndrome brought on by an event that is not limited to a single peripheral nerve (Dutton, 2004). The second type involves direct partial or complete injury to a nerve or one of its major branches. This page focuses on type 1.
Type 1 is caused by an abnormal reaction of the sympathetic nervous system following an injury (Dutton, 2004). CRPS typically will occur in a single extremity following trauma or surgery (Eijs et al., 2011). This will normally affect either an arm or a leg. The incidence of CRPS type I, is between 1 and 2% after a fracture, 2 to 5% after peripheral nerve injury and between 7 and 35% in prospective Colles’ Fractures. There also are a larger number of patients who have no known cause but still end up with CRPS Type I. This is not just limited to an upper extremity injury.
Mechanism of Injury
According to most of the sources that I reviewed there are certain injuries that have a more likely occurrence of CRPS, but it is somewhat ambiguous as to the known factors. As mentioned early, CRPS has a high incidence in people with distal extremity fractures. According to one article the trauma does not have to be a fracture but can be as simple as a minor sprain (Rho, Brewer, Lamer, & Peter, 2002). Once an injury occurs there is damage to the nerves. The nerves are then unable to properly control blood flow, feeling (sensations), and temperature of the affected area. Because the nerves are functioning incorrectly there can be problems with blood vessels, bones, muscles, nerves, and skin. The sympathetic nervous system normally affects the body by vasoconstricting blood vessels, increasing HR and force of contraction, and it activates sweat glands. Normally, this is a very beneficial mechanism that our body's use very day, however, in people CRPS they have an over active sympathetic nervous systems in some area of their body. This causes sweating and vasoconstriction of blood vessels in that area which in turn causes multiple signs and symptoms and the diagnosis of CRPS.
Signs and Symptoms
There are four different stages of CRPS. During all four stages pitting or non-pitting edema, will likely be present (Dutton, 2004). The first stage of CRPS may span a couple weeks or as long as a couple months. It is associated with persistent, burning pain, and edema. Other symptoms of this stage include increased sensation to touch, sweating, and increased nail and hair growth. The most important part about stage one is to try and get your patient moving (Stehno-Bittle, 2011). If the patient does not move their limb stiffness will increases with time, due to fibrosis and adhesions (Dutton, 2004). Stage two of CRPS can last several months. This stage presents with persistent pain and at this point stiffness begins to set in. The affected limb can be swollen, cool, and cyanotic. Due to the swelling and blood flow changes there is hair loss and cracked brittle nails. The third and final stage can last an unlimited amount of time. At this point there is atrophy of skin, subcutaneous tissue, and muscle (Stehno-Bittel, 2011). Once CRPS has progressed to stage three it rarely reversible and there are permanent changes in the extremity. There are typically tightened muscles and contractures, muscle wasting, and pain in the entire limb. There is some inconsistency as to whether there is a fourth stage or not. For those that believe there is a fourth stage it is characterized by two years post onset and at this point everything is irreversible.
CRPS can be diagnosed through X-rays, bone scans, and nerve conduction studies. However, these may not have positive findings until CRPS has progressed to the point of atrophy in the limb. Bone scans and X-rays will not show a change until there is atrophy in the bone
Treatment
There is not one clear intervention or exercise treatment that works best for CRPS. According to one source the best treatment plan requires a combined team effort. Most sources tend to agree that there is no cure for CRPS, however the disease can be slowed and hopefully the person can continue to live a normal life. CRPS is a disorder that can spontaneously resolve itself during any of the previously mentioned stages. It is more likely to resolve itself if it is caught in the first stage, as it progresses to bone and muscle tissue it is less likely to be reversed.
Therapeutic Exercise
The quicker a person is diagnosed with CRPS the better. This allows a person to begin therapy earlier. One source says that immobilization and overprotection of the limb is ineffective and that therapy exercise should be started immediately (Dutton, 2004). When using Ther Ex for CRPS the key is to try to avoid excess pain and not re-aggravate the injury with PT. The exercises should be progressed slowly, beginning with PROM and moving through AAROM, to AROM. ROM exercises should all be in a pain free range. Depending on the joint that is affected there should be some weight bearing exercises added to the exercise program (Dutton, 2004). By trying to incorporate weight bearing exercises and ROM exercise it helps a patient be able to go about their ADL’s. There have also been positive therapeutic effects for functional therapies and observing a mirror image of the unaffected limb (Patterson, 2011).
Patient Education
Patients need to be educated as to the fact that it is important to continue to move the joint or joints that are affected by the CRPS. However, with this movement remind them that it needs to be in a pain free ROM if possible. It also may be beneficial to explain what the diagnosis of CRPS means, the stages of CRPS, and why physical therapy and movement helps. It may also be beneficial to explain that with lack of movement there is atrophy and weakness that will occur.
Assistive Equipment
No assistive devices were found in research. Most of the research I reviewed wanted the patient to attempt to bear weight through the affected limb and use the affected limb as much as possible to avoid atrophy. By immobilizing the limb it can lead to demineralization, vasomotor changes, edema, and trophic changes (Dutton, 2004)
Manual Therapy
I was unable to find any supported evidence for passive accessory movements, but in most the sources I reviewed they talked about the benefit of passive physiologic movements. Most of the exercise related sources stated that passive range of motion is a very effective way to begin treatment to hopefully desensitize the limb. Once a patient can do PROM, they should be progressed to AROM as quickly as possible.
CRPS is very commonly caused by a fracture (Colle’s Fracture is very common), which means that PAM is contraindicated in a lot of these cases until the fracture has healed completely.
Home Instruction
Home instruction for CRPS is to elevate the affected limb as often as possible. The limb should also be mobilized several times during the course of the day. This should still be in a pain free ROM. Remind the patient to try to use the affected limb as much possible (within pain range) and not to over protect it. Exercises can be simple passive or active ROM activities. It can be very simple and include any degrees of freedom the joint may have. Depending on the stage a patient is in and how sensitive the patient is simple weight bearing exercises can be added.
Pain Control and Modalities
Pain control can be obtained through pain medicines, steroids, and blood pressure medicines. In some cases antidepressants can also help. For some patients these medicines do not work and there are more invasive procedures to try to help the pain. Some techniques include: injected medicine that numbs affected nerves/pain fibers around spinal cord, internal pain pump that directly delivers medicine to the spinal cord, and surgery that cuts the nerves to destroy the pain (unclear as to if it helps or hinders).
Modalities that we can use include TENS. A TENS unit may help in the desensitization process (helps decreases edema, sensitivity, and sympathetic response). The electrodes are placed over the peripheral nerve associated with the nerve injury (commonly median or ulnar nerves). During therapy using TENS may allow the patient to be able to perform AROM, where as without it they may not be able to stand the pain. The TENS unit works by blocking or interfering with the pain receptors through the gate theory.
In some cases of CRPS, desensitization programs are used. These programs begin by using very soft textured materials and rubbing them over the surface of the skin. As the nerves begin to acclimate to these materials a more abrasive material is used. The idea is to acclimate the patient to different materials such as socks, shirts, sheets, etc.
I found one source that said that ultrasound could be used to deliver heat and create vasodilation, but I was unable to find any solid evidence backing up the use of ultrasound to treat CRPS.
Sources
"Causes, Incidence, and Risk Factors." Complex Regional Pain Syndrome. U.S. National Library of Medicine, 18 Nov. 0000. Web. 02 Mar. 2012. <http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004456/>.
"Complex Regional Pain Syndrome (CRPS)." Complex Regional Pain Syndrome(CRPS). Web. 02 Mar. 2012. <http://www.cmki.org/LMHS/Chapters/35-ComplexRegionalPainSyndrome.htm>.
Dutton, Mark (2004-03-26). Orthopaedic Examination, Evaluation & Intervention (Kindle Location 28468). McGraw-Hill. Kindle Edition.
Eijs, F. V., Stanton-hicks, M., Zundert, J. V., Faber, C. G., Lubenow, T. R., Mekhail, N., Kleef, M. V., et al. (2011). EVIDENCE-BASED MEDICINE 16 . Complex Regional Pain Syndrome. Pain Practice, 11(1), 70-87.
Patterson, R. W., Li, Z., Smith, B. P., Smith, T. L., & Koman, L. A. (2011). Complex regional pain syndrome of the upper extremity. The Journal of hand surgery, 36(9), 1553-62. doi:10.1016/j.jhsa.2011.06.027
Rho, R., Brewer, R., Lamer, T., & Peter, W. (2002). Complex regional pain syndrome. Mayo Clinic Proceddings, 77(2), 174. Retrieved from http://www.springerlink.com/index/j7tx97wk0avt99u3.pdf
Stehno-Bittel, Lisa. "CRPS." Pathophysiology Class. Kansas City. Lecture.
Triangular Fibrocartilage Disc Injury
Definition: Triangular Fibrocartilage Complex (TFCC) is the articular disc between the triquetrum carpal and the distal ulna. Specifically the triangle’s base is attached to the medial edge of the ulnar notch of the radius. The triangle’s point/apex attaches to the lateral part of the ulnar styloid base. It cushions compressive forces and stabilizes the distal radioulnar joint. Both surfaces are smooth and concave to allow carpal gliding, especially during pronation and supination. Many ligaments and structures support the TFCC.
MOI:
Sign/Symptoms:
Diagnostics:
There are 2 classes of TFCC: traumatic and degenerative
TFCC Compression Test: reproduction of pain/clicking with ulnar deviation of wrist with forearm in neutral
Piano Key Sign: Depress distal ulna from dorsal to volar with the hand pronated; (+) if painful laxity in the affected wrist compared with the contralateral wrist
Ulnar Carpal Sag
MRI
Surgical Treatment:
Open Repair or Arthroscopic Repair only with traumatic types
Conservative Treatment:
NSAIDs
Immobilize in cast/splint
Avoid excess pronation because it puts ulnar head at risk for dorsal displacement
Physical Therapy to increase wrist ROM, strengthen surrounding structures, improve circulation
Modalities:
Cold pack or ice to control pain and edema. If there is a scar from surgery then ultrasound may break up adhesions. Paraffin bath may help in proliferative or remodeling stages of healing.
Ther Ex: wrist stretches, hand putty for fine motor techniques, PROM/AROM for wrist and digits, tendon glides (lumbrical grip, hook fist, full fist), isometrics (ex. 10 reps 4 times/day), isotonics if no edema is present, light ADLs with 5lb max
Manual Therapy: distraction for pain relief (1-2 bouts of 20-30 seconds), possible surgical scar management through massage but no specific evidence
Assistive Device: Splint with wrist in slight flexion and ulnar deviation
Education: Explain the anatomy of the triangular fibrocartilage complex; instruct patient to avoid ulnar deviation, excess pronation, and other mechanisms of injury. Modify activity and suggest ideas for safe wrist positions at work, in sports, etc. Make sure they are using an appropriate size racket/bat for sports
HEP: see Ther Ex, give only a few key exercises at a time that don’t involve equipment to increase patient compliance, NSAIDS and ice to relieve pain
References:
Dutton, M. (2004). Orthopaedic: Examination, evaluation, & intervention. New York, NY:McGraw-Hill.
Loudon, J., Swift, M., Bell, S. (2008). The Clinical Orthopedic Assessment Guide
Triangular Fibrocartilage Complex - Wheeless’ Textbook of Orthopaedics. (n.d.). Retrieved March 3, 2012, from http://www.wheelessonline.com/ortho/triangular_fibrocartilage_complex
Triangular Fibrocartilage Complex Injuries - Physiopedia - the free resource for the physiotherapy and physical therapy profession. (n.d.). Retrieved March 3, 2012, from http://www.physio-pedia.com/index.php/Triangular_Fibrocartilage_Complex_Injuries
Retrieved 3/3/3/12 from http://www.mdguidelines.com/triangular-fibrocartilage-complex-tfcc-tears
http://www.requestphysicaltherapy.com/Home/PatientEducation/tabid/2456/ctl/View/mid/4260
DeQuervain’s Syndrome
Definition
DeQuervain’s Syndrome, also called DeQuervain’s Tenosynovitis, is an inflammation of the tendon sheath (synovium) surrounding the abductor pollicis longus and extensor pollicis brevis when the tendons become irritated. The swelling changes the shape (stenosis) of the first dorsal compartment of the wrist making it difficult for the tendons to move as they should.
Mechanism of Injury
DeQuervain’s Syndrome is most commonly caused by overuse of the APL and EPB tendons by repeated radial and ulnar deviation movements. Activities that may cause such overuse include painting, hammering, golf, typing, knitting, and so on. The overuse causes the extensor retinaculum to thicken and the fibro-osseus canal to narrow resulting in the tendons becoming entrapped and compressed. Other possible risk factors or reasons include an association with pregnancy and rheumatoid arthritis. It is most commonly found in middle-aged women.
Signs/Symptoms
Common signs and symptoms include:
Localized swelling and tenderness along the radial styloid process.
Pain and tenderness along the thumb side of the wrist radiating into the forearm and thumb.
Pain is more severe with ulnar deviation, thumb flexion, adduction, extension, and abduction.
The pain may be gradual or sudden.
Crepitus of tendons moving through extensor sheath.
Palpable thickening of extensor sheath and tendons distal to it.
Loss of thumb CMC abduction.
A catching or snapping sensation may be felt by the patient.
DeQuervain’s Syndrome is identified by a positive Finkelstein’s test. The Finkelstein test is performed by having the patient make a fist around their thumb and then, stabilizing the forearm, ulnarly deviate the wrist by applying the pressure to the second metcarpal. A positive test is indicated by pain along the region of the APL and EPB tendons.
This test may also be positive in Wartenburg’s syndrome, basilar thumb arhtrosis, or intersection syndrome.
Radiographs may also be done to help differentially diagnose from bony pathologies. Differential diagnosis may include arthritis of the first carpometacarpal joint, scaphoid fracture and nonunion, radiocarpal arthritis, Wartenburg’s syndrome (entrapment of superficial radial sensory nerve), and intersection syndrome (pain on posterior wrist caused by flexion and extension).
Treatment Strategy
Modalities/Pain Control
The main pain control is to rest the area. Cryotherapy, iontophoresis, and phonophoresis may be used acutely. For chronic DeQuervain’s Syndrome, thermal modalities such as hot pack and thermal ultrasound can be helpful. NSAIDS may work for some less severe patients and corticosteroid injections may be used as a last resort before surgery if therapy does not help.
Manual Therapy
Manual therapy may include a number of different mobilizations and manipulations such as:
Mulligan’s mobilization techniques (radial glide of proximal carpal row and ulnar glide of trapezium)
Capitate manipulation
CMC joint mobilizations
Carpal bone mobilizations
Transverse friction massage over the first dorsal compartment and APL and EPB tendon may be performed.
Assistive Devices
A thumb spica splint will most often be used to limit the ROM for approximately 3-6 weeks and is to be worn all day. This splint is in 15 degrees wrist extension, thumb midway between palmar and radial abduction, and 10 degrees of thumb MP joint flexion. Splint should be made to where patient can still oppose thumb to the second and third phalanges in order to still be functional while wearing it.
Education
The patient should know to take rest from actions causing pain until the syndrome gets well enough to tolerate those movements again, which should be by the end of the splint use. In addition, the patient should understand the importance of appropriate body mechanics and the reasoning behind them.
Exercise
Stretching can include:
Opposition stretch
Touch the tip of the thumb to the tip of the little finger and hold for 6 seconds, repeat 10 times.
Wrist stretch
Flexion and extension with elbow straight holding for 15-30 seconds, repeat 3 times.
Strengthening/Endurance can include:
Wrist flexion
Hold weight with palm up and bend wrist upward, slowly lower back to starting position. Do 3 sets of 10.
Wrist extension
Hold weight with palm down and bend wrist upward, slowly lower back to starting position. Do 3 sets of 10.
Wrist radial deviation
Hold weight with thumb facing upward and bend wrist bringing thumb towards ceiling but keeping forearm still, slowly lower back to starting. Do 3 sets of 10.
Grip strength
Squeeze a ball of putty or rubber ball holding for 5 seconds. Do 3 sets of 10.
Finger spring
Place rubber band around ends of thumb and fingers and open fingers to stretch band. Do 3 sets of 10.
Home Exercise Program
The home exercise program should closely resemble the above exercises. Household items such as a can of soup, a water bottle, or a hammer can replace the handweight if needed. Exercises should be performed once a day.
Some cases may need surgery if no improvement seen with therapy. This surgery includes cutting the tendinous sheath to allow for more room, but may involve complications.
References**
AAOS. "De Quervain's Tendinitis (De Quervain's Tendinosis) - OrthoInfo - AAOS." OrthoInfo. AAOS, Oct. 2007. Web.
27 Feb. 2012. <http://orthoinfo.aaos.org/topic.cfm?topic=a00007>.
Coleman, Scott, and Phyllis Clapis. "De Quervain's Tenosynovitis Rehabilitation Exercises." Summit Medical Group. RelayHealth, 2009. Web. 03 Mar. 2012. <http://www.summitmedicalgroup.com/library/sports_health/de_quervains_exercises/>.
Dutton, M. (2004). Orthopaedic: Examination, evaluation, & intervention. New York, NY:McGraw-Hill.
Loudon, Janice, Marcie Swift, and Stephania Bell. The Clinical Orthopedic Assessment Guide. Champaign, IL: Human Kinetics, 2008