Carpal Tunnel Syndrome (CTS) Rehabilitation Protocol

Pathophysiology

Carpal Tunnel Syndrome (CTS) is a common condition caused by compression of the median nerve as it travels through the carpal tunnel in the wrist. The carpal tunnel is a narrow passageway formed by the carpal bones and the transverse carpal ligament. This compression can lead to a variety of symptoms including pain, numbness, tingling, and weakness in the hand and fingers, particularly the thumb, index, middle, and radial half of the ring finger. Contributing factors can include repetitive hand motions, prolonged wrist flexion or extension, trauma, pregnancy, obesity, and certain medical conditions like diabetes and rheumatoid arthritis. The compression results in ischemia and inflammation of the nerve, disrupting its function. If left untreated, prolonged compression can lead to permanent nerve damage and loss of hand function.

Rehabilitation Phases

This protocol outlines a progressive rehabilitation program for CTS, divided into three phases. Progression through each phase is dependent on the patient’s symptoms, functional abilities, and response to treatment. Close monitoring and communication between the patient and therapist are essential.

Phase I: Protection (Acute Phase – Approximately 0-4 weeks)

Goals:

• Reduce pain and inflammation.
• Protect the median nerve from further injury.
• Maintain range of motion (ROM) in unaffected joints.
• Educate the patient on proper posture and activity modification.

Interventions:

• Wrist Splinting: A neutral wrist splint should be worn at night and potentially during the day, especially during activities that exacerbate symptoms. The splint maintains the wrist in a neutral position to minimize pressure on the median nerve.
• Activity Modification: Educate the patient on avoiding activities that aggravate symptoms, such as repetitive hand motions, forceful gripping, and sustained wrist flexion or extension. Modify workstation ergonomics to promote neutral wrist posture.
• Modalities for Pain and Inflammation:
  • Ice: Apply ice packs to the wrist for 15-20 minutes several times per day.
  • Ultrasound: Therapeutic ultrasound may be used to reduce pain and inflammation.
  • Iontophoresis: May be used to deliver anti-inflammatory medication (e.g., dexamethasone) directly to the affected area.
• Gentle Range of Motion (ROM) Exercises: Perform gentle ROM exercises of the fingers and thumb to maintain joint mobility and prevent stiffness. Focus on active assisted or passive ROM initially.
  • Finger Flexion and Extension: Individually and collectively flex and extend the fingers.
  • Thumb Opposition, Abduction, and Adduction: Move the thumb across the palm to touch each fingertip, and move the thumb away from and towards the hand.
• Tendon Gliding Exercises: Perform tendon gliding exercises to improve tendon excursion and reduce adhesions. These exercises include:
  • Straight Fist: Fingers and thumb straight.
  • Hook Fist: MCPs extended, PIPs and DIPs flexed.
  • Full Fist: MCPs, PIPs, and DIPs flexed.
  • Table Top Fist: MCPs flexed, PIPs and DIPs extended.
  • Straight Thumb Fist: Fingers flexed, thumb straight.
• Nerve Gliding Exercises: Gentle nerve gliding exercises can help to mobilize the median nerve within the carpal tunnel. These exercises should be performed carefully and stopped if they cause increased pain or paresthesia.
  • Wrist Extension with finger extension.
  • Wrist Extension with finger flexion.

Phase II: Loading (Subacute Phase – Approximately 4-8 weeks)

Goals:

• Progressively increase wrist and hand strength and endurance.
• Improve functional use of the hand.
• Continue to reduce pain and inflammation.
• Restore full ROM.

Interventions:

• Progressive Strengthening Exercises: Begin with light resistance exercises, gradually increasing the weight or resistance as tolerated.
  • Grip Strengthening: Use a soft stress ball or theraputty.
  • Pinch Strengthening: Use clothespins or pinch putty.
  • Wrist Flexion and Extension: Use light dumbbells or resistance bands.
  • Forearm Pronation and Supination: Use light dumbbells.
• ROM Exercises: Continue ROM exercises, progressing to active ROM and stretching as tolerated.
• Tendon Gliding and Nerve Gliding Exercises: Continue tendon and nerve gliding exercises, increasing the frequency and intensity as tolerated.
• Scar Tissue Mobilization (if applicable): If there is any scar tissue present due to surgery, gentle scar mobilization techniques can be used to improve tissue mobility and reduce pain.
• Ergonomic Modifications: Continue to reinforce proper ergonomic principles at home and at work. Ensure workstation setup is optimized to minimize wrist strain.
• Proprioceptive Exercises: Begin proprioceptive exercises to improve hand awareness and coordination. Examples include:
  • Object manipulation
  • Picking up small objects

Phase III: Return to Function (Chronic Phase – Approximately 8+ weeks)

Goals:

• Return to pre-injury activity level.
• Maintain strength, ROM, and flexibility.
• Prevent recurrence of symptoms.

Interventions:

• Activity-Specific Training: Gradually reintroduce activities that were previously limited due to CTS. Modify techniques as needed to minimize wrist strain.
• High-Repetition Endurance Exercises: Focus on building endurance for repetitive hand and wrist movements.
• Advanced Strengthening Exercises: Continue strengthening exercises, increasing the weight or resistance as needed to meet functional demands.
• Ergonomic Education and Reinforcement: Continue to emphasize the importance of proper ergonomics and activity modification to prevent recurrence.
• Self-Management Strategies: Educate the patient on self-management techniques, including:
  • Regular stretching and strengthening exercises.
  • Proper posture and body mechanics.
  • Early recognition and management of symptoms.
• Functional Capacity Evaluation (FCE): If necessary, a FCE can be performed to assess the patient's ability to perform job-related tasks.

Common Special Tests for Carpal Tunnel Syndrome

• Phalen's Test: The patient flexes both wrists and holds them together for 60 seconds. A positive test is indicated by the reproduction of paresthesia in the median nerve distribution.
• Tinel's Sign: The examiner taps over the median nerve at the wrist. A positive test is indicated by the reproduction of paresthesia in the median nerve distribution.
• Carpal Compression Test: The examiner applies direct pressure over the carpal tunnel for 30 seconds. A positive test is indicated by the reproduction of paresthesia in the median nerve distribution.
• Semmes-Weinstein Monofilament Testing: Assesses sensory thresholds in the hand to detect nerve compression.

Disclaimer: This protocol is a general guideline and should be adapted to meet the specific needs of each individual patient. Consult with a qualified healthcare professional for personalized treatment recommendations.