hand pain/ sensory deficits- Carpal Tunnel CPG

Question 1

What diagnostic test should you do with a suspected carpal tunnel patient?

Answer 1

A evidence
Semmes- Weinstein Monofilament Testing (SMWT)- 2.83 or 3.22 for threshold of normal light touch and static 2PD (2 point discrimination) on middle finger
For mod- severe- use 3.22 to any radial finger for threshold for normal

Question 2

What tests and measures can you administer for those suspected to have CTS

Answer 2

B evidence

Katz Hand diagram, Phalen test, Tinels sign, and carpal compression test

Question 3

What other subjective and objective measures should you document for patients with CTS

Answer 3

1. Age ( > 45 years)
2. Whether shaking hands relieves their symptoms
3. Sensory loss of the thumb
4. Wrist ratio index ( >.67)
5. Boston Carpal Tunnel Questionarre and Symptom Severity Scale (CTQ-SSS)- > 1.9
   Presence of 3 or more findings = acceptable diagnostic accuracy

Question 4

What recommendation can be made about UL Neurodynamic tests? Scratch- collapse test? Tests of vibration?

Answer 4

Conflicting evidence- therefore no recommendation can be made

Question 5

What are the outcome measures recommended for CTS? What if the patient is electing for non- surgical management?

Answer 5

B evidence

1. CTQ- SSS- only one recommended for non surgical management
2. CTQ- FS (Carpal tunnel questionnaire- functional scale)
3. DASH (Disability of the Arm and Shoulder)

Question 6

What physical performance measures are recommended for those with CTS? Surgery versus non- surgery?

Answer 6

C evidence
Surgery: DMPUT- Dellon- Modified Moberg Pick up Test
Non- surgery: PPB (Purdue Peg board)
Others: Jebsen Taylor Hand Function Test, Nine- Hold Peg Test

Question 7

What recommendations are made about lateral pinch?

Answer 7

A evidence

Should NOT be used

Question 8

What recommendations can be made for assessing grip strength following CTS?

Answer 8

B evidence

Should NOT be used when assessing short term <3 mo.

Question 9

What recommendation can be made about grip strength and 3 point or tip pinch strength in suspected CTS? Post surgery?

Answer 9

C evidence- Can be used in suspected patients

D evidence- conflicting evidence following surgery

Question 10

What recommendations are made regarding provocation testing for those with non- surgical/ surgical managed CTS?

Answer 10

C- NOT to use vibration/ threshold tests for non- surgical patients, Phalens test for surgical patients
D- conflicted evidence for 2 point discrimination and threshold testing for surgical patients

Question 11

What recommendations can be made about assistive technology for patients with CTS

Answer 11

C evidence-

Alternative strategies- use of arrows, touch screens, alternating mouse hand, keyboards with reduced strike force

Question 12

What orthosis recommendation can be made for CTS

Answer 12

B evidence
Neutral wrist position- worn at night for short term relief
C evidence
Can adjust wear time including day time, symptomatic, or full- time use when night- only is ineffective
can also add MCP joint immobilization to modify wrist position if no relief
Can be used for pregnant patients

Question 13

What Biophysical Agents SHOULD/ CAN you use for CTS?

Answer 13

C evidence

1. Trial of superficial heat for short- term relief
2. Microwave shortwave diathermy- mild to moderate idiopathic CTS
3. Trial of IFC for short- term relief- without pacemakers for mild to moderate CTS
4. Phonophoresis with non- surgical management

Question 14

What biophysical agents should NOT be used for CTS?

Answer 14

B evidence:

1. Iontophoresis- for mild/ moderate CTS
2. Low level Laser Therapy- or other non- laser light therapy
3. Magnets

C evidence:
4. Thermal Ultrasound- for mild/ moderate CTS

Question 15

What recommendation can be made about non- thermal U/S?

Answer 15

Conflicting evidence- no recommendation can be made

Question 16

What recommendation is made for manual therapy for CTS?

Answer 16

C evidence
cervical spine and upper extremity
D evidence
Neurodynamic mobilization- conflicting evidence

Question 17

What recommendations are made regarding therex for CTS?

Answer 17

C evidence

Combined orthotic/ stretching program for those with mild/ moderate CTS without thenar artopthy and normal 2PD

Question 18

What is the prevalence for men versus women for CTS?

Answer 18

Women 2X more than men

Question 19

What forms the carpal tunnel?

Answer 19

Carpal bones and the transverse carpal ligament

Question 20

What tendons pass thru the carpal tunnel?

Answer 20

(4) FDS- Flexor digitorum superficialis
(4) FDP- Flexor digitorum profundus
Single tendon from FPL- Flexor Pollicus longus

Question 21

What is the most superficial structure in the carpal tunnel?

Answer 21

Median nerve

Question 22

What do the sensory branches do the median nerve innervate?

Answer 22

Thumb, index finger, middle, and radial half of the ring fingers

Question 23

What motor branches do the median nerve innervate?

Answer 23

the first and 2nd lumbrical muscles
Opponens pollicus
ABP- abductor pollicus brevis
Superficial portion of the flexor pollicus brevis

Question 24

What nerve innervates the thenar eminence/ carpal tunnel?

Answer 24

Palmar cutaneous branch- branches off median nerve 5cm proximal to wrist

Question 25

What nerve innervates the area of the scaphoid tubercle?

Answer 25

Lower antebrachial cutaneous

Question 26

What is the blood supply to the median nerve

Answer 26

Radial and ulnar arteries

Question 27

Other than the classic signs, what are some of the pathoanatomical features seen with CTS?

Answer 27

Can see pain, proximal to shoulder, elevated carpal tunnel pressure, ischemic nerve changes, and compression from adjacent structures

Question 28

What are some factors that lead to poor outcomes for non- surgical management?

Answer 28

Longer symptom duration, + phalen test, thenar eminence muscle wasting

Question 29

What are the best predictors for success for non- surgical management of CTS?

Answer 29

Shorter symptom duration ( < 1 year) | Lower severity of night- time symptoms

Question 30

What is the leading cause of Acute CTS? Other causes?

Answer 30

Distal radius fractures | Spontaneous bleeding, thrombosis, dislocation of metacarpal base, infection, pregnancy, fracture

Question 31

What intrinsic risk factors have the strongest link to CTS?

Answer 31

Obesity, age, female sex Risk increases linearly with MRI and doubles with BMI > 30 kg/m, and in those > 50 y/o Female sex increases by 1.5-4X

Question 32

What are some other intrinsic risk factors associated with CTS but to a lesser extent?

Answer 32

DM, OA, musculoskeletal disorders, estrogen replacement therapy, CV disease risk factors, hypothryoidism, family h/o CTS, lack of activity, wrist ratio > .70, wrist palm ratio > .39, short wide hand, short stature

Question 33

What are some conflicting risk factors with CTS?

Answer 33

RA, smoking, alcohol abuse, oral contraceptive use, menopause, parity, hysterectomy, or oophorectomy q

Question 34

What occupational risk factor had the strongest association with CTS?

Answer 34

Forceful hand exertions Weaker associations with high psychological demand paired with low decision authority, vibration, prolonged off neutral wrist position, repetitive work Computer users- not at increased risk

Question 35

What are some differential diagnostics for CTS?

Answer 35

Cervical radiculopathy, TOS, diabetic/ polyneuropathy, other median neuropathies- like pronator teres syndrome, ulnar and radial tunnel syndrome, ALS, MS