Neuromuscular and nervous systems clinical application- Carpal Tunnel Syndrome

Question 1

carpal tunnel syndrome (6) is created by structures of the wrist?

Answer 1

transverse carpal ligament
scaphoid tuberosity and trapezium
hook of hamate and pisiform
volar radiocarpal ligament and volar ligamentous extensions b/t carpal bones

Question 2

what ligaments (2) create carpal tunnel syndrome?

Answer 2

transverse carpal ligament
volar radiocarpal ligament and volar extensions between the carpal bones

Question 3

what bony structures (4) create carpal tunnel syndrome?

Answer 3

scaphoid tuberosity and trapezium
hook of hamate and pisiform

Question 4

what structures (10) pass through the carpal tunnel?

Answer 4

median nerve
4 flexor digitorum profundus tendons
4 flexor digitorum superificialis tendons
flexor pollicis longus tendon

Question 5

carpal tunnel occurs as a result of compression to what structure where it passes through the carpal tunnel?

Answer 5

median nerve

Question 6

normal tissue pressure within the carpal tunnel is __-__ mm Hg

Answer 6

2-10

Question 7

carpal tunnel syndrome can result in tissue pressure within the carpal tunnel greater than __ mm Hg

Answer 7

30

Question 8

carpal tunnel syndrome can result in tissue pressure within the carpal tunnel greater than 30 mm Hg that further increases with __ and __ of the wrist

Answer 8

flexion and extension

Question 9

increase in tissue pressure within the carpal tunnel greater than 30 mm Hg produces __ in the median nerve

Answer 9

ischemia

Question 10

increase in tissue pressure within the carpal tunnel greater than 30 mm Hg produces ischemia in the median nerve, resulting in __ and __ disturbances in the median nerve distribution of the hand

Answer 10

sensory and motor

Question 11

is there an exact known etiology of carpal tunnel syndrome?

Answer 11

no, it is unclear

Question 12

although there is no exact known etiology of carpal tunnel syndrome conditions that produce __ of the carpal tunnel can contribute to CTS

Answer 12

inflammation

Question 13

what conditions (13) can contribute to CTS?

Answer 13

repetitive use
rheumatoid arthritis
tumor
pregnancy
diabetes
trauma
hypothyroidism
wrist sprain/fracture
edema
inflammation
fibrosis
congenital narrowing of the tunnel
vitamin B6 deficiency

Question 14

most patients are diagnosed with CTS between __-__ years of age, with greater prevalence in men/women

Answer 14

35-55
women

Question 15

what will a patient with carpal tunnel syndrome initially present (2) with?

Answer 15

sensory changes
paresthesias within the median nerve distribution of the hand that may radiate into the UE, neck and shoulder

Question 16

what are the symptoms (6) of carpal tunnel syndrome?

Answer 16

night pain
weakness of the hand
muscle atrophy
decreased grip strength
decreased wrist mobility
clumsiness

Question 17

muscle atrophy associated with carpal tunnel syndrome is often initially noted in the __ __ __ muscle and progresses to the __ muscles

Answer 17

abductor pollicis brevis; thenar

Question 18

what imaging studies can confirm carpal tunnel syndrome?

Answer 18

electromyography and electroneurographic studies
MRI

Question 19

what type of imaging (2) can be used to diagnose a motor conduction delay along the median nerve within the carpal tunnel?

Answer 19

electromyography and electroneurographic studies

Question 20

what type of imaging is sometimes used to identify inflammation of the median nerve, altered tendon or nerve positioning within the tunnel or thickening of the tendon sheath?

Answer 20

MRI

Question 21

what specifically are electromyography and electroneurographic studies used to diagnose related to carpal tunnel syndrome?

Answer 21

motor conduction delay along the median nerve within the carpal tunnel

Question 22

what specifically is an MRI study used to identify (3) related to carpal tunnel?

Answer 22

inflammation of the median nerve
altered tendon or nerve positioning within the tunnel
thickening of the tendon sheath

Question 23

what additional information should be obtained to confirm diagnosis of carpal tunnel syndrome?

Answer 23

physical exam
history
review of symptoms

Question 24

what type (1) of testing (3) along with other symptoms will assist to confirm the diagnosis of carpal tunnel syndrome?

Answer 24

provocation testing-
Tinnel’s
Phalen’s
tethered median nerve stress test

Question 25

what subjective history (9) should be documented for a patient with diagnosed/suspected carpal tunnel syndrome?

Answer 25

PMH medications h/o symptoms current health status social history/habits occupation living environment social support system leisure activities

Question 26

what objective tests/measurements (13) should be performed during an examination of a patient with diagnosed/suspected carpal tunnel syndrome?

Answer 26

A&O pain perception assessment scale environmental/home and work barriers/hazards (current and potential) community and work integration A/PROM joint integrity and mobility: hypomobility, swelling/inflammation, Tinel's sign, Phalen's test, tethered median nerve stress test body mechanics: dexterity and coordination muscle strength assessment (including hand mm) wrist and hand circumferential measurements skin and nailbed assessment sensation assessment potential utilization of splinting/bracing functional assessment

Question 27

what symptoms (3) can arise with advanced CTS?

Answer 27

muscle atrophy of the hand radiating pain in the forearm and shoulder nerve damage with motor and sensory loss

Question 28

unrelieved compression of the median nerve where it passes through the carpal tunnel creates initial __ with some __ of the axons

Answer 28

neurapraxia; demyelination

Question 29

unrelieved compression of the median nerve where it passes through the carpal tunnel creates eventual __ and __ degeneration within the nerve distribution

Answer 29

axonotmesis; Wallerian

Question 30

neurapraxia

Answer 30

mildest form of acute peripheral nerve lesion/injury in which there is a conduction block due to myelin dysfunction but axon is preserved

Question 31

nerve conduction is preserved __ and __ to a peripheral nerve lesion resulting in neurapraxia

Answer 31

proximal and distal

Question 32

a peripheral nerve lesion/injury resulting in neurapraxia typically recovers __ and __ within __-__ weeks

Answer 32

rapidly and completely within 4-6 weeks

Question 33

axonotmesis

Answer 33

a peripheral nerve lesion/injury that is more severe than neurapraxia resulting in damage to axons with preservation of the connective tissue sheath and supporting structures

Question 34

axontmesis is a reversible/irreversible peripheral nerve injury

Answer 34

reversible

Question 35

axontmesis can result in distal __ degeneration

Answer 35

Wallerian

Question 36

the peripheral nerve damaged via axonotmesis can regenerate __ to the site of the lesion at a rate of __ mm/day

Answer 36

distal; 1

Question 37

recovery from axonotmesis is variable, ranging from __ to __ recovery and __ may be required for repair

Answer 37

spotty to no recovery; surgery

Question 38

Wallerian degeneration

Answer 38

peripheral nerve degeneration to the myelin sheath and axon that occurs distally to site of injury/lesion; occurs due to axonotmesis

Question 39

initial type of management of CTS?

Answer 39

conservative

Question 40

what does initial conservative management of CTS include (3)?

Answer 40

local corticosteroid injections splinting with neutrally positioned wrist orthosis physical therapy management

Question 41

recent pharmacological management of CTS includes what pharmocological agent? how is it administered?

Answer 41

Methylprednisone injections proximal to the carpal tunnel

Question 42

methylprednisone injections have recently been incorporated into pharacological management of carpal tunnel syndrome and are injected __ to the carpal tunnel

Answer 42

proximal

Question 43

what does physical therapy initially include (3-6) for a patient with CTS?

Answer 43

spinting carpal mobilization gentle stretching *may include biomechanical analysis and adaptation of occupation, work place, leisure activities and living environment

Question 44

if conservative management fails, the patient may require what?

Answer 44

surgery for carpal ligament release and median nerve decompression

Question 45

newer carpal ligament release/median nerve decompression surgical techniques allow for what 3 positive outcomes?

Answer 45

smaller incisions less manipulation of the median nerve highly successful for long-term symptom relief

Question 46

what does post-surgical physical therapy following carpal ligament release/median nerve decompression initially include (6)?

Answer 46

moist heat with e-stim cryotherapy gentle massage scar desensitization tendon gliding exercises AROM

Question 47

what modalities (2) are initially recommended for post-carpal ligament release/median nerve physical therapy?

Answer 47

moist heat with e-stim cryotherapy

Question 48

initially following carpal ligament release/median nerve decompression a patient should avoid what movements/actions?

Answer 48

wrist flexion forceful grasp

Question 49

a patient can progress their physical therapy program from initial interventions __ weeks following carpal ligament release/median nerve decompression

Answer 49

4

Question 50

progress of a patient's physical therapy program from initial interventions 4 weeks following carpal ligament release/median nerve decompression includes what interventions (5)?

Answer 50

active wrist flexion gentle stretching putty exercises light, progressive resistive exercise continued body mechanics modificaitons

Question 51

active wrist flexion can be incorporated into a patient's physical therapy program __ weeks following carpal ligament release/median nerve decompression

Answer 51

4

Question 52

light, progressive resistive exercise can be incorporated into a patient's physical therapy program __ weeks following carpal ligament release/median nerve decompression

Answer 52

4

Question 53

4 weeks following carpal ligament release/median nerve decompression, __ __ against gravity should be avoided due to tendency for irritation and inflammation

Answer 53

radial deviation

Question 54

post-surgical rehab following following carpal ligament release/median nerve decompression typically lasts __-__ weeks

Answer 54

6-8 weeks

Question 55

what should an initial home exercise program for a patient with CTS include (4)?

Answer 55

continued stretching and strengthening avoiding active wrist flexion and radial deviation against gravity splint compliance work/leisure modification compliance

Question 56

physical therapy intervention should improve a patient's condition and reduce symptoms of CTS within __-__ weeks

Answer 56

4-6

Question 57

CTS can have __ longterm effects on some patients while having __ effects of others?

Answer 57

minor to no, debilitating

Question 58

if a patient does not respond positively to the rehabilitation process, it is possible for longterm effects of CTS including?

Answer 58

permanent motor and sensory impairment along the median nerve distribution

Question 59

what is a common differential diagnosis to CTS?

Answer 59

ulnar nerve compression in the tunnel a guyon

Question 60

pathology of ulnar nerve compression in the tunnel of guyon?

Answer 60

inflammation to the ulnar nerve between the hook of hamate and pisiform

Question 61

what are common MOIs (4) resulting in ulnar nerve compression in the tunnel of guyon?

Answer 61

leaning during extended handwriting leaning on bike handles while riding repetitive gripping activities trauma

Question 62

what will a patient with ulnar nerve compression in the tunnel of guyon initially present with (4)?

Answer 62

paresthesias along the ulnar nerve distribution weakness and atrophy of the hypothenar musculature decreased pisiform mobility impaired grip strength

Question 63

how is ulnar nerve compression in the tunnel of guyon managed?

Answer 63

conservative intervention of surgical intervention