you should know about carpal tunnel syndrome
Carpal tunnel syndrome is the most neuropathy which occurs in the upper limbs where there is compression of the median nerve that passes through the carpal tunnel / carpal tunnel. The neuromuscular disorders experienced by a number of people where the incidence increases to workers who perform activities to be repetitive wrist movements. Many studies investigating the pathophysiology, diagnosis and treatment of this syndrome. However, neuromuscular mechanisms involved are still not known. Diagnosis is more sensitive and capable of detecting multiple compression events (columna vertebral cervical and carpal tunnel syndrome) which matches the treatment are still experiencing difficulties (Karolezak, 2005).
Carpal tunnel syndrome is the most common neuropathy, in which the median nerve compression that passes through the carpal tunnel. The main symptoms associated with CTS ie burning pain sensation at night, paresthesia and thenar muscle atrophy, activity limitations and inability to work (Karolezak, 2005).
This syndrome can occur after a hand doing strenuous activity or repeated or it could be followed by a wrist injury such as a fracture, dislocation, but often also no significant history of trauma.
Data The National Center for Health Statistics United States in 1994 that 849,000 patients visit the doctor as suffering from neuropathy problems on the median nerve. NOTE: The Bureau of Labor of Statistics in 1994, showed that 1.7 percent is a condition associated with the workplace. Factors contributing to CTS include repetition, force / strength, mechanical stress, posture, vibration and temperature (Strickland, 2001).
Workers on an assembly and packaging, users rarely use the computer and the working tools are the most likely of developing this syndrome, especially women aged 30 to 60 years. Especially in those who are pregnant or after the klimaterium.
Can also be found in patients with myxoedema, wrist joint arthritis, gout and bone degeneration with an unknown cause (Subagiartha, 2000).
Paresthesias, hypesthesia and arthralgia felt in the fingers, especially the surface of the fingertip. Fingers feel stiff in the morning. After the hands and fingers moved about, stiffness and pain can be eased, but paraesthesia or hypesthesia on the fingertips are still felt. Goods are held often in spite unwittingly (Subagiartha, 2000).
Carpal tunnel syndrome is not always uniform. The most common and easily recognized are the symptoms of numbness of the fingers when you wake up the morning, can also be accompanied by a burning sensation or tingling. The fingers are the fingers on the volar surface innervated by the median nerve. Many patients tell that the taste subside or disappear when his hands moved about or elevated (Subagiartha, 2000).
Physiotherapy problematic arising from CTS include; Impairment is pain, numbness / thick, tingling in the palms of your hands until the fingers part palmar accordance with the distribution of innervation nerve median, a potential decrease LGS wrist and fingers, functional limitation that their disorders perform daily activities involving wrist hands like washing, ironing, sweeping and others.
To overcome these problems associated with CTS can use various modalities of physiotherapy among others, with Ultra Sound (US), the median nerve stretching, therapeutic manipulation of the left hand. With the modalities given to people, is expected to help reduce the problems arising from the case so that patients can use to move his wrist back to normal.
Management CTS grouped into two, namely, treatment operative and non-operative. Operative therapy is usually given to patients with severe CTS symptoms of persistent, severe sensory disturbances, and / thenar motor weakness. Non-operative therapy given to patients with mild to moderate CTS with intermittent symptoms. Non-operative therapy may include use of splints, stretching the nerves, hand manipulation therapy, therapeutic ultrasound (US), activity modification, oral medications, etc. (Currier, 1998).
Therapeutic ultrasound is a physical therapy modalities are commonly used to improve the network of temperature, the effect of the US on the network is a change in blood flow, tissue metabolism, nerve function, and extensibility of connective tissue. The increase in temperature by the US would increase the pain threshold in humans. Increased temperatures also affect nerve regeneration. Heating and mechanical effects of the heating process by the US affects the ability of nerve fibers to enhance the action potential. However, the physiological mechanisms for continuous application US will increase nere conduktion veloxity (NCV) (Oztaz, 1998).
Ebenbicher et al (1998) conducted a controlled clinical trial to evaluate the therapeutic use of US in patients with mild to moderate bilateral CTS. Found that US treatment provides anti-inflammatory effect, stimulation of nerve regeneration and conduction that will facilitate the recovery of nerve compression. US therapy provides short-term effect on the reduction of pain in patients with mild to moderate CTS (Ebenbichler, 1998). While Halle JS (1981), Consentino AB (1983) and Ozgur Oztas et al (1998) in his research to get a different result that US therapy did not leave a change in nerve conduction velocity (Oztas, 1998). They concluded that the US treatment does not cause a significant effect on the recovery of nerve conduction. To get the goal as expected, then do exercise therapy (median nerve stretching), and the left hand manipulation therapy. With the provision is expected to help reduce the complaints in patients with CTS.
1. Does the Ultra Sound (US) effect to reduce pain in conditions of Carpal Tunnel Syndrome?
2. Are Stretching and influential hand manipulation therapy to reduce pain in conditions of Carpal Tunnel Syndrome?
1. The general objective
a. To disseminate information on the condition physiotherapy Carpal Tunnel Syndrome among medical.
b. Adding insight among physiotherapists.
2. Special Purpose
1. To know the benefits of Ultra Sound on condition Carpal Tunnel Syndrome in reducing pain.
2. To determine the benefits of stretching and hand manipulation therapy on the condition of Carpal Tunnel Syndrome in reducing pain.
A. Description of Cases
Carpal Tunnel Syndrome (CTS) is a collection of symptoms due to compression of the median nerve in the carpal tunnel when through (carpal tunnel) in the wrist. The manifestation of this syndrome are pain and tingling (paraesthesia) (Sidharta, 1996).
According to Samuel, 1999 CTS is a pressure neuropathy / compression of the median nerve in the carpal tunnel at wrist hand, in this case precisely in the bottom left hand flexor retinaculum. Carpal tunnel located in the central part of the wrist where the bone and ligaments form a narrow tunnel through which some of the tendons and the median nerve. The bones karpalia form the base and sides of the tunnel are hard and rigid while the roof is formed by the flexor retinaculum (transverse carpal ligament and palmar carpal ligament) is strong and arched over the karpalia bones. Any changes that narrows the tunnel will cause pressure on the most vulnerable structures in it that the median nerve.
2. Anatomy and Biomechanics Wrist
Wrist Joint composed by three bones: the radius bone, the ulna bone and carpal bones. Where the carpal tunnel wrist lies a skeleton in the form of the eight carpal bones are composed of two rows. Rows consists of a proximal (lateral and medial: naviculare, lunate, triquertum, and pisiformis). Rows of distal (trapezium, trapezoideum, capitatum and hamate). Carpal bones of the hand arcing arrangement with the concave part facing toward the palm. The room is covered by a transverse ligament carpi forming a narrow waterway called the carpal tunnel.
The carpal tunnel contains many structures, namely:
a. Four tendon of the m. flexor digitorum superficialis
b. Four of m. flexor digitorum profundus
c. The tendon of the m. flexor pollicis longus
d. The median nerve (De Wolf, 1994)
When movement flexi dorsal wrist muscles that work are: m. extensor carpi radialis longus, m. extensor carpi radialis brevis, m. extensor digitorum communis, m. digiti minimi, m. extensor pollicis longus and m. extensor indicis. Where the motion is in the sagittal plane with distance joints normally 0-90º. When flexi wrist palmar movement of muscles that work is m. flexor carpi radialis, m. carpi ulnar assisted by m. palmar lonus, m. flexor pollicis longus and m. flexor digitorum profundus. Where the motion is in the sagittal plane with distance joints normally 0-90º. So the range of motion of wrist-0-90º 90º sagittal plane. When motion Radio-Ulnar Deviation, 0º initial position when the forearm and finger 11 (index) in a straight line radial deviation (abduction palms facing forward in anatomical position) and ulnar deviation (adduction) 30º, 20º-0-30º written.
The median nerve, formed from the fasciculus lateralis origin roots C5, C6, C7 and C8 and T1 medial fasciculus. The median nerve above the elbow does not have branches to the elbow joint articular or muscular branches innervate pollicis longus, pronator Quadratus. After giving branches to the muscles of the forearm to the various movements of the arms and fingers below the ligament carpi transverse nerve median forked, the lateral (motor) mempersyarafi muscle abductor pollicis brevis, flexor pollicis brevis, the opponent pollicis and muscle lumbricalles unity and second, being the medial branch (sensory) mempersyarafi part volar radius of 1, 2, 3 and ½ finger to 4 (lateral side) and the central part until the radial side also dipersyarafi by n. the median.
Basically any situation that causes stress / compression of the median nerve in the carpal aisle can be an etiology of CTS. CTS is caused by: (1) Idiopathic, (2) thickening of connective tissue such as arthritis (RA, OA), (3) metabolic disorders, (4) Trauma, can be chronic wrist due to over use, (5) Heriditer form of narrowness carpal tunnel.
Characteristics of CTS is an increased numbness in the fingers when I wake up the morning with tingling / burning, motor disorders fingers, pain in the joints interphalangeal and hipotropi thenar muscles on further conditions (Sidharta, 1996).
Incidents in this case are: (1) More women than men (10: 1), (2) Age most 40-50 years, (3) The incidence of approximately 515/10000 population (Parjoto, 2000).
5. Changes Pathology
Muscle contraction repeatedly or continuously and static will cause spasm, so that the blood circulation is not smooth. This will cause a buildup of lactic acid and chemicals such as bradykinin, and histamine. With the accumulation of these substances will stimulate sensory nerve endings or nerve pain (nociceptors) and will be delivered to the spinal cord nerves further by acendent delivered to the brain and be interpreted ie pain. With the earlier pain can lead to muscle spasm which is the protection of their pain, and the patient will limit pergerakkannya especially that cause pain. Furthermore, in the long term may arise muscle weakness that eventually lead to impaired function and motion associated with the function of the left hand.
CTS occurs when the median nerve compressed in the carpal tunnel anatomical structure. Compression can be caused by the increased volume of the carpal tunnel, the median nerve enlargement, or reduction in cross-sectional area of the carpal tunnel. The third cause of this, which is the most common cause is the increased volume of the carpal tunnel, but what is the cause of the increase in volume is still unclear to this day. Allegedly one of the causes is tenosynovitis due to repetitive trauma (Phallen, 1951; Nissen, 195; Hybinette, 1975). Flexi-extension movement repeatedly and continuously in the wrist and fingers will increase the pressure on the tendon that causes tenosynovitis and in turn causes compression of the median nerve. Fuchs, Nathan, and Mayers (1991) found an inflammatory process in 10% of patients, whereas Faithull, Moir and Ireland (1986) found the existence of edema in 7% of patients (Cailliet, 1994).
Mild compression on the peripheral nerves will decrease the blood flow epineural. Axonal transport will be disrupted, due to axonal compression pressure in endoneural will increase and lead to paresthesia. By Caillet (1988) This nerve disorder dikategoriksn into two stages, namely (Caillet, 1994):
Distention of capillaries intrafasikuler will increase the pressure intrafasikuler causing constriction of capillaries. Furthermore, disruption of nutrients and hyperexcitability of nerve fibers. If continuous pressure to disrupt the venous circulation, edema will occur, causing further neurological disorders.
Capillary compression occurs, causing anoxia and result in damage to the capillary endothelium. Protein into the tissues and cause edema further. Protein can not exit through the perineurium resulting in accumulation of fluid in endoneurial that will inhibit axonal metabolism and nutrition. Fibroblast proliferation caused by ischemia and scarring that will cause kontriksi surrounding soft tissue. At this late stage, nerve lesions may be irreversible and cause permanent sensory and motor Gannguan.
6. Clinical Signs And Symptoms
Generally, complaints arise gradually and specific are:
a. Pain in the hand that usually occur in the evening or early morning and people often wake up because of pain. Patients are often on their own resolve complaints by raising his hand layout, by gesticulating or rub, it turns out the pain can be reduced. Complaints also dropped when the hand / wrist more rest and vice versa.
b. Numbness, tingling, lacking taste or menggeleyar (such as taxable strom) usually finger 1, 2, 3 and ½ finger to 4 but never a complaint on 5th finger.
c. Sometimes the pain can be felt in the upper arm and neck, but the numbness, tingling confined to the distal wrist only.
d. The fingers, hands and wrists were swollen and stiff, especially morning and disappeared after the grind.
e. Movement of the fingers are less skilled, for example embroider / picking up small objects.
f. There are also patients who present with his palm muscles shrink and more and more shriveled.
Signs can be found by Sidharta (1996) in general is:
a. Test positive tinnel
b. Pain in the joints interphalangeal
c. Weakness of the muscles that disyarafi the median nerve (advanced stage).
d. Hipotropi muscles thenor a further manifestation
7. Classification CTS
CTS classification based electrodiagnostic studies (Padua et al, 1997)
Degree classification Electrodiagnostics Inspection Results
Grade 1 Very mild
(Very mild CTS) Standard test normal
Comparative test abnormal
Grade 2 Mild
(Mild CTS) Sensory abnormal
Grade 3 Medium
(Moderate CTS) Sensory and motor abnormal
Grade 4 Weight
(Severe CTS) no sensory response
Abnormal distal motor latency
Grade 5 Very heavy
(Extreme CTS) No response to sensory and motor
According Kazt (1990), the diagnostic criteria are based on clinical experience the paneliti, many patients symptoms are found on the border of grade classification to one another.
a. 0. degrees Asymptomatic
1) There are no signs or symptoms of CTS
2) Examination of sensory and motor nerve conduction abnormalities may be found in about 20% of the population
3) Does not require therapy
b. 1. Symptomatic Intermittent degrees
1) paresthesia wiper arm
2) There is no neurological deficit
3) One possible provocation test positive
4) Examination of sensory and motor nerve conduction may be normal
5) Conservative therapy
c. Degree 2. Persistent Symptomatic
1) neurologic deficits in accordance with the distribution of the median nerve
2) provocation tests positive
3) Examination of sensory and motor nerve conduction abnormal
4) conservative or operative therapy
d. Degrees 3. Weight
1) thenar muscle atrophy
2) Examination elektromiografis: fibrillation or motor neuropathy unit
3) Operative Therapy
Complications that may arise in the Carpal Tunnel Syndrome (CTS) due to compression, among others: (1). Athrofi thenar muscles, (2). Sensory loss on the radial part of your palm and palmar sides of the first three fingers, (3). Deformity "ape hand" (the thumb of a plot by hand and athropi muscles thenar), was not able to distance or memflexikan thumb / do abduction in his own field, gengggaman hand weakened, especially the thumb and index finger, and these fingers tend to hold hyperextensi and thumb abduction, unable to flex the distal phalank thumb and forefinger.
9. Medical Diagnostics
Medical diagnosis is a diagnosis given by the doctor. In the examination of motion found their pain left wrist area median flexi, Phalen test and test tinnel. The entire examination of the above done on both hands, so in this case as a medical diagnosis of Carpal Tunnel Syindrome Sinistra.
The majority of the patients complained about pain pinned CTS-interphalangeal joints. Hypertrophy thenar muscles is a further manifestation of the CTS. Reynold phenomenon occasionally found in patients with CTS. In mild cases of CTS with conservative therapy prognosis is generally good, the general prognosis is also good postoperative (18 months). The complications that arise after surgery found their weakness and loss of sensibility persistent disribusi area of the median nerve. The most severe complication is reflex sympathetic dystrophy that is characterized by severe pain, hyperalgesia, disestesia and trophic disorders. Although the prognosis of CTS with conservative therapy is quite good, but the risk for recurrence remains. In case of recurrence, the procedure either conservative or operative treatment can be repeated.
B. Management of Physiotherapy on condition Carpal Tunnel Syndrome Sinistra
Specific checks checks are performed to support the diagnosis such as Phalen's Test, Test Tinnel, Prayer Test, Test discriminatory 2 points, etc.
1) Phalen's test
Wrist sufferers maintained for approximately 30 seconds in full palmar flexi position. And the results revealed positive results that indicate pain.
2) Thinnel test
This test supports the diagnosis if there is paraesthesia or pain in the median nerve distribution when performed percussion on the carpal tunnel hand position slightly dorso flexion. And the results obtained from the test above is positive.
3) Phrayer test
Extend the wrist with maxsimal custody for 30 seconds and then release it will be pain in the wrist and the results of the examination conducted by the author shows positive results.
4) Discrimination 2 points
By looking at the weak yamg sensory nerve distribution medisnus using two pointy objects, but from the tests carried out are widening the distance between the two points ..
a. The mechanism of occurrence of problems: explain how a complaint journey experienced by the patient.
1. Description Problems Physiotherapy
In patients with Carpal Tunnel Syndrome (CTS) will arise the problems such as: network-level disruption and functional disorders. Impaired network level (impairment) in the form of: 1) The pain that arises especially at night / early morning until the patient is awake. This pain is caused due to chronic inflammation of the carpal tunnel until there is irritation of the median nerve. 2) The existence of numbness and tingling (burning) in the palm of the hand to the fingers on a hand kirinyan 1-3, while functional disorders (functional limitation) are often found in patients with CTS is patient decreased activity everyday hand function, eg activity holding fork at meals, washing clothes, hair tie, cooking, wipe, buttoning clothes, while wearing a bra, and when to thread a needle.
Disability: Potential disruptions functional activities that require mobility of his left hand, for example, because the happy mother sewing, because it hurts the quality function decreased left hand while holding the needle, the patient deteriorated when the activity in the kitchen as a housewife, and others.
2. Physiotherapy Program
a. Interest Physiotherapy
1) Short-Term Objectives:
a) Reduce the pain in his left hand
b) Reduce numbness and tingling in his left hand
2) Long-Term Goals:
a) Restoring the ability of hand optimally functional activities
b) Prevent re-traumatization
b. Intervention technology
Intervention must be in accordance with the needs of the patient or the patient's main complaint. In order to do next intervention patients can do so with a sense of comfort and fit on the end goal to be achieved. Then interventions that can be provided include:
Ultra Sound can reduce pain, reduction of pain in getting from thermal effects. The structure of the carpal area is composed of bones, ligaments, tendons, and muscles all of which shaped electrical modalities physiotherapist hard so that penetration can penetrate hard tissue is ultra sound.
a. The use of pain with ultra sound
Value threshold of stimulation will be increased after the administration of ultra sound with an intensity of 1.5 W / cm2 for 5 minutes. The mechanism of the installation of heat effects (Lehman, 1998). Liberation of histamine (Dyson, 1998) fibrasi effect of ultrasound on pain gate (Palag, 1998), and a US trial found usage with low pulse can stimulate spending or release of histamine (Dyson, 1998). Histamine causes dilation of local blood vessels, causing acceleration cleaning substances or chemicals that can cause pain.
b. The effects obtained from an ultrasound, among others:
1) Effect of Mechanical
The effect was first obtained by the body is the mechanical effects of Ultra Sound Waves cause the stretching and sealing in the network with the same frequency as the frequency of ultra sound.
Therefore, the stretching and the sealing will result in:
a) Changes in volume of the body's cells by 0.02%
b) Changes in permeability of the cell membrane and membrane tissues.
c) Simplify the process of metabolism.
2) Heat Island Effect
Effect of heat is the result micromassage. How much effect the heat produced is not the same for each tissue depends on several factors that can be determined, for example: ultra sound application form (continuous or intermittent), duration of therapy, intensity. Besides, the absorption coefficient also play a role in this regard. 'Lehman' suggests that the Ultra Sound Award at a dose of 1 Watt / cm2 in continyu in muscle tissue will raise the temperature of 0.070 / sec.
3) Biological Effects
The biological effect is seen as an answer to the effect mekanikl and thermal influences.
The effects were obtained:
a) Increases blood circulation
Absorption of US energy among others generate heat effect. The body will react to the heat by vasodilatation. This dilation effect through mechanism:
(1). By the liberation of substances irritating tissue network.
(2). By their irritation afferent nerve fibers (bermyelin thick).
(3). As a further consequence of the process that happened during the two is relaxasi muscles.
b) Muscle Relaxation
Relaxation of muscle obtained from the improvement of blood circulation due to irritating substances in addition to the network will be transported vibration US could affect afferent nerve fibers. Directly and the result is relaxasi muscle.
c) Increasing the permeability of the membrane
It turned out that the US can increase tissue permeability. This effect turned out to be good at it continyu implementation or disconnected. Through this vibration mechanism is driven into the cell membrane that can lead to a change ynag ion concentration will also affect the value of the threshold of stimulation of cells.
d) Effects on peripheral nerves
According to some US researchers may polarize the efferent nerve fibers. For example: US crimped indicated that the vibration intensity of 0.5 W / cm2 with waves can continyu excitatory effect of peripheral nerves.
e) The effect of the reduction of pain
From the few experiences that the US can reduce pain. Basic pain relief is obtained inter alia from:
1) The improvement of the blood circulation in the tissues
2) Normalization of muscle tone
3) reduced the degree of acidity
4) Stimulation of the afferent nerve fibers
Here Stretching Exercise therapy is one treatment efforts using body movement exercises, either actively or passively (Kisner, 1996).
The form of training as follows:
a) Stretching the median nerve, the form of training as follows:
The principle of stretching: stretching of the median nerve is pinched, the position of the head counterclockwise rotation, accompanied by breathing exc.
(1). Stretching the left wrist palmar flexi (active)
Patients sit ongkang ongkang, asked to raise his arm shoulder length (horizontal abduction 900), then moved wrist palmar maximal flexi until outstretched, the position of head rotation towards the opposite hand pain, followed by breathing ECX (5-8 x repetition) ,
(2). Stretching Flexi Dorsal wrist of the left (active)
Same as above but flexi Dorsal hand position.
(3). The fifth finger was asked to hold strong, head rotation to right (5-8x repetition)
Massage on the left wrist (carpal tunnel) with transverse technique with constant pressure without lifting a hand from the network DiMassage, performed by two therapists thumb.
c) Manipulation hand
1) Stretching carpal bone in left wrist
The position of the hands of the patient supine
Second hand therapists are among the proximal and distal carpal bones the patient's hand, then move in the opposite direction / pulled away from each other towards distal and proximal.
2) Position the hand supination
Same way as above
3) Stretching carpal bone between the left carpal tunnel, using both thumbs palmar therapist at the hands of the patient, the therapist other four fingers in dorsal hands of the patient, laludi move towards top-down (anterior- superior) alternately, 5-8 x repetition.
Objective: reduce the emphasis on carpal tunnel.
4) Stretching using hand therapist on the patient's left wrist toward the distal lateral.
a. Patients felt that doing exercises that have been recommended by the therapist every morning and evening
b. Patients are advised to do therapy with warm water rndaman, how to merndam limited left hand wrist in a basin of water, it is less than 10 minutes, do 2x a day
c. Suggested that reducing the workload when washing, cooking, or activity that may worsen the situation.
d. When entering kejarum sewing thread, recommended needle is placed in the new wide-open first cork is inserted, so easy when handling.
4. End of Treatment Results
Evaluation is a measure to compare data before and after therapy for easier and more accurate in knowing the development of therapies.