Case Study: Carpal Tunnel Syndrome

CARPAL TUNNEL SYNDROME : A Patient Case

MUSLIHAH BINTI MOHD RAZALI (A139018) ANIZAH BINTI LAMIRON (A137987)

INTRODUCTION •

Carpal Tunnel Syndrome - arises from the intermittent intermittent or continuous compression or entrapment of the median nerve as it passes through the carpal tunnel from the wrist to the hand.

(Fisher et al 2004)

INTRODUCTION •

Carpal Tunnel Syndrome - arises from the intermittent intermittent or continuous compression or entrapment of the median nerve as it passes through the carpal tunnel from the wrist to the hand.

(Fisher et al 2004)

The median nerve (yellow) can become pinched as it runs through the carpal tunnel, the space between the wrist bones and the transverse carpal ligament (white). This leads to numbness or pain and the loss of function in parts of the hand and fingers associated with carpal tunnel syndrome. syndrome.

POPULATION AT RISK •

Three times more common in women than in men.

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More common in middle aged women.

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More commonly seen in older people.

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People who experience job stress.

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Obese individuals.

CASE INVESTIGATION

PATIENT: MRS. J •

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Gender: Female Age: 45 years old Job: Computer-based financial advising business. Diagnosis: Carpal Tunnel Syndrome (CTS) on her right wrist. Typical week’s activities: working 8-10 hours per day, five days a week at her home-based computer workstation, meal preparation, and scrapbooking with friends.

MRS J’S SYMPTOMS & SIGNS Symptoms •

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Intermittent pain, numbness or paresthesia in hand Subjective hand swelling and stiffness Wrist pain

Signs •

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Weakness of resisted thumb abduction Decreased grip strength Shaking or flicking one's hands for relief during maximal symptoms

CURRENT FUNCTIONAL ABILITIES & LIMITATIONS •

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Unable to type for more than five consecutive minutes without symptoms of pain and paresthesia. Uncertain of proper wrist positioning when performing various tasks, including using her computer keyboard, calculator and phone. Had difficulty with several aspects of meal preparation; opening jars, cutting food, picking up heavy containers and preparing meals.

CURRENT FUNCTIONAL ABILITIES & LIMITATIONS (cont.) •

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Having the most difficulty with performing certain scrapbooking tasks; cutting photos with scissors into intricate shapes, using a “corner rounder” tool, and cutting paper with a “trimmer”. Having a difficult time sleeping at night due to wrist pain at night and the stress related to not being able to perform her necessary work and cooking responsibilities.

OCCUPATIONAL THERAPY PROCESS

Assessments

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Goniometry - To assess range of motion.

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Dynamometer - To assess grip strength.

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Visual Analog Scale (VAS) - Used before and after work related tasks as a self-perceived measure of pain. A score of “0” would be no pain at all and a score of “10” would be the worst pain possible.

Performance in Areas of Occupation

For Mrs. J these included: Instrumental Activities Of Daily Living (IADL): meal preparation Work: completing work tasks such as typing (Job Performance) Leisure: participating in scrapbooking activity (Leisure Participation) •

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Instrumental Activities Of Daily Living (IADL) Performance Observed Mrs. J was observed in doing a simulated cooking task Performance Patterns Identified •

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Mrs. J placed her right wrist in extreme extension when cutting with a knife and when opening the lid of the peanut butter jar and jelly jar. Had difficulty manipulating the jar lids due to decreased grip strength.

Hypothesis Refined •

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Mrs. J’s decreased ability to perform tasks of daily life was due to poor wrist positioning resulting in pain. Mrs. J’s work station was set up in a way that did not promote proper upper positioning which may contribute to her overall discomfort when performing work related tasks.

Selected Outcome

1. Long term goal: •

Mrs. J will cook a meal for herself with minimal assistance from her two children for their family dinner.

2. Short term goals: •

Mrs. J will complete a 3-5 step cooking task with a reported VAS of less than 3/10.

WORK Performance Observed Mrs. J was observed at a computer workstation in the therapy room which was set up to stimulate her personal computer workstation. Performance Patterns Identified Mouse and mouse pad were placed 14 inches lateral to her monitor and keyboard which resulted in poor postural mechanics. •

Hypothesis Refined Same as IADL •

Selected Outcome

1. Long term goal: •

Mrs. J will be able to independently perform work activities safely for an 8-hour day.

2. Short term goal: •

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Mrs. J will demonstrate the set up at her home based work station with moderate assistance and will adhere to ergonomic instruction in order to tolerate working a 3-hour work day. She will demonstrate the ability to safely sustain a 5-hour work day using adaptive equipment.

LEISURE Performance Observed Mrs. J was observed in the therapy room doing simulated scrapbooking tasks. Performance Patterns Identified Mrs. J placed her wrist in extreme extension when cutting paper shapes and trimming pictures. Frequently rested the proximal region of her palmar surface on the table surface that she was working on. •

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Hypothesis Refined Same as IADL •

Selected Outcomes 1. Long term goal: •

Mrs. J will independently complete 5 pages out of her 20 page scrapbook for her fathers 70th birthday.

2. Short term goals: •

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Mrs. J will tolerate greater than 5 minutes using the necessary scrapbooking tools with a reported pain level of less than 3/10. Mrs. J will tolerate greater than 10 minutes of activity with no more than one rest period.

OCCUPATIONAL THERAPY INTERVENTIONS •

Guide to physical therapy practice:  –

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Therapeutic Exercise Functional training in self-care and home management

Therapeutic Exercise •

Tendon Gliding Exercise

Therapeutic Exercise •

Nerve Gliding Exercise

Functional Training In Self-care and Home Management •

Ergonomically Work Station  –

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Posture  –

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The positioning of equipment was altered to become more ergonomically correct, and certain equipment was added to support performance Proper postural positioning was promoted during scrapbooking activities by having the participants in a large room with adequate table space and ergonomically-correct chairs.

Share home chores  –

Mrs. J started giving her children daily kitchen chores related to meal preparation.

Functional Training In Self-care and Home Management •

Learn new techniques  –

Learning new cooking strategies and techniques to promote proper wrist positioning and prevent pain

OUTCOME RELATED TO ASSESSMENTS •

Upon completion of the assessment and interventions, it was determined that the three activities of work, meal preparation, and scrapbooking were of greatest importance to Mrs. J (importance scores of 10/10, 9/10 and 9/10, consecutively).

ALTERNATIVE TREATMENT OPTION If treatment is unsuccessful for severe CTS, a referral to their physician could lead to the following options as seen in the literature: Efficacy of surgical release of carpal tunnel ● After 3 months: 80% success rate for surgery, 54% for the splinting group after 3 months. ● After 18 months: increased to 90% for surgery and 75% for splinting (Gerritsen et al).

STANDARDS AND REGULATIONS

REFERENCES •

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Bruce Fisher, Ron Gorsche and Patricia Leake. May 2004. Diagnosis, Causation and Treatment of Carpal Tunnel Syndrome: An Evidence-Based Assessment Arthritis Foundation, Malaysia Dr. Grace Walker Gray. 2008. Carpal Tunnel Syndrome and Occupational Therapy