Episode 1648 - A Cert-Ortho approach to CTS

Dr. Lindsey Hughey // #ClinicalTuesday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Lindsey Hughey discusses a modern approach to carpal tunnel syndrome (CTS), including when central findings are present. Lindsey discusses examination and treatment, including the use of the rehabilitation every-minute-on-the-minute style (rEMOM) exercise dose.

Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog.

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EPISODE TRANSCRIPTION

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LINDSEY HUGHEYGood morning, PT on ICE Daily Show. How are you? Welcome to Clinical Tuesday, my favorite day of the week. I am Dr. Lindsay Hughey from our extremity management team, and I am here to chat with you today about an ortho-cert approach to carpal tunnel syndrome. And what do we do when it's not just the carpal tunnel, when we also see some central symptoms? So I am going to unpack what a fitness-forward approach looks like, how we will use our manual therapy to modulate symptoms, and then what psychologically informed looks like for this condition when we think about combining all the courses from our OrthoCert and putting that all together in an integrative way, how we can approach this condition. and then I'll leave you with a couple rehab e-moms at the end, so stay for that. CARPAL TUNNEL SYNDROME OVERVIEW So first off, let's briefly review what the subjective and objective presentation with someone with carpal tunnel syndrome and then possible central considerations that are present as well. Think double crush is kind of a common medical term present. So for that CTS, that carpal tunnel syndrome, we'll see classic sensory anesthesias or paresthesias in those first three fingers and then possibly that radial half of the ring finger. There may be motor deficits in our first and second lumbricals, opponent's pollicis, abductor pollicis brevis. So think about in your objective exam, thub abduction and thumb flexion may be weak. We'll also see, from an objective perspective, locally we'll see a positive phalanx and tonels, and then our carpal compression test. Patients will complain of interruption in gripping and daily tasks. They may even drop objects or have to shake out their hand to ameliorate symptoms. Often symptoms are worse at night, and then when they first wake up in the morning, and then tend to improve as the day goes on. When we also consider there might be some central things going on, it's that person that not only complains of what I just told you and had objective exam findings, but they also say they have some numbness tingling along that C5, C6 dermatome. They may complain of some local neck tightness or achiness in that mid to lower cervical spine area. on exam, you will find a UPA or central PA will elicit those familiar symptoms when you're around C5, C6. In addition, that dermatome distribution will be impaired and then reflex changes in that biceps reflex might be abnormal compared to that uninvolved side and we really understand the whole clinical picture when we use a body chart right and we really listen to that subjective and dial in their ags and eases so you find out when all of that's on board that there's two things going on at the same time and here's where we'll need our ortho hats where we need to put into practice what we know in our cervical class and what we know from our extremity class. APPLYING FITNESS FORWARD So first off what is fitness forward? when that's one of our primary pillars. So what does that mean for this condition and in general? Well, we are going to approach the whole human in front of us. We know that this typically affects females later in that fourth and fifth decade. they are two times females are two times more likely than males to have this condition and so appreciate that in that decade that's either you know a career focused time or family focused or a mix of the two so consider the stressors for that human that may or may not be involved in that decade. And then we see some links to obesity as well. So thinking about the whole human holistically, we see worsening symptoms for those that have higher BMIs. So not only will we consider the whole human from a fitness forward perspective, but we're going to think about how can we attack local tissue getting irritability down. So think about local tissue in the hand and even in that C5, C6 area of cervical spine. And then we'll start with local treatment but then eventually we're already thinking about how globally will we make this human more resilient and robust in their grip strength and their overall upper quarter strength. So even day one when we're trying to just calm symptoms we're thinking fitness forward. How fit will you let me get you? We're gonna consider those system influence that I already mentioned, sex and possible stressors in life. We're gonna consider mindset, the physical activity levels of that human, because again, I said there's links to increased BMI and obesity. So we're dealing with an underlying systemic inflammation probably on board as well. We'll think about what's that sleep hygiene like? Are they getting the eight to nine hours of sleep? How's their diet and hydration? Are they getting half their body weight in ounces? Are they eating colorfully? That is all a part of fitness for it. So it's not just loading them up locally, globally, making tissues robust, but really we want a whole system-wide robustness. MANUAL THERAPY FOR CARPAL TUNNEL SYNDROME And the way we'll first approach these humans is through symptom modulation, through our manual therapy techniques. This is how we'll really get trust and buy-in when we're dealing with carpal tunnel syndrome, or CTS, and then there's central possible involvement as well. double crush, whatever kind of terminology makes you comfortable. I tend to think labels limit. And if you've been to our extremity course, you know that. So symptom modulation locally first looks like bracing, actually. So an over-the-counter splint at night is first-line defense because that's when symptomatology is worse because we're sleeping in that phalanx position. And if there's worsening symptoms in the day, we'll even recommend a wearing schedule during the day. But we first start with night. We'll educate on any ags and easing postures, right? If moving in and out of postures is really important. We don't want someone hunched over like this all the time, and we also don't want someone being perfectly erect. So depending on their job and life and family functions, we'll give some advice there as well, as our education starts to dampen irritability and symptomatology. Our manual therapy perspective though, so here's our second pillar coming to play. is that we are going to target the CT junction and then an upper T spine. And we're going to use manipulation. You'll hear at our course that if you have any upper quarter symptoms and you have a pulse, you are going to get some kind of thoracic manipulation. for that neurophysiologic effect. So what you learn in your cervical and total spine thrust courses, you're going to bring forward here. And this is going to help dampen pain, not only centrally right in the cervical spine, but also we see pain dampening and increase motor output in our upper quarter when we use those techniques. So those will be our go-to techniques, prone CT junction, and then our upper T-spine manip. In addition, doing some lateral gliding for a pumping action in those higher irritability stages targeted at that C5, C6 area. Follow up for that will be some cervical retractions to get a pumping action centrally. And we may or may not combine that with some traction. a manual therapy perspective from extremity management local to those carpal bones and that wrist, we'll actually start doing some wrist mobilization. Extension's often a common impairment here, so we'll work into progressive extension, mobilizing those carpals, and we'll even do this nice soft tissue splay technique. If you've been to the course, you