Does your patient complain of numbness in their fingers? Have they told you that they have dropped things as if their hand has decided to stop holding on? Do they tell you that their fingers, in particular their thumb, index and middle fingers, feel clumsy, weak, or painful? These are common ways that carpal tunnel syndrome (CTS) can affect a patient’s functioning. Luckily, you don’t have to be a certified hand therapist to help your patients conservatively manage their CTS symptoms (although OTs do make great hand therapists!). As an occupational therapist, you are equipped with the knowledge and tools to help patients conservatively manage symptoms of their CTS.
What is carpal tunnel syndrome?
Carpal tunnel syndrome is the most common type of nerve compression disorder in the upper extremity. According to the United States 2010 National Health Interview Survey administered by the Center for Disease Control, nearly 5 million workers were affected by CTS within the last 12 months (Luckhaupt, Dahlhamer, Ward, Sweeney, Sestito, Calvert, 2013).
In CTS, the median nerve is pinched or compressed at the wrist. When the median nerve is compressed, a person could experience decreased sensation, numbness, and tingling of their thumb, index, middle, and part of their ring finger. Some patients may even tell you that they drop things such as water bottles, keys, or their toothbrush as if they lost control of their hand. In more severe cases of CTS, you may even be able to see atrophy of the muscles in the palm of the hand, complete loss of sensation in the affected fingers, and loss of function of the hand. (Lim, Chee, Girdler, & Lee, 2017).
The median nerve, tendons of the finger flexor muscles, and vasculature share a common tunnel at the wrist called the transverse carpal ligament. This ligament is usually cut with surgical management of CTS to relieve pressure inflicted on the median nerve when conservative treatment has not resolved the symptoms. However, before surgery is recommended, there are many ways that an occupational therapist can help alleviate or even eliminate the symptoms of CTS though patient education, activity modification, and adaptive equipment.
How can an OT treat CTS?
1. Patient Education
As OTs, we’re in the perfect position to teach patients strategies to help manage their CTS symptoms. The first step is to educate patients on the basic anatomy of the wrist and median nerve. That means brushing the dust off of your anatomy books and showing your patients where the median nerve is located in their wrist and how certain activities and positions can aggravate their symptoms.
How can the median nerve be compressed? Internal pressure can aggravate the median nerve in the wrist. This can occur from frequent gripping or edema. Gripping causes the small muscles between our fingers to migrate into the carpal tunnel increasing its volume. Swelling or edema in the wrist can occur from trauma as a secondary symptom from injuries such as a distal radial fracture. In these cases, you will need to adapt certain suggestions made later in this article. External forces such as laying the palm of the hand flat on surfaces, having the wrist in a fully flexed or extended position, or from wearing a watch or hair tie around your wrist a tad too tight can compress the median nerve.
2. Joint Protection
Understanding the mechanisms that increase CTS symptoms makes it much easier for patients to apply joint protection strategies in their day to day lives. As an OT, you can work with patients to figure out how their daily activities aggravate their symptoms and how to avoid, modify, or adapt them. Below are a few examples:
- Wakes up with hands numb? They may be sleeping in a position that flexes or extends their wrist, therefore compresses their nerve. Suggest a wrist brace at night to keep their wrist in a neutral position. If you are in a facility that fabricates custom orthotics, you can make a resting hand splint yourself! Custom splints or prefabricated braces can even be helpful to wear during the day if their symptoms are quite severe.
- Avoid prolonged gripping.
- Avoid flattening your hand flat on surfaces as with keyboarding. Instead teach your patient how to use the “floating hands” technique.
- Avoid pinching. Instead teach your patient to grab items with two hands and use bigger muscles for tasks.
- Avoid vibration which is common for those that ride motorcycles or have shaky car steering wheels. Instead recommend a non-slip silicone steering wheel cover which will decrease the amount of grip strength required and also widen your grip.
- Relax hands frequently throughout day. Your hands get tired so taking a rest from repetitive manual tasks will allow your hands to rest.
3. Adaptive Equipment
Occupational therapists can also teach patients how to decrease compression of their median nerve through the use of adaptive equipment such enlarged grips, built-up handles, and electric jar openers. North Coast Medical Supply publishes a catalog full of products that range from household and kitchen aides to modalities that can be used at home such as cold and hot packs. All of these can help improve patients’ participation in ADLs while managing their CTS symptoms. You can get you catalog for free or have it sent to your patients here. To read more about how modalities can be used in various settings, check out this article about the fundamentals of heat modalities.
With patient education, application of joint protection principles, and adaptive equipment, OTs can play a key role in helping patients manage their CTS and even delay or prevent the need for more invasive procedures. If you find yourself interested in the treatment of CTS and other conditions of the upper extremity, you may want to consider becoming a certified hand therapist. You can learn more on how to become one here.
In the meantime, give these a try and let us know what you or your patients think in the comments below!
- Echigo, A., Aoki, M., Ishiai, S., Yamaguchi,M., Nakamura, M., & Sawada, Y. (2008). The excursion of the median nerve during nerve gliding exercise: An observation with high-resolution ultrasonography. 21(3),221-228.doi: https://doi.org/10.1197/j.jht.2007.11.001.
- Lim, Y., Chee, D., Girdler, S., Lee, H. (2017). Median nerve mobilization techniques in the treatment of carpal tunnel syndrome: A systematic review. Journal of Hand Therapy, 30, 397-406. doi: https://doi.org/10.1016/j.jht.2017.06.019.
- Luckhaupt, S., Dahlhamer, J., Ward, B., Sweeney, M., Sestito, J., Calvert, G. (2013). Prevalence and work relatedness of carpal tunnel syndrome in the working population, United States, 2010 National Health Interview Survey. American Journal of Medicine, 56 (6), 615-624. doi: 10.1002/ajim.22048.
- Horng, Y, Hseigh, S., Lin, M., Chang, Y., Lee, K., Liang, H. (2014). Ultrasonographic median nerve changes under tendon gliding exercises in patients with carpal tunnel syndrome and healthy controls. Journal of Hand Therapy, 27(4), 317-324. Doi: https://doi.org/10.1016/j.jht.2014.07.007.