Carpal Tunnel Syndrome

Wahyu Sita Wardani

 Data Base Identity (October 26th 2015)

 Name : Mrs. T
 Sex : Female
 Age : 75 years old
 Address : Kertajaya, Surabaya
 Occupation : Housewife
 Religion : Moslem
 Ethnic : Javanese
 Marital status : Married

Referred from Neurology outpatient clinic with Carpal Tunnel

Syndrome Bilateral

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Chief complain : Rasa tebal pada jari tangan
kanan dan kiri
History of present illness
• The patient felt numbness of her right and left hand
especially at the thumb, index and middle fingers area
since three years ago .She also start to felt tingling
sensation at her fingers when she hold cooking utensils
such as ‘sutil’ or knife.
• The numbness decreased after she shooked or rest her
hand.
• She also felt pain at the wrist, with VAS = 8/10, especially
felt when she does ‘sujud’ position in Shalat activity or
lifting heavy objects.

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 History of Activity Daily Living
o She’s already being a housewife for more than 30 years,
her activity usually washing clothes, cooking and
cleaning.
o Now she’s living with her husband, her last daughter and
grandchildren. Nowadays her housewife activity is done
with being helped by her daughter and grand daughter.
o She used to work as a ‘sembako’ seller at traditional
market for more than 30 years . After she get the
complaint on her hand, she’s stop doing this activity
about two years ago.. She usually do the weighing (e.g.
rice, fluor ,oil), sometimes lifting sacks of fluor or any
other sembako.

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 History of Past Illnesses
• Hypertension since 40 years ago, routinely
controlled, being treated with :
- Amlodipin 10mg 1x/day
- Noparten 10mg 1x/day
• Dyslipidemia (+)  Simvastatin 1x/day.
• Diabetic mellitus (-)
• Trauma (-)

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 Physical Examination
GENERAL STATUS
CM, independent ambulation, normal gait, right handed
Body Weight : 54 Kg. BP : 120/70 mmHg
Body Height : 146 cm. HR : 85 x/minutes
BMI : 26,83 kg/cm²

Head & Neck : no anemia, icterus, cyanosis & dyspneu

Thorax : Cor : S1–S2 sound, murmur -, gallops -
Pulmo : vesiculer, wheezing -/-, ronchi -/-
Abdomen : Meteorismus -, Hepar / Lien : unpalpable
Extremities : warm acral +/+

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Physiatric Examination
Musculoskeletal examination

Cervical ROM MMT

Flexion F (0-450) 5
Extension F (0-450) 5
Lateral Flexion F/F (0-450) 5/5
Rotation F/F (0-600) 5/5

Trunk ROM MMT

Flexion F (0-800) 5
Extension F (0-300) 5
Lateral Flexion F/F (0-350) 5/5
Rotation F/F (0-450) 5/5
Shoulder ROM MMT

Flexion F/F (0-1800) 5/5

Extension F/F (0-600) 5/5
Abduction F/F (0-1800) 5/5
Adduction F/F (0-450) 5/5
Ext. Rotation F/F (0-900) 5/5
Int. Rotation F/F (0-700) 5/5

Elbow ROM MMT

Extension-Flexion F/F (0-1500) 5/5

Forearm supination F/F (0-800) 5/5
Forearm pronation F/F (0-800) 5/5
Wrist ROM MMT
Flexion F/F (0-800) pain 5/5
Extension F/F (0-700) pain 5/5
Radial deviation F/F (0-200) pain 5/5
Ulnar deviation F/F (0-300) pain 5/5
Fingers ROM MMT

Flexion
MCP F/F (0-900) 5/5 Lumbricales
PIP F/F (0-1000) 5/5 FlexorDig. Superficialis
DIP F/F (0-900) 5/5 Flexor Dig. Profundus

Extension F/F (0-300) 5/5 Ext. Digit. Communis

Ext. Indicis Propius
Ext. Dig. Minimi

Abduction F/F (0-200) 5/5 Dorsal Interossei

Abd. Dig. Minimi

Adduction F/F (200-0) 5/5 PalmarInterossei

Thumb ROM MMT
Flexion
MCP F/F (0-900) 5/5 Flexor PollicisBrevis
IP F/F (0-800) 5/5 Flexor PollicisLongus

Extension F/F (0-300) 5/5 Ext. Poll.Brevis

Ext. Poll. Longus
Abduction F/F (0-700) 5/5 AbduktorPollicisLongus
5/5 AbduktorPollicisBrevis
Adduction F/F (500-0) 5/5 AdduktorPollicis
Opposition 5/5 Opponen Poll.
5/5 Opponen Dig. Minimi
Hip ROM MMT
Flexion F/F (0-1200) 5/5
Extension F/F (0-300) 5/5
Abduction F/F (0-450) 5/5
Adduction F/F (0-200) 5/5
Ext. Rotation F/F (0-450)5/5
Int. Rotation F/F (0-450) 5/5
Knee ROM MMT
Extension-Flexion F/F (0-1350) 5/5

Ankle ROM MMT

Plantar Flexion F/F (0-500) 5/5
Dorsi Flexion F/F (0-200) 5/5
Inversion F/F (0-350) 5/5
Eversion F/F (0-150) 5/5
Toes ROM MMT
Flexion
MTP F/F (0-300) 5/5
IP F/F (0-500) 5/5
Extension F/F (0-800) 5/5

Big Toe ROM MMT

Flexion
MTP F/F (0-250) 5/5
IP F/F (0-250) 5/5
Extension F/F (0-800) 5/5
 Neurological Examination
o N. Cranialis I –XII : normal
o Physiological Reflexes :
• BPR +2/+2
• TPR +2/+2
• KPR +2/+2
• APR +2/+2
o Pathological Reflexes :
• Babinski -/-
• Chaddox -/-
• HT -/-
• Sensory deficits :
– 25% at left hand (palmar area, dig I, II, and III)
– 25% at right hand (palmar area, dig I, II, and III)
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 Local Status at
Regio Manus D/S
I : Inflammation -/-, Swelling -/-,
Redness -/-, Deformity -/-, Atrophy +/+
Special Test
P : Warm -/-
Slight atrophy at right thenar muscle
Severe atrophy at left thenar muscle • Prayer test : +/+
Tenderness at palmar area of hand D/S • Phallen test : +/+
• Tinnel’s sign : +/+
• Fromen test : -/-
• Finkelstein test : -/-
• TOS I, II, III : -/-, -/-,
-/-
 Compression test : -/-
 Spurling test : -/-
 Distraction test : -/-
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 Hand Function
 Grasp : Functional / Functional
 Hook : Functional / Functional
 Pinch : Functional / Functional
 Opposition : Functional / Functional
 Cylindrical : Functional / Functional
 Spherical : Functional / Functional
EMG Results (from Neurology Department)

• Impression :
Secara neurofisiologis klinis didapatkan Severe demyelinating
sensorymotor mononeuropathy N. Medianus kanan dan kiri setinggi
pergelangan tangan (Severe CTS Bilateral) (Sisi Kanan Lebih Berat)
 Diagnosis

Bilateral Carpal Tunnel Syndrome

(D>S) + Hypertension + Dyslipidemia

Functional diagnose

1. Impairment o Numbness and tingling sensation at palmar area, 1st,

2nd and 3rd finger at right and left hand
o Right and left compression of median nerve
o Slight atrophy at right thenar muscle, severe atrophy at
left thenar muscle
o Tenderness at palmar area of hand D/S
o Hypertension
o Dyslipidemia
2. Disability Problem of ADL while cooking and while doing sujud position
in praying

3. Handicap
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Problem List:
1. Medical :
1. Bilateral Carpal Tunnel Syndrome
Problem List
2. Hypertension
3. Dyslipidemia
2. Surgical : Bilateral Carpal Tunnel Syndrome
3. Rehabilitation Medicine
• R1 (Ambulation) :-
• R2 (ADL) : Difficulty to cook , doing sujud in
praying
• R3 (Communication) :-
• R4 (Psychological) : She’s worry about her condition
• R5 (Social Economy) :-
• R6 (Vocational) :-
• R7 (Others) :
• Numbness and tingling sensation on palmar, 1st ,2nd and 3rd Finger both
hand
• Tenderness at palmar area of hand D/S with vas 8/10
• Slight atrophy at right thenar muscle
• Severe atrophy at left thenar muscle
• Hypertension
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• Dyslipidemia
 Planning

Surgical :Neurology Outpatient Clinic already consulted her

to Orthopaedy Outpatient Clinic and suggested her
to undergo surgery but she refused the surgery
Medical :
• Analgesic (Meloxicam 1x15 mg, given from
Neurology Outpatient Clinic)
• Continue the medication from Internal Medicine for
her hypertension and dyslipidemia
Rehabilitation Medicine:
P. Dx : -
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P. Tx :
• OT : Sensory resensititation both hands
Tendon gliding exercise Nerve gliding exercise

Modality : - High TENS, with frequency 100 Hz, intensity as tolerate,

for 20 Minutes, 3x/week
- USD, at right and left Flexor Retinaculum,
with frequency 3 Mhz, intensity 1.0 W/cm2, pulsed,
for 5 minutes duration, 3x/week
Orthesa `: Resting wrist splint

P. Mx : Clinical Sign, VAS, MMT, Sensory, Muscle Atrophy, Blood

Pressure, Cholesterol

P. Ed. : Health Education & Home Exercise Program

 Explain about the patient condition
 Avoid repetitive movement on both hand
 ADL modification (utensils modification)
 Contrast Bath
 Continue exercise at home 21
 Summary
Reported female 75 y.o.referred from Neurologic Outpatient
Clinic with CTS bilateral. Numbness of both hand especially
on palmar, 1st, 2nd and 3rd finger since 3 years ago.
Tingling sensation felt when she hold kitchen utensils and
doing sujud when she’s pray. She is a housewife with full
housework activity and used to be a sembako seller.

From Physical Examination we found slight atrophy at right

thenar muscle, severe atrophy at left thenar muscle, tender
point at wrist area D/S, and sensory deficits. Prayer test,
phallen test, and tinnel’s sign are positive in both hand. We
diagnosed this patient with Bilateral CTS.
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 Summary
For the treatment, we plan to give sensory
resensititation, tendon gliding exercise, nerve
gliding exercise for both hand. We also plan to
give High Tens and USD at flexor retinaculum
for both hand and resting wrist splint.
We educate the patient to understand her
condition, to avoid/modificate repetitive
movement, contrast bath and continue
exercise at home
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Thank You !