7 New Skills for Carpal Tunnel Syndrome

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A 2020 paper by Schmid confirmed that Carpal Tunnel Syndrome is by far the most common peripheral nerve entrapment, affecting one in ten adults at some point in their lifetime. (And the lifetime risk increases to an astonishing 84% in diabetics). (1,2) 

Like nearly every other musculoskeletal condition, there’s a vast difference between merely treating someone and consistently applying best practices. Fortunately, your ChiroUp team tracks game-changing chiropractic best practices for more than 100 conditions, including carpal tunnel syndrome. This blog summarizes the past two years of CTS research and highlights the top emerging concepts for clinical success. 

Skill 1: Don’t Be Fooled by Imposters

Paresthesias involving the palmar aspect of the first 3 ½ digits with nocturnal awakening is 77.4% sensitive for the diagnosis of CTS. (3) But what does it mean if the numbness also involves the palm?

The palmar cutaneous branch of the median nerve originates in the forearm and travels outside of the carpal tunnel to innervate the palm; thus, CTS symptoms that involve the palm suggest pronator teres syndrome, or at least an alternate source of nerve irritation. (4) Approximately 12% of CTS patients have concurrent pronator teres syndrome. (5) Check out this smarter-by-the-minute tutorial to learn how to differentiate CTS from PTS.

Skill 2: Assess Peripheral Nerve Entrapment

Nerves are dynamic structures that need the ability to glide and stretch. (15) Edema and fibrosis can impair this normal movement and often translate into neurogenic complaints, like carpal tunnel syndrome. 

Nerve tension maneuvers, like the following median nerve tension tests, place a nerve under maximum stretch to elicit irritation. These maneuvers have emerged as essential components of an upper extremity neuropathy evaluation (in much the same way a straight leg raise is vital to assessing sciatica). Median nerve testing may be performed passively by the clinician or actively by the patient.

Skill 3: Incorporate Neurodynamic Techniques

Positive nerve tension tests suggest a need for nerve flossing maneuvers to restore normal neurodynamics. In the past two years, multiple studies have shown that neurodynamic techniques like median nerve flossing effectively treat CTS complaints. (8-12) Incorporating neurodynamic techniques leads to long-term improvements in CTS pain, symptom severity, and strength. (13)

What’s the difference between nerve tensioning and nerve flossing?

Nerve tensioning places both ends of a nerve under maximum stretch and is primarily used for testing purposes and occasional late-stage rehab.

Nerve flossing entails tensioning one end of the nerve while simultaneously releasing tension on the other end. This repetitive motion glides the nerve back and forth through its path and aims to release adhesions that have developed along the way. Therapeutic nerve flossing can be performed in-office by the clinician or as part of a home-based program.

Skill 4: Don’t Skip Your Time-Tested Tools

Manipulation and mobilization of cervical or carpal restrictions (especially the navicular bone) have ongoing support as effective tools for CTS. (6,7) 

Watch Dr. Corey Campbell from the Motion Palpation Institute demonstrate a straightforward wrist motion assessment plus manipulation here.

Skill 5: Prescribe the Most Potent Rehab

Not surprisingly, clinical outcomes improve when home exercise programs include neurodynamic exercises, i.e., nerve gliding and nerve flossing. (9,11,12) Mobility exercises, like carpal ligament stretching, have also shown benefit. (14) 

Skill 6: Empower Your Patients

The final piece of the puzzle involves motivating your patient to participate in their own recovery. Providers who employ patient-empowerment tools, like a well-developed written report of findings, have a much better chance for successful clinical outcomes. Your report of findings should include straight-forward answers to five essential questions:

• What’s causing the problem?

• What are you going to do to treat my problem?

• How long will it take to see results?

• What ADLs should I change to speed recovery?

• Exactly why and how do I perform the recommended exercises?

Skill 7: Never Stop Improving

If you liked this blog, you will want to get started with a ChiroUp account which includes: 

• The most sensitive & specific orthopedic tests

• The most effective manual therapy techniques 

• The most appropriate exercises and ADL’s

• Additional clinical pearls for achieving exceptional outcomes

• References

  1. Schmid AB, Fundaun J, Tampin B. Entrapment neuropathies: a contemporary approach to pathophysiology, clinical assessment, and management. Pain Reports. 2020 Jul;5(4). Link

  2. Singh R, Gamble G, Cundy T. Lifetime risk of symptomatic carpal tunnel syndrome in Type 1 diabetes. Diabetic medicine. 2005 May;22(5):625-30. Link

  3. Hegmann KT, Merryweather A, Thiese MS, Kendall R, Garg A, Kapellusch J, Foster J, Drury D, Wood EM, Melhorn JM. Median Nerve Symptoms, Signs, and Electrodiagnostic Abnormalities Among Working Adults. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2018 Aug 15;26(16):576-84. Link

  4. Davis DD, Kane SM. Median Nerve Palsy. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2020. Link

  5. Özdemir A, Acar MA, Güleç A, Durgut F, Cebeci H. Clinical, Radiological, and Electrodiagnostic Diagnosis of Pronator Syndrome Concurrent With Carpal Tunnel Syndrome. The Journal of Hand Surgery. 2020 Jul 22. Link

  6. Sault JD, Jayaseelan DJ, Mischke JJ, Post AA. The Utilization of Joint Mobilization As Part of a Comprehensive Program to Manage Carpal Tunnel Syndrome: A Systematic Review. Journal of Manipulative and Physiological Therapeutics. 2020 Aug 26. Link

  7. Sault JD, Jayaseelan DJ, Mischke JJ, Post AA. The Utilization of Joint Mobilization As Part of a Comprehensive Program to Manage Carpal Tunnel Syndrome: A Systematic Review. Journal of Manipulative and Physiological Therapeutics. 2020 May 1;43(4):356-70. Link

  8. Wolny T, Linek P. The Effect of Manual Therapy Including Neurodynamic Techniques on the Overall Health Status of People With Carpal Tunnel Syndrome: A Randomized Controlled Trial. Journal of manipulative and physiological therapeutics. 2018 Oct 1;41(8):641-9. Link

  9. Keskin Y, Kilic G, Taspinar O, Posul SO, Halac G, Eren F, Erol E, Urkmez B, Aydin T. Effectiveness of home exercise in pregnant women with carpal tunnel syndrome: Randomized Control Trial. Link

  10. Fernández-de-Las-Peñas C, Arias-Buría JL, Cleland JA, Pareja JA, Plaza-Manzano G, Ortega-Santiago R. Manual Therapy Versus Surgery for Carpal Tunnel Syndrome: 4-Year Follow-up From a Randomized Controlled Trial. Physical Therapy. 2020 Aug 6. Link

  11. Hamzeh H, Madi M, Alghwiri AA, Hawamdeh Z. The long term effect of neurodynamics vs exercise therapy on pain and function in people with carpal tunnel syndrome: A randomized parallel-group clinical trial. Journal of Hand Therapy. 2020 Jul 30. Link

  12. Abdolrazaghi HA, Khansari M, Mirshahi M, Ahmadi Pishkuhi M. Effectiveness of Tendon and Nerve Gliding Exercises in the Treatment of Patients With Mild Idiopathic Carpal Tunnel Syndrome: A Randomized Controlled Trial. HAND. 2021 Apr 15:15589447211006857. Link

  13. Wolny T, Linek P. Long-term patient observation after conservative treatment of carpal tunnel syndrome: a summary of two randomised controlled trials. PeerJ. 2019 Nov 8;7:e8012. Link

  14. Shem K, Wong J, Dirlikov B. Effective self-stretching of carpal ligament for the treatment of carpal tunnel syndrome: A double-blinded randomized controlled study. Journal of Hand Therapy. 2020 May 1. Link

  15. Wilgis EF, Murphy R. The significance of longitudinal excursion in peripheral nerves. Hand Clin. Nov 1986;2(4):761-6. Link