1st Case Report

Medical Rehabilitation in Patient with Carpal Tunnel Syndrome

Oleh :
dr. Jenisa Reivana Febiola Symons
20015107003

Pembimbing :
dr. Lidwina Sengkey, SpKFR-K
dr. Christopher Lampah, Sp.KFR

Program Pendidikan Dokter Spesialis I

KSM Ilmu Kedokteran Fisik dan Rehabilitasi
Fakultas Kedokteran Universitas Sam Ratulangi
RSUP Prof.Dr. R.D.Kandou
Manado
2022

1
 INTRODUCTION

Carpal tunnel syndrome (CTS), an entrapment neuropathy of the median

nerve at the wrist, is the most common compression neuropathy of the upper
extremity. This syndrome produces paresthesias, numbness, pain, subjective
swelling, and, in advanced cases, muscle atrophy and weakness of the areas
innervated by the median nerve. The condition is often bilateral, although the
dominant hand tends to be more severely affected.1 Carpal Tunnel Syndrome is
characterized by a clinical syndrome in which nerve damage is coupled with
abnormal sensation and pain.2 The patient may awaken with hand or finger pain
and paresthesias and complain of hand clumsiness and dropping objects. In
approximately 50% of patients, there is no clear etiology.3 Based on a study
conducted by the American Academy of Orthopedic Surgeons in the United States,
the incidence of CTS is 1–3 cases per 1,000 people per year, with a prevalence of
50 cases per 1,000 people in the general population. However, the incidence can be
as high as 150 cases per 1,000 people per year, with a prevalence of 500 per 1,000
people in high-risk groups.4 CTS is ten times more common in females as compared
to males and the peak age of CTS occurrence is 40-60 years.5
The carpal bones of the wrist are arranged in two rows, a proximal and a
distal row, each consisting of four bones. Proximal row is from lateral to medial
and when viewed from anteriorly, the proximal row of bones consists of scaphoid,
lunate, triquetrum bone, and pisiform. Distal row is from lateral to medial and when
viewed from anteriorly, the distal row of carpal bones consists of trapezium,
trapezoid, capitate, and hamate.6 The carpal bones allow for limited flexion,
extension, radial deviation and ulnar deviation of the wrist. The carpal bones form
a volar concave arch or carpal tunnel, with the pisiform and hook of the hamate on
the ulnar side and the scaphoid tubercle and the crest of the trapezium on the radial
side. The four bony prominences are joined by the flexor retinaculum (transverse
carpal ligament), which forms the roof of the carpal tunnel. The ligament can course
2 to 5 cm longitudinally, 2 to 3 cm in width and 0.5 cm in thickness.7 The four
tendons of the flexor digitorum profundus, the four tendons of the flexor digitorum

2
superficialis, and the tendon of the flexor pollicis longus pass through the carpal
tunnel, as does the median nerve.6
The median nerve innervates the muscles in the anterior compartment of the
forearm except for the flexor carpi ulnaris and the medial part of the flexor
digitorum profundus (ring and little fingers). It leaves the cubital fossa by passing
between the two heads of the pronator teres muscle and passing between the
humero-ulnar and radial heads of the flexor digitorum superficialis muscle. The
median nerve continues a straight linear course distally down the forearm in the
fascia on the deep surface of the flexor digitorum superficialis muscle. Just
proximal to the wrist, it moves around the lateral side of the muscle and becomes
more superficial in position, lying between the tendons of the palmaris longus and
flexor carpi radialis muscles.

Figure 1. Carpal tunnel’s structure8

Patients with CTS may present with a variety of symptoms and signs.
Women are affected more often than men and is often bilateral but more severe in
the dominant hand. Repetitive hand and wrist has been associated with CTS. A
number of medical condition are associated with CTS, including diabetes,
hypothyroidsm and reumathoid arthrithis. Infrequently CTS can be caused by a
mass lesion at the wrist, such as a ganglion cyst or neurofibroma or associated with
acute trauma to the wrist. The great majority of cases of CTS are idiopathic.10 The
classic symptoms of CTS include numbness and paresthesias in the radial 3½
fingers. A typical early complaint is awakening in the night with numbness or pain
in the fingers. Symptoms during the day are often brought out by activities placing

3
the wrist in substantial flexion or extension or requiring repetitive motion of the
structures that traverse the carpal tunnel. Many patients report symptoms outside
the distribution of the median nerve as well.1 The patient may describe the
symptoms as being positional, with symptoms relieved by the shaking of a hand,
often referred to as the flick sign. Patients may complain of a sense of swelling in
the hands, often noting that they have difficulty wearing jewelry or watches. Some
patients also report dry skin and cold hands. In the later stages of CTS, the
numbness may become constant and motor disturbances more apparent, with
complaints of weakness manifested by a functional decrease of strength. Patients
may then report dropping objects.1 Usualy the thenar eminence will be spared any
sensory abnormalities because the palmar cutaneous branch comes off proximal to
the carpal tunnel. Weakness of the median innervated muscles of the hand can be
perceived as difficulty opening jars, buttoning, or dropping objects. Weakness
involves primarily thumb abduction and opposition. When severe, atrophy of the
thenar eminence can be seen.10
On examination, sensation may or may not be abnormal in the median
territory at rest. A two-point sensory discrimination test is thought to be the most
sensitive of the bedside examination techniques. The Tinel’s sign is often present
when tapping over the median nerve of the wrist is held passively flexed, may also
provoke symptom. A Tinel’s sign is present in more than half of CYS cases. A
Phalen maneuver usually produces parasthesias within 30 seconds to 2 minutes in
CTS; it is more sensitive than the Tinnel’s sign and has fewer false positive results.
Most commonly, the Phalen maneuver will produce parasthesias in the middle or
index fingers. 11
The goal of treatment is the resolution of symptom and preservation of hand
function. If carpal tunnel syndrome is identified early, conservative treatment is
recommended. Initially patient should be instructed in modifying symptom
provoking wrist movement. Prognosis and management of carpal tunnel syndrome
is done with a multidisciplinary team includes the primary caregiver, nurse
practioner, physical therapist, orthopedic surgeon, and emergency department
physician.11

4
 CASE REPORT

I. Identity
Name : Mrs. D. T
Number of Medical Record : 740976
Gender : Female
Age : 55 years old
Date of birth : Manado, April 17th 1966
Address : Kairagi Permai
Cell phone number : 082344140642
Religion : Christian
Occupation : Housewife
Admitted to hospital : July 1st, 2021
Method of payment : Badan Penyelenggara Jaminan Kesehatan / BPJS
Reffered From : Neurology Department with diagnosis Carpal
Tunnel Syndrom Bilateral

II. Anamnesis (Autoanamnesis)

Taken on July 1st, 2021 by Autoanamnesis
Chief Complaint
Pain on both wrist

History of Present Illness

Pain on right wrist felt since December 2020 (7 months ago) and left wrist
since June 2021 ( 1 month ago), especially while working using both hand, like
when she do house work like cleaning, cooking, and when she do sewing, driving,
using handphone, make up and holding a heavy thing. Pain feels like sharpen pain,
no radiating pain. Pain increase if she doing activities and decrease when she take
analgetic medicine such as Paracetamol. She also started to felt numbness in the
both hand, feels more pain and numbness in right wrist. To overcome it, she usually
flick her hands to relieve it. She also said she sometimes drop something she hold
like handphone. She also complained that sometimes she woke up at night because

5
of the pain and numbness especially in right hand. Usually she likes to sleeps facing
to the right and she sleep with her hands placed below her head. Then she went to
neurologist to examine and was referred to Physical Medicine and Rehabilitation to
get further treatment. There were no complains on her neck, shoulder and elbow.

History of past illness:

She has hypertension from 15 years ago, regularly treat by Micardis 40 mg
once a day. She also has Hipercolesterolemia since 15 years ago and treat by
atorvastatin 20 mg a day.

Medication and Allergies:

Patient has no history of allergy. Patient had already taken amitriptyline
6,25 mg three times a day from neurologist.

Family history:
There is no family member who had this problem.

Habitual status:
Patient is right handed. For the last 20 years she used her both hand to all
kind of housewife activity such as cleaning, laundering, cooking, etc.

History of Functional Activity

Her Functional Abilities were normal before getting ill.

Social History:
- Home Environment and living Situation
Patient lives in 1 floor permanent house, 3 bed rooms, 1 bath rooms. She slept
in the main bedroom which is about 4 x 3 m2. Her bathroom is about 2x2 m2
with sitting toilet. The source of water is from a well and electricity from PLN.

6
- Family Support
The patient is a widow, her husband is passed away 3 years ago. She has 2
child, first child is an office worker and the second child is a government
employees.

- Vocational Activities and Recreation

The patient is right handed, before getting sick she used do all kind of
housewife duty actively such as grinding onions, chili about 10 minutes
everyday, sweeping, cooking, washing clothes with hand 2 times a week and
dishes, ironing clothes, cleaning the house, lift heavy object (groceries) about
5-10kg. She like to do make up. Habit to use both hands actively in repetitive
movement of wrists and digits, she usually bathed using a dipper and awkward
wrist positions such as spending time with handphone such as texting while
lying on the bed. Now after getting sick, she difficult to doing household and
her hobby.

- Finances and Incomes Maintenance

The source of the patient's daily living expenses is the salary of their children.
The patient does not know for sure how much their children's salary will be, but
the patient feels that it is sufficient for their daily living expenses.

- Psychosocial History
Patient has adequate orientation to person, place, time and situation. She has
good memory skills and judgement. Patient has an anxiety about her hands
function later on but well motivated to follow instructions from physiatrist
regularly. Hamilton Rating Scale for anxiety is 10 (Mild anxienty).

Hope
The patient hopes than she can recovery and return to her activities.

7
III. Physical examination
General Physical Examination
Consciousness : compos mentis
Vital signs : Blood pressure: 130/80 mmHg Pulse: 84x/minute
RR: 24x/minute Temperature: 36.2⁰C
Nutritional status : Body weight: 55 kg, Height: 155 cm, BMI : 22,9 kg/m2
Head : No deformity, head in the midline.
Hair : Black straight hair, hard to be pulled out.
Eyes : Conjunctiva not pale, sclera not icteric, isochoric pupils, Ꝋ 3 mm/3
mm.
Nose : No septal deviation, normal nasal mucosa, no secret, no sign of
inflammation.
Ear : Normal ear canal, no serumen, no secret.
Oral Cavity : Good oral hygiene, normal oropharynx.
Throat : T1/T1, no hyperemic, symmetric arc of pharynx, no deviation of
uvula.
Neck : Trachea in the midline, normal JVP, no thyroid or lymph node
enlargement.
Chest : Symmetrical shape in static and dynamic.
Pulmo : symmetrical breathing, sonor on both side, no ronchi, no wheezing
Heart : normal heart sound I-II, no murmur, no gallop
Abdomen : No defense muscular, no enlargement of liver and spleen, tympanic
sound on percussion, normal peristaltic sound.

Neuromuscular Status
Posture :
Anterior :
Head is in midline, symmetrical shoulders, symmetrical body-arm distance, no
varus or valgus of bilateral leg and ankle
Posterior :
Head is in midline, symmetrical shoulders, symmetrical body-arm distance,
normal vertebrae alignment, no pelvic obliquity

8
 Lateral :
Forward head with normal lordotic cervical and kyphotic thoracal, no
hyperlordotic lumbal, no genu recurvatum.

Upper Extremity Region

Look : Deformity (-), Redness (-), Oedem (-)
Feel : Warmth (-), tenderness (-)
Move :
Region ROM MMT
Shoulder :
Flexion Full/Full 5/5
Extension Full/Full 5/5
Abduction Full/Full 5/5
Adduction Full/Full 5/5
Internal Rotation Full/Full 5/5
External Rotation Full/Full 5/5
Elbow :
Fleksion Full/Full 5/5
Ekstension Full/Full 5/5
Forearm :
Supination Full/Full 5/5
Pronation Full/Full 5/5

Local Status of wrist and hand:

Look : No edema, no hyperemic, no mass, muscle atrophy (+) at right thenar
muscle.
Feel : - Pressure pain on both wrist region
- Sensory test : normal
- Proprioception : identifying direction & position were normal
- Pulsation of radialis artery is adequate, symmetric between right and
left side, and capillary refill symmetric between right and left

9
Move : Pain at full flexion and extension of both wrist
Examination on Range Of Motion of Wrist
Movement Right Left
Flexion – 75º– 0–80º 80º – 0– 70º
Extention
Radial deviation – 20º – 0– 30 º 20º – 0– 30º
Ulnar deviation

Visual Analog Scale (VAS) at right and left wrists

X X
0 3 4 10
(Left) (Right)

Muscle of Motor Function of the Median Nerve

Action Muscle Dextra Sinistra
Forearm pronation Pronator teres, 5 5
pronator
quadratus
Wrist flexion, radial Flexor carpi 5 5
side radialis
Flexion of IP joint of Flexor pollicis 4 5
thumb longus
Flexion of proximal IP Flexor digitorum 5 5
joint of digits 2–5 superficialis

10
 Flexion of distal IP Flexor digitorum 5 5
joints of digits 2 and 3 profundi I and II
Thumb abduction Abductor pollicis 4 4
brevis
Opposition of thumb Opponens 4 5
and 5th digit pollicis
Extension of finger at Lumbricals to 5 5
proximal IP joint with index and middle
MCP joint fixed fingers

Lower Extremity Region

Look : Deformity (-), Redness (-), Oedem (-)
Feel : Warmth (-), tenderness (-)
Move :
Region ROM MMT
Hip :
Flexion Full/Full 5/5
Extension Full/Full 5/5
Abduction Full/Full 5/5
Adduction Full/Full 5/5
Internal Rotation Full/Full 5/5
External Rotation Full/Full 5/5
Knee :
Fleksion Full/Full 5/5
Ekstension Full/Full 5/5
Ankle :
Flexion Full/Full 5/5
Extension Full/Full 5/5

11
Neuromuscular status
Upper and Lower Extremity
Right Left
Movement Normal Normal
Muscle strength 5/5/5/5 5/5/5/5
Muscle tone Normal Normal
Muscle atrophy Absent Absent
Physiological reflex Normal Normal
Pathological reflex Absent Absent
Sensibility Normal Normal

Functional Examination
Hand Function
Left Hand Right Hand
Opposition normal Poor
Reposition normal Normal
Abduction of the thumb Poor Poor
Adduction of the thumb normal Normal
Flexion of the thumb normal Poor
Extension of the thumb normal Normal
Power grip Poor Poor
Precision grip normal Poor

Table 5. Provocation test specified for CTS

Provocation test Dextra Sinistra
Tinnel’s sign + +
Phallen’s test + +
Reverse Phallen’s test + +
Carpal compression test + +

12
Table 6. Provocation test to differentiate from another disease
Provocation test Dextra Sinistra
Spurling - -
Allen test - -
Adson test - -
Roos test - -
Tinnel’s sign of ulnar nerve - -

BOSTON CARPAL TUNNEL SYNDROME QUESTIONNAIRE (BCTQ)

(R: Right Hand L: Left Hand)
1. How severe is the hand or wrist pain that you have at night?
1. Normal
2. Slight (L)
3. Medium (R)
4. Severe
5. Very serious
2. How often did hand or wrist pain wake you up during a typical night in the
past two weeks?
1. Normal
2. Once (L)
3. 2 to 3 times (R)
4. 4 to 5 times
5. More than 5 times
3. Do you tipically have pain in your hand or wrist during the daytime?
1. No pain

13
 2. Slight (L)
3. Medium (R)
4. Severe
5. Very serious
4. How often do you have hand or wrist pain during daytime?
1. Normal
2. 1-2 times / day (L)
3. 3-5 times / day (R)
4. More than 5 times
5. Continous
5. How long on average does an episode of pain last during the daytime?
1. Normal
2. < 10 minutes (R-L)
3. 10-60 continued
4. > 60 minutes
5. Continous
6. Do you have numbness or tingling at night?
1. Normal
2. Slight (L)
3. Medium (R)
4. Severe
5. Very serious
7. Do you have weakness in your hand or wrist?
1. Normal
2. Slight (R-L)
3. Medium
4. Severe
5. Very serious
8. Do you have tingling sensations in your hand?
1. Normal
2. Slight (L)
3. Medium (R)

14
 4. Severe
5. Very serious
9. How severe is numbness (loss of sensation) or tingling at night?
1. Normal
2. Slight (L)
3. Medium (R)
4. Severe
5. Very serious
10. How often did hand numbness or tingling wake you up during a typical
night during the past two weeks?
1. Normal
2. Once (L)
3. 2 to 3 times (R)
4. 4 to 5 times
5. More than 5 times
11. Do you have difficulty with the grasping and use of small objects such as
keys or pens?
1. Without difficulty
2. Little difficulty (L)
3. Moderately difficulty (R)
4. Severe difficulty
5. Very difficulty

Functional Status Scale (FSS) (R: right hand; L: left hand)

Cannot do at
Activity No Mild Moderate Severe all due to
difficulty difficulty difficulty difficulty Hand or Wrist
symptoms
1. Writing 1 (R-L) 2 3 4 5
2. Buttoning of 1 (L) 2 (R) 3 4 5
clothes

15
3. Holding a book 1 2(R-L) 3 4 5
while reading
4. Gripping a phone 1 2(R-L) 3 4 5
5. Opening a jar 1 2 3(R-L) 4 5
6. Household 1 2(L) 3(R) 4 5
chores
7. Carrying grocery 1 2 3(R-L) 4 5
of bags
8. Bathing and 1(L) 2(R) 3 4 5
dressing

BCTQ at right hand is 2.8 ; at left hand is : 2

FSS at right hand is 2.25 ; left hand is : 1.87

IV. Additional Examination :

EMG on June 9th 2021 :

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Comment :
- Pemeriksaan NCS motorik N. medianus, ulnaris kanan dan kiri dalam batas
normal
- Pemeriksaan NCS sensorik N. medianus kanan didapatkan distal latensi
memanjang, amplitudo SNAP normal dan KHS sensorik menurun.
- Pemeriksaan Lumbrikal motoric N. medianus kiri, didapatkan selisih distal latensi
lebih dari 0,2 ms
- Pemeriksaan NCS sensorik N. medianus kiri, N. ulnaris kanan dan kiri dalam
batas normal

Kesan : Carpal Tunnel syndrome dextra grade 2/6, sinistra 1/6

IV. Case Summary

Pain on right wrist felt since December 2020 (7 months ago) and left wrist
since June 2021 ( 1 month ago), especially while working using both hand, like
when she do house work like cleaning, cooking, and when she do driving, using
handphone, make up and holding a heavy thing. Pain feels like sharpen pain, no
radiating pain. Pain increase if she doing activities and decrease when she take
analgetic medicine such as Paracetamol. She also started to felt numbness in the
both hand, feels more pain and numbness in right wrist. To overcome it, she usually
flick her hands to relieve it. She also complained that sometimes she woke up at
night because of the pain and numbness especially in right hand. Usually she likes
to sleeps facing to the right and she sleep with her hands placed below her head.
Then she went to neurologist to examine and was referred to Physical Medicine and
Rehabilitation to get further treatment. There were no complains on his neck,
shoulder and elbow.
On physical examination, patient was compos mentis with normal vital
signs. Local status of both wrists and hands there have not thenar muscle atrophy,
normal sensation at thumb, index finger, middle finger, and radial side of ring finger
of both hands, Provocation test Tinnel’s sign of median nerve, Phallen’s test,
Reverse Phallen’s test, and Carpal compression test (+) at both hands.

17
VI. Working Diagnosis
- Clinical diagnosis : carpal tunnel syndrome bilateral
- Topical diagnosis : median nerve at carpal tunnel bilateral
- Etiological diagnosis : cumulative trauma disorder

- Functional diagnosis :
ICF CODE DESCRIPTION PATIENTS CONDITION
Body Function
b440 Wrist and hand function weakness at right hand
b280 Sensation of pain pain at both hands
Body Structure
S720 Structure of shoulder region Joints of both wrist
S810 Structure of areas of skin Tingling sensation both hands
Activities and Participation
D445 Hand and arm use limitation on function of both
hands in opposition, thumb
abduction, grasping, handling
objects, pinching, wrist flexion
and extension
D170 Writing Difficulty writing
D449 Carrying, moving and Difficult to carrying object
handling objects, other
specified
D640 Doing housework disturbances in doing house
working such as cooking,
grooming, grinding, opening
jar and washing
Environmental Factors
e315 Extended family Supporting from her children
Personal factor
do exercise rarely; age 55 years old, habit to use both hands actively in repetitive
movement of wrists and digits.

18
VII. Prognosis
- Quo ad vitam : Bonam
Her disease is currently not life threatening and there are no complications just
interfering her daily activities.

- Quo ad sanationam : Dubia ad Bonam

With medical rehabilitation program regularly, expected can decreased the
symptoms and improve her hand functional.

- Quo ad fungsionam : Dubia ad Bonam

According to Bartkowiak et al in 2020, Low Level Laser therapy combine
with nerve and tendon gliding in patients with mild to moderate CTS can give
improvement in visual analog scale, hand grip strength and the Boston
Questionnaire after 2 weeks treatment.19
Gatheride et al in 2020, in their research in subjects with mild or mild to
moderate CTS asked to wear a neutral wrist splint for 6 weeks had improvement
in symptoms, functional deficits, and median sensory distal peak latencies.20

VIII. Goals
Short goals:
1. To educate and reassure the patient about the condition.
2. To decrease pain in both wrist from moderate to mild pain or to no pain.
3. To decreased tingling sensation and numbness at both hands
4. To improve muscle strength by giving strengthening exercise of specific muscle

Long goals:
1. Prevent recurrence
2. Hand function back to normal
3. Activity daily living back to normal
4. Self-management of symptoms by patient
5. Patient return to his vocational activity as a housewife

19
IX. Rehabilitation Program: (June, 30th 2021)
NO PROBLEM ASSESMENT PROGRAM
1. Pain on boths of Reduce pain on -Low Laser Level Therapy
hands boths of hands (LLLT) 3 J/cm2applied on
(VAS) acupuncture points of the
median nerve at the wrist (in
the middle of the wrist in
supination position) for 5
minutes.
-Cold pack 10-15 minutes
everyday after hand
activities
-Tendon and nerve gliding
exercise
-Ergonomic modification of
hand (night resting splint)
2. Weakness on right Increase muscle Strengthening exercise of
hand strength of the m. flexor pollicis longus, m.
hand abductor pollicis brevis, m.
(m. flexor pollicis opponens pollicis of the
longus, m. right hand
abductor pollicis
brevis, m.
opponens pollicis
of the right hand)
3. Limitation of hand Increase hand - Exercise for increase
function (grasping, function (grasping, hand function
handling objects, handling objects,
pinching) pinching)

20
 4. Limitation of ADL Can do ADL -ADL training use of graded
(do house hold such activity in mild and activity as tolerate
as: cooking, moderate intensity -education for patient to do
washing clothes, ADL in mild and moderate
lifting heavy object intensity as tolerate
groceries)
5. Worried about his Relieve anxiety Psychological support for
illness patient and family

X. FOLOW UP
I. July 16th 2021 II. August 16th 2021 III. September 6th 2021

Subjective - Pain decreased in both - Pain decreased in both - Tingling sensation

hands, numbness both hands, numbness both and Numbness at both
hands decreased only after hands decreased hands decrease.
theraphy and still - Slight limitation on - No pain at both wrist
persistent during the day. pitching, grasping, -No limitation on
-Limitation on pitching, opposition, hand pitching, grasping,
grasping, opposition, hand prehension opposition, hand
prehension and ADL - ADL using both hands. prehension
using both hand - ADL using both hands.
Objective Hemodinamic status in Hemodinamic status in -Hemodinamic status
normal limit normal limit in normal limit
-Pain at right wrist (VAS -Pain at right wrist (VAS - No pain at both wrist
3) and left wrist (VAS 2) 2) and left wrist (VAS 1) - No limitation ROM at
- Hand Function: - Hand Function: wrist
Power grip : fair Power grip : fair - Hand Function:
Precision grip : fair Precision grip : good Power grip : good
MMT Precision grip : good
- m. Flexor pollicis longus MMT MMT
: 5/4 - m. Flexor pollicis - m. Flexor pollicis
- m. Abductor pollicis longus : 5/4 longus : 5/5
brevis : 4/4 - m. Abductor pollicis - m. Abductor pollicis
brevis : 5/4 brevis : 5/5

21
 - m. Opponens pollicis - m. Opponens pollicis - m. Opponens pollicis
: 5/4 : 5/4 : 5/5
-BCTQ at left hand: -BCTQ at left hand: -BCTQ at left hand:
symptom severity scale symptom severity scale symptom severity
(SSS) is 1,87 (SSS) is 1,5 scale (SSS) is 1,2
functional status scale functional status scale functional status scale
(FSS) is 1,6 (FSS) is 1,5 (FSS) is 1,1
-BCTQ at right hand: -BCTQ at right hand: -BCTQ at right hand:
symptom severity scale symptom severity scale symptom severity
(SSS) is 2,3 (SSS) is 2 scale (SSS) is 1,1
functional status scale functional status scale functional status scale
(FSS) is 2 (FSS) is 1,8 (FSS) is 1,2
Hamilton scale 10 Hamilton scale 8 Hamilton scale is 6

Assessment Carpal tunnel syndrome Carpal tunnel syndrome Carpal tunnel

bilateral bilateral syndrome bilateral

Program -Low Laser Level Therapy -Low Laser Level Low Laser Level
(LLLT) 3 J/cm2applied on Therapy (LLLT) 3 Therapy (LLLT) 3
acupuncture points of the J/cm2applied on J/cm2applied on
median nerve at the wrist acupuncture points of acupuncture points of
(in the middle of the wrist the median nerve at the the median nerve at the
in supination position) for wrist (in the middle of wrist (in the middle of
5 minutes. the wrist in supination the wrist in supination
-Tendon and nerve gliding position) for 5 minutes. position) for 5 minutes.
exercise -Tendon and nerve - Tendon and nerve
- Strengthening exercise gliding exercise gliding exercise
of m. flexor pollicis - Strengthening exercise -ergonomic
longus, m. abductor of m. flexor pollicis modification of hand
pollicis brevis, m. longus, m. abductor (modification
opponens pollicis of the pollicis brevis, m. household utensils at
right hand opponens pollicis of the home according to
- Exercise for increase right hand limited hand function,
hand function - Exercise for increase resting both hands
hand function periodically daily,

22
-Ergonomic modification -Ergonomic avoid hand’s activities
of hand modification of hand with wrist in flexion or
- Active ROM exercise as - Active ROM exercise extension
tolerated for both wrist as tolerated for both - splinting removal, but
- ADL training use of wrist if the nocturnal pain
graded activity - ADL training use of reappear again, the
- use Resting splint for graded activity patient can use it at
both hands in neutral - use Resting splint for night
position during night both hands in neutral - Home program :
Home program : position during night -The patient also being

-The patient also being Home program : educated ergonomic

educated ergonomic -The patient also being modification and

modification and educated ergonomic modification of

modification of household modification and household utensils at

utensils at home according modification of home according to
to limited hand function household utensils at limited hand function
-resting both hands home according to -resting both hands
periodically daily limited hand function periodically daily

-avoid hand’s activities -resting hands -avoid hand’s activities

both
with wrist in flexion or periodically daily with wrist in flexion or

extension. -avoid hand’s activities extension.

-Cold pack 10-15 minutes with wrist in flexion or
everyday after hand extension.
activities -Cold pack 10-15
minutes everyday after
hand activities

23
 VAS BCTQ
5 3
4 2.5
3 2
2 1.5
1 1
0 0.5

1-Sep
4-Aug
11-Aug
18-Aug
25-Aug
7-Jul
14-Jul
21-Jul
28-Jul
30-Jun

0
SSS Dextra SSS Sinistra FSS Dextra FSS Sinistra

VAS Left Wrist VAS Right Wrist 30-Jun 16-Jul 16-Aug 6-Sep

Muscle Strength
6

0
FPL Right FPL Left APB Right APB Left OP Right OP Left

30-Jun 16-Jul 16-Aug 6-Sep

24
 DISCUSSION

In this case report, we discuss about a 55 years old female patient who was
diagnosed with Carpal Tunnel Syndrome bilateral. The diagnosis was constructed
by anamnesis, physical examination and electrodiagnostic study.
Patient comes with chief complain pain on both wrists. According to the
literature patient complain of wrist and arm pain associated with parasthesias in the
hand. The pain may be localized to the wrist or may radiate to the forearm, arm, or
rarely, the shoulder; the neck is not affected. 11
In this patient, pain on both wrist associated with paresthesia and numbness
are felt at daytime working using both hand such as when she do house work like
cleaning, cooking, and when she do driving, using handphone, make up and holding
a heavy thing. The nocturnal symptom occurred because patient said she always
sleep with her hands placed below her head. While symptoms presents, patient often
flicked his hands to relieve it. No other complains at forearm, elbow, shoulder and
neck in this patient. This is consistent with literature that says symptoms are
classically worse at night, causing nocturnal wakening, and relieved by flicking the
hand and placing them in a dependent position. 11
Patient also has weakness in her both hands, especially in her right hand.
She said that she often drop something she hold like handphone and felt difficult
when open jar. According to literature weakness of the median innervated muscles
of the hand can be perceived as difficulty opening jars, buttoning, or dropping
objects. Muscle weakness can be noted in “LOAF” muscles (Lumbricals 1 and 2,
Opponens pollicis, Abductor pollicis brevis, and 4 heads of the Flexor Digitorum
Superficialis). Detectible clinical weakness is usually limited to the abductor
pollicis brevis, because the other muscles of the thumb (flexor pollicis brevis and
adductor pollicis) receive dual innervation by both the ulnar and median nerves.
Weakness of thumb opposition can appear as the disease advances, manifested by
difficulties with fine manual coordination.2
Tinel sign is elicited by lightly percussing the median nerve at the wrist with
a reflex hammer. Phalen sign is performed by flexing and holding the wrist with
some pressure at 90 degrees for 1 minute. The reverse Phalen maneuver is the same

25
test completed with forced extension. With active nerve compression, paresthesias
in the median nerve territory may be elicited with either maneuver.10 In this patient,
There are pressure pain on both carpal region, and pain at full flexion and extension
of both wrist. There also ROM limitation at both wrist. The provocative test such
as Tinnel’s sign, Phallen’s test, Reverse Phallen’s test, and Carpal compression test
was positive at both hands.
For this patient we use Boston Carpal Tunnel Questionare (BCTQ) and
Functional Status Scale (FSS). The most widely used instrument to quantify the
severity of clinical impairment and follow-up studies is BCTQ (Boston Carpal
Tunnel Questionnaire), the first specific patient-oriented score proposed for CTS.
Its internal consistency, validity, and reproducibility have been demonstrated and
its sensitivity to clinical change has been confirmed by many studies. It has two
distinct scales, the Symptom Severity Scale (SSS) which has 11 questions and uses
a five-point rating scale and the Functional Status Scale (FSS) containing 8 items
which have to be rated for degree of difficulty on a five-point scale. Each scale
generates a final score (sum of individual scores divided by number of items) which
ranges from 1 to 5, with a highest score indicating greater disability. In this case,
BCTQ is used at first visit and every follow up to quantify the therapy’s progress,
which get more severe by time due patient was unable to rest both hands and still
actively using it; also probably because the patient wasn’t following the
physiatrist’s theraphy programs regularly. 12
The treatment of CTS falls under two categories: conservative and surgical.
Conservative treatment is generally offered to patients suffering from mild to
moderate symptoms of CTS. Options of such treatment include oral and
transvenous steroids, corticosteroids, vitamins B6 and B12, nonsteroidal anti-
inflammatory drug (NSAIDs), ultrasound, yoga, carpal bone mobilization and the
use of hand splints.10 Treatment of CTS begins with modification of repetitive or
awkward activities that precipitate paresthesias.8,13
The goal of the treatment is the resolution of symptoms and preservation of
hand function. The goal of rehabilitation is to improve the functional status of
patients, rather than only symptom relief.19 Rehabilitation must address the patterns
of hand use, which exacerbates the symptoms of CTS in many individuals. Icing

26
after long periods of use has been advocated to reduce the pain and swelling. In
addition, it is important that patients be instructed in a program of general physical
conditioning.10
Patient treated with Low Level Laser Therapy (LLLT). LLLT for the
treatment of CTS has been utilized to reduce symptoms. Several studies have
attempted to determine the impact of laser radiation on nerve conduction,
regeneration and function. The first FDA clearance for laser therapy was based on
a 1995 study of IR laser (830nm) therapy for approximately 100 General Motors
employee with Carpal Tunnel Syndrome. This randomized double –blind controlled
study compared the effect of physical therapy combined with laser and laser versus
physical therapy alone for the treatment of carpal tunnel syndrome. Grip and pinch
strength, radial deviation range of motion (ROM), median nerve motor conduction
velocity across the wrist, and incidence to return to work were significantly higher
in the laser-treated group than in the control group. The treatment protocol was to
apply 3 J (90 mW for 33 seconds) during therapy for 5 weeks. A recent review of
seven studies of laser or light therapy for the treatment of carpal tunnel syndrome
found that two controlled studies and three open protocol studies reported laser to
be more effective than placebo. The studies finding benefit applied higher dose laser
(>9 J or 32 J/cm2) than those not finding benefit (1.8 J or 6 J/cm2). Laser light
treatment was applied to the area of the carpal tunnel. 11,13 The effect of laser light
on pain may be mediated by its effects on inflammation, tissue healing, nerve
conduction, or endorphin release or metabolism. Analgesic effects are generally are
most pronounced when laser or light is applied to the skin overlying the involved
nerves or nerve innervating the area of the involved dermatome.13

27
 Tendon gliding of the finger flexor tendons and nerve gliding of the median
nerve exercises are recommended for conservative management of symptoms
related to CTS. A study had proved that intermittent exercise of active wrist and
finger motion for 1 minute can lower pressure in the carpal tunnel. Based on this
experiment, the author recommends frequent 1-minute bouts of active motion
throughout the day. This can serve as part of the basis for tendon- and nerve-gliding
exercises so frequently utilized in managing CTS. These exercises may have a
positive effect on CTS, in part, by facilitating venous return or edema dispersion in
the median nerve.14
Nerve gliding or Neuromobilization techniques include repetitive motions
of the segment that produces the symptoms as well as combination of movements
in the more distal and proximal segments. Since nerves are viscoelastic structures
they may respond to mobilization procedures and techniques, similar to those for
the musculoskeletal system, with purpose to correct such abnormal neural tensions
and re-establish the proper movement of the neural tissue. This will result in a pain
free state with subsequent improvement in the patient’s functional ability level
which is most of times the final goal.
The treatment position used is identical to the neurodynamic testing
position. That includes 3 sets of 10 repetitions in each set, at a moderate pace and
a 3 second hold at the final stretched position. The therapist may focus more in that
segment of the nerve but always including all segments of the nerve in the technique
respecting the continuity of the neural tissue. The first few sessions all the
neuromobilization treatment positions should happen passively. As the treatments
progress the therapist may include active patient movements in the various
components of the maneuver. Usual patient responses may include, a feeling of
‘‘stretching’’, tissue tension, light numbness, slight increase of pain symptoms
during the technique. Such symptoms are usually reduced or eliminated
immediately at the end of the procedure.15

28
 This patient was encouraged to use wrist splint in neutral position at both
hands at night time. Properly fitted splint can assist in controlling symptoms of CTS
and should be offered to most patients as a first line of care. Splinting the wrist in
a neutral (0°) flexion/extension rotation position is generally agreed upon as the
favored technique. The recommendation for this position is supported by in vivo
studies which have used indwelling catheters to measure carpal tunnel pressure
while varying the wrist position. The consensus is that the lowest carpal tunnel
pressure occurs with the wrist in a neutral (0°) anatomic position. Usually, the splint
should be worn for 4 to 6 weeks, with gradual weaning from the splint and return
10
to activity. Today, static wrist-hand orthoses are most commonly used for the
treatment of carpal tunnel syndrome. This orthosis includes wrist positioning in
neutral (i.e., 0 degrees of extension) and allows full freedom of thumb and finger
movement. CTS commonly results from the overuse of the wrist and hand causing
inflammation with in the CT.16
Sosic et al show that wearing night splint in a neutral position can increase
the carpal tunnel space, decrease compression of MN and therefore alleviate the

29
symptoms. And they suggest that splinting already improves the patients outcomes
measurement and brings relief symptoms, so that no additional costly physical
therapy would be necessary, and also that study showed that night time splinting
lasting > 12 weeks was beneficial not only for patients with mild CTS but also for
those with advanced CTS.17 Most patients will achieve maximal symptom relief
through splinting within 2 to3 weeks. Complete resolution of this syndrome can
occur if wrist orthoses are applied early, when symptoms first appear.17

In this patient was encouraged to use wrist splint in neutral position at boths
hand at night time. After use resting splint about weeks, it’s show improvement the
level of paraesthesia and hand grip strength.

30
 DAFTAR PUSTAKA

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13. Cameron Michelle H. Physical Agents in Rehabilitation Fifth Edition.
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