PHYSICAL THERAPY MANAGEMENT

(MEDIAN NERVE INJURY)

Kurnia Putri Utami, S.Ft, M.Biomed, Physio

Department of Physiotherapy
Faculty of Health Science
University Of Muhammadiyah Malang
Introduction

+ Symptomatic compression neuropathy of the median nerve at the

level of the wrist, characterized physiologically by evidence of
increased pressure within the carpal tunnel and decreased
function of the nerve at the level (American Academy of
Orthopaedic Surgeons)
+ Most common peripheral nerve compressive disorder in the upper
extremity
+ Affects male and female individuals of varying ages and is not
specific to ethnic or occupational factors
 Anatomy +The Median Nerve extends along the middle of the arm and forearm to
the hand
+It arises by two roots, one from the lateral and one from the medial cord
of the brachial plexus
+After it descends the proximal arm, the nerve crosses the antecubital
fossa deep to the biceps aponeurosis between the biceps tendon and
pronator teres, lying on the distal brachialis muscle.

(Murphy& Morrisonponce, 2020)

 (YT by Human Anatomy, Kenhub, 2014)

Anatomy (Video)
Symptoms

+ Numbness, tingling in the tumb and index, middle and radial half of
the fingers, burning pain ,distal forarm pain, diminished grip and
pinch strength and loss of sensation
+ Symptom may vary day to day
The Progress

+ Patients may notice aggravation of symptoms with static gripping of objects

such as a phone or steering wheel but also at night or early in the morning. 

+ Many patients will report an improvement of symptoms following shaking or

flicking of their hand.

+ As the disorder progresses, the feeling of tingling or numbness may become

constant and patients may complain of burning pain.

+ The final symptoms are weakness and atrophy of muscles of the thenar
eminence. These combined effects of sensory deprivation and weakness may
result in a complaint of clumsiness and loss of grip and pinch strength or
dropping things
 Proximal edge of the transverse
carpal ligament

Adjacent to the hook of the hamate

Common Areas
of Compression
Space-occupying lesion
The Risk Development
+ Vocation
+ Occupation
+ Lifestyle
+ Gender
+ Genetics
Three Causes
+ Compromised oxygen delivery and resulting ischemia
+ Decreased longitudinal excursion of the median nerve
+ Injury or compression to carpal structures secondary to
mechanical influence
Manual Test
+ Upper Limb Tension Test
ULTT 1
ULTT 2A
+ Tinel’s percussion test
Developed by Tinel in 1915. Gingerly tapping over an irritated
nerve may produce paresthesias at the percussion site and in
the nerve distribution. This test is not used exclusively to test
for CTS and is often used generally to test for nerve irritation.
+ Phalen’s Test
Developed by Phalen, an American Surgeon (1966). Increased
carpal tunnel pressure is achieved as the patient is positioned in
bilateral wrist hyperflexion by pressing dorsal hands together for 60
seconds; a positive test result is symptom reproduction in median
nerve distribution. (Reverse Phalen test is conducted in “praying
hands” fashion, achieving wrist hyperextension.)
+ Carpal compression Test
In 1991, Durkan developed this simple test. It is performed by
applying direct pressure on the carpal tunnel for up to 1 minute. The
test is considered to be positive if the subject reports
paresthesia/dysesthesia in the median nerve distribution.
 + Disability of Hand and Shoulder

Outcome Measure Quistionnaire (DASH)

+ Boston Carpal Tunnel Quistionnaire (BCTQ)
 Boston Carpal Tunnel Syndrome Quistionaire (BCTQ)

(Ball et al, 2011)

 EMG

NCV

Standard of CTS
Diagnostic MRI

ULTRASOUND
Physical Therapy
Management
Modalities IR

Electrophysical
LASER Agent
TENS

ULTRASOUND
Manual Therapy

Neural Mobilization (Sliders / Tensioners)

Carpal Bone Mobilization

Soft Tissue Mobilization

Proprioceptive Neuromusculer Facilitation

Neural Mobilization Technique
(Santana et al, 2015)
Sensory Relearning
+ Behavioural intervention that makes use of ‘learning-dependent’
cortical plasticity
+ Graded tactile stimuli are used in combination with attention and
intermittent use of visual feedback to facilitate improved tactile
discrimination in the hand or upper limb
+ The SR programme proposes short intensive periods of tactile
stimulation with and without vision, combined with cognitive
learning techniques, to improve sensibility and function of the hand.
(Jerosch-Herold et al, 2016)
 Home Program &
Education

Ergonomic Task
Modification modification
REFERENCE
+ Ball, C., Pearse, M., Kennedy, D., Hall, A., and Nanchahal, J. (2011).
Validation of a one-stop carpal tunnel clinic including nerve conduction studies
and hand therapy. The Annals of The Royal College of Surgeons of England,
93(8), pp. 634-638.
+ Carp, Stephen J. 2015. Peripheral Nerve Injury : An Anatomical and
Physiological Approach for Physical Therapy Intervention.Philadelphia : F.A
Davis Company
+ https://www.youtube.com/watch?v=8iYxrZKAZU&feature=emb_logo
+ Jerosch-Herold, C., Houghton, J., Miller, L., & Shepstone, L. (2016). Does
sensory relearning improve tactile function after carpal tunnel decompression?
A pragmatic, assessor-blinded, randomized clinical trial. The Journal of hand
surgery, European volume, 41(9), 948–956.
+ Martin, Suzanne., Kessler, Mary. 2016. Neurological Interventions For Physical
Therapy 3rd Edition. USA:Saunders
+ Murphy KA, Morrisonponce D.2020. Anatomy, Shoulder and Upper Limb,
Median Nerve. [Updated 2020 Jul 31]. In: StatPearls [Internet]. Treasure Island
(FL): StatPearls Publishing
+ Santana, H. H. S., Fernandes, D. E. I. A. V., Medrado, A. P., and Nunes, S. K.
(2015). Neurodynamic mobilization and peripheral nerve regeneration: A
narrative review. Int J Neurorehabilitation, 2(2).