#PTonICE Daily Show – Tuesday, January 23rd, 2024 – A Cert-Ortho approach to CTS

In today’s episode of the PT on ICE Daily Show, Extremity Division Leader Lindsey Hughey discusses a modern approach to carpal tunnel syndrome (CTS), including when central findings are present. Lindsey discusses examination and treatment, including the use of the rehabilitation every-minute-on-the-minute style (rEMOM) exercise dose.

Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog.

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Good morning, PT on ICE Daily Show. How are you? Welcome to Clinical Tuesday, my favorite day of the week. I am Dr. Lindsay Hughey from our extremity management team, and I am here to chat with you today about an ortho-cert approach to carpal tunnel syndrome. And what do we do when it’s not just the carpal tunnel, when we also see some central symptoms? So I am going to unpack what a fitness-forward approach looks like, how we will use our manual therapy to modulate symptoms, and then what psychologically informed looks like for this condition when we think about combining all the courses from our OrthoCert and putting that all together in an integrative way, how we can approach this condition. and then I’ll leave you with a couple rehab e-moms at the end, so stay for that.

So first off, let’s briefly review what the subjective and objective presentation with someone with carpal tunnel syndrome and then possible central considerations that are present as well. Think double crush is kind of a common medical term present. So for that CTS, that carpal tunnel syndrome, we’ll see classic sensory anesthesias or paresthesias in those first three fingers and then possibly that radial half of the ring finger. There may be motor deficits in our first and second lumbricals, opponent’s pollicis, abductor pollicis brevis. So think about in your objective exam, thub abduction and thumb flexion may be weak. We’ll also see, from an objective perspective, locally we’ll see a positive phalanx and tonels, and then our carpal compression test. Patients will complain of interruption in gripping and daily tasks. They may even drop objects or have to shake out their hand to ameliorate symptoms. Often symptoms are worse at night, and then when they first wake up in the morning, and then tend to improve as the day goes on. When we also consider there might be some central things going on, it’s that person that not only complains of what I just told you and had objective exam findings, but they also say they have some numbness tingling along that C5, C6 dermatome. They may complain of some local neck tightness or achiness in that mid to lower cervical spine area. on exam, you will find a UPA or central PA will elicit those familiar symptoms when you’re around C5, C6. In addition, that dermatome distribution will be impaired and then reflex changes in that biceps reflex might be abnormal compared to that uninvolved side and we really understand the whole clinical picture when we use a body chart right and we really listen to that subjective and dial in their ags and eases so you find out when all of that’s on board that there’s two things going on at the same time and here’s where we’ll need our ortho hats where we need to put into practice what we know in our cervical class and what we know from our extremity class.

So first off what is fitness forward? when that’s one of our primary pillars. So what does that mean for this condition and in general? Well, we are going to approach the whole human in front of us. We know that this typically affects females later in that fourth and fifth decade. they are two times females are two times more likely than males to have this condition and so appreciate that in that decade that’s either you know a career focused time or family focused or a mix of the two so consider the stressors for that human that may or may not be involved in that decade. And then we see some links to obesity as well. So thinking about the whole human holistically, we see worsening symptoms for those that have higher BMIs. So not only will we consider the whole human from a fitness forward perspective, but we’re going to think about how can we attack local tissue getting irritability down. So think about local tissue in the hand and even in that C5, C6 area of cervical spine. And then we’ll start with local treatment but then eventually we’re already thinking about how globally will we make this human more resilient and robust in their grip strength and their overall upper quarter strength. So even day one when we’re trying to just calm symptoms we’re thinking fitness forward. How fit will you let me get you? We’re gonna consider those system influence that I already mentioned, sex and possible stressors in life. We’re gonna consider mindset, the physical activity levels of that human, because again, I said there’s links to increased BMI and obesity. So we’re dealing with an underlying systemic inflammation probably on board as well. We’ll think about what’s that sleep hygiene like? Are they getting the eight to nine hours of sleep? How’s their diet and hydration? Are they getting half their body weight in ounces? Are they eating colorfully? That is all a part of fitness for it. So it’s not just loading them up locally, globally, making tissues robust, but really we want a whole system-wide robustness.

And the way we’ll first approach these humans is through symptom modulation, through our manual therapy techniques. This is how we’ll really get trust and buy-in when we’re dealing with carpal tunnel syndrome, or CTS, and then there’s central possible involvement as well. double crush, whatever kind of terminology makes you comfortable. I tend to think labels limit. And if you’ve been to our extremity course, you know that. So symptom modulation locally first looks like bracing, actually. So an over-the-counter splint at night is first-line defense because that’s when symptomatology is worse because we’re sleeping in that phalanx position. And if there’s worsening symptoms in the day, we’ll even recommend a wearing schedule during the day. But we first start with night. We’ll educate on any ags and easing postures, right? If moving in and out of postures is really important. We don’t want someone hunched over like this all the time, and we also don’t want someone being perfectly erect. So depending on their job and life and family functions, we’ll give some advice there as well, as our education starts to dampen irritability and symptomatology. Our manual therapy perspective though, so here’s our second pillar coming to play. is that we are going to target the CT junction and then an upper T spine. And we’re going to use manipulation. You’ll hear at our course that if you have any upper quarter symptoms and you have a pulse, you are going to get some kind of thoracic manipulation. for that neurophysiologic effect. So what you learn in your cervical and total spine thrust courses, you’re going to bring forward here. And this is going to help dampen pain, not only centrally right in the cervical spine, but also we see pain dampening and increase motor output in our upper quarter when we use those techniques. So those will be our go-to techniques, prone CT junction, and then our upper T-spine manip. In addition, doing some lateral gliding for a pumping action in those higher irritability stages targeted at that C5, C6 area. Follow up for that will be some cervical retractions to get a pumping action centrally. And we may or may not combine that with some traction. a manual therapy perspective from extremity management local to those carpal bones and that wrist, we’ll actually start doing some wrist mobilization. Extension’s often a common impairment here, so we’ll work into progressive extension, mobilizing those carpals, and we’ll even do this nice soft tissue splay technique. If you’ve been to the course, you know, and if you’re on the fence, you’ll join us to learn this, but a splay technique to just open up right where that median nerve travels through where all of our flexor retinaculum is, it gets tight in there when there’s inflammation on board. So just doing some soft tissue mobilization and splay. And it’s interesting is this is a tech, the technique we teach is one that was actually used in that PTJ study in 2020 from De La Penas and crew, where they looked at four-year follow-up of those with carpal tunnel syndrome that did conservative care, which was only three bouts of PT, and this splay stretch was included in the 30 minutes of manual therapy that these folks got, and they compared this group to those that went on to get surgery, and they followed them over four years. What was similar about both groups is both groups got education and they got tendon and nerve glides. And what we saw is similar similarities. So meaning pain and function was the same whether you got surgery or conservative care, which lets us know that our conservative care, our manual therapy techniques like this splay technique can be a really powerful resource for our patients to modulate symptoms and to lower that irritability in their tissues. In addition, not only will we do some wrist extension mobs, do that splay stretch, but we’ll also work locally at that thenar eminence. And we will target our wrist flexors with myofascial decompression, soft tissue massage, and or dry needling. So targeting wrist flexors, forearm pronators, and the thenar eminence anywhere where that median nerve could be compressed. So those are our manual therapy targets.

Moving on to our next pillar, psychologically informed, how do we address psychological considerations for this human that has CTS and then symptoms along that C5, C6 dermatome with reflex changes as well? Well, we’re going to have a conversation about lifestyle, about what we call meds health. Simply that is M is mindfulness, E is exercise, D is diet, and sleep. And this is a nice framework to address lifestyle behaviors. Now we might not address them all at once and we’ll choose our education and dose it wisely, right? We don’t want to fire hydrant lifestyle behavior modification to patients, but we do want to make sure all the pillars and how they’re functioning are in the background of our mind. So consider M mindset. or mindfulness what we’re thinking here is what can we give this human that’s kind of stressed and in pain to just calm their system and one really great way to bring them into a more parasympathetic state is doing breathing so breathing in just five minutes a day physiologic sighing right, where you do that two inhalations through your nose and exhale has been found to be beneficial in reducing physiologic factors like heart rate and just calming our system. So consider that can be an easy thing to integrate into a patient’s life that is stressed or maybe suggesting some green space, go out for a walk and or journaling if that is their thing. from an e-perspective, exercise, what I want you thinking about is just what’s their physical activity like? Are they getting their 10,000 steps daily? Are they meeting the daily requirements of physical activity, which is 30 to 60 minutes every day, right? We want a total of 150 to 300 minutes a week. Is this human getting that activity? And if we consider some of the common profiles, which is obesity and being female in that later decades of life, we need to consider what is that like and how can we influence them to move more to help with this inflammatory state that’s going throughout their body. D is diet, so education on what is your diet like? Are you eating enough protein to support healing and function? Can you reduce that sugar intake to calm inflammation? Can you eat colorfully, eating more plants, again, to help control inflammation? How’s your hydration? Are you getting half your body weight in ounces? These are additive behaviors that we can help, always trying to add first and then take away if necessary. And then finally that final pillar, sleep. How is sleep hygiene? Talk to this human about maybe very dark in the room an hour before bed, no heavy big meals or your phone or TV. This can help just with quality of sleep. So consider that psychologically informed piece is so important. And you’ll kind of notice that there’s always a synergy between our pillars, right? You can’t be fitness forward, right? And build up local tissue and global tissue robustness if you don’t first symptom modulate through manual therapy, right? And our manual therapy needs to be excellent and executed well with the right dosage so that we can be effective in symptom modulation, which gives us this modulating window of opportunity to then load them better locally and then globally when we think about the upper quarter. And then the psychologically informed piece, we need solid education and lifestyle counsel to help this whole human, this whole system be more robust in their world. And that’s why the trifecta and the synergy of the pillars is so important.

I want to leave you with two rehab EMOMs inspired by exercises that we learn in our cervical course and then exercise that we prescribe in our extremity course. So, and if you want to write it down, feel free, but early in our care with high irritability, I would suggest a 12 minute rehab EMOM that looks like this. We’re thinking about someone that has lots of numbness, tingling, lots of inflammation on board. All ADLs and IADLs are limited. their sleep sucks, right? They need a massive blood pump. Minute one, we’re going to do a UBE, a salt bike, or echo, or rower, whatever the patient loves. Minute two, we’re going to do tending glides because we see tending glides in some of our RCTs being superior than our nerve glides and helping create a local pump to our flexor tissues. Number three, minute three, is nerve glides, right? We’re going to do a slider glider for that median nerve and even try to get that cervical spine involved. And then number four, we’re going to do cervical retraction with or without traction. So we put that band on a secure surface and there’s this traction environment where we’re offloading the lower to mid cervical and then doing some pumping action cervical retraction. We’ll do that three rounds and that’s why it’s a 12 minute rehab EMOM, early in care, high inflammation on board. I’m going to leave you one more EMOM, and then we’ll call it a day for PTL Nice. But later in care, when irritability is dampened, right, and we more are at that lower irritability stage, there’s no longer numbness and tingling symptoms. We’re thinking about robustness of local and global tissue, and we’re working on resilience, we want to layer in more volume and intensity. So we’ll use that same structure, 12 minutes. Minute one, we’re going to do grip training. So we are going to specifically target doing a spherical grip. So you would turn that kettlebell upside down and work on carries, which works on the whole upper quarter, arm at side or arm here. So we get that cuff firing up as well. And we’ll work on that. You can even work on your tip grip or palmar grip as well to really target median nerve and the muscles that feeds. That’s minute one. Minute two, we’re going to do some wrist flexion and wrist extension exercise. Recommend rehab dose if you’ve been to one of our courses, you know, that’s 8 to 20 reps 3 to 4 sets Anywhere from 30 to 80 percent intensity, right? You’ll meet the patient where they’re at minute two again just a repeat wrist flexion extension exercise and then minute three will be pronation supination and then finally minute four we’ll actually do prone cervical retraction off the table to start building up robustness of the cervical extensors. These are just two examples of how when you take our ortho cert courses specifically our spine courses and then our extremity courses it’s helpful to prepare you for management for something like cts when there’s also that double crush right there’s involvement um centrally and distally.

Our author’s cert, we would love you to be a part of it and learn more about it. If you’re interested or the first time you’re hearing this, check us out on ptlonice.com and it’ll tell you all the courses required, total spine thrust, cervical, lumbar, extremity management, and testing for this is free. You just take those courses and you test out at the end. It’s been a blast kind of talking to you about how we integrate our classes. From an extremity management perspective, class is coming up. Mark and I are both on the road this weekend, and there’s still, there’s one spot left in Mark’s course in Fayetteville, North Carolina. There’s lots of spots left in Burlington, New Jersey, if you want to join us. And then the following weekend, we’re at it again. We will be in Highland, Michigan, and then Scottsdale, Arizona, and we have spots. So again, ptonice.com to check out OrthoCert, and then check out extremity management courses. Thank you for your time this morning and in listening to that OrthoCert approach to CTS. Happy Tuesday, everyone. And if you think about it, wish our CEO a happy, happy birthday. He’ll love that. See y’all later.

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