case study: carpal tunnel syndrome
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CARPAL TUNNELSYNDROME :
A Patient Case
MUSLIHAH BINTI MOHD RAZALI (A139018)
ANIZAH BINTI LAMIRON (A137987)
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INTRODUCTION
Carpal Tunnel Syndrome - arises from the
intermittent or continuous compression or
entrapment of the median nerve as it passesthrough the carpal tunnel from the wrist to
the hand.
(Fisher et al 2004)
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The median nerve
(yellow) can become
pinched as it runs
through the carpal
tunnel, the space
between the wrist bones
and the transverse carpalligament (white). This
leads to numbness or
pain and the loss of
function in parts of thehand and fingers
associated with carpal
tunnel syndrome.
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POPULATION AT RISK
Three times more common in women than in
men.
More common in middle aged women.
More commonly seen in older people.
People who experience job stress.
Obese individuals.
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CASE
INVESTIGATION
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PATIENT: MRS. J
Gender: Female Age: 45 years old
Job: Computer-based financial advising
business. Diagnosis: Carpal Tunnel Syndrome (CTS) on
her right wrist.
Typical weeks activities: working 8-10 hoursper day, five days a week at her home-basedcomputer workstation, meal preparation, andscrapbooking with friends.
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MRS JS SYMPTOMS & SIGNS
Symptoms Intermittent pain, numbness or paresthesia in
hand
Subjective hand swelling and stiffness
Wrist pain
Signs
Weakness of resisted thumb abduction Decreased grip strength
Shaking or flicking one's hands for relief during
maximal symptoms
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CURRENT FUNCTIONAL ABILITIES &
LIMITATIONS
Unable to type for more than five consecutiveminutes without symptoms of pain andparesthesia.
Uncertain of proper wrist positioning whenperforming various tasks, including using hercomputer keyboard, calculator and phone.
Had difficulty with several aspects of mealpreparation; opening jars, cutting food,picking up heavy containers and preparingmeals.
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Having the most difficulty with performingcertain scrapbooking tasks; cutting photoswith scissors into intricate shapes, using a
corner rounder tool, and cutting paper witha trimmer.
Having a difficult time sleeping at night due to
wrist pain at night and the stress related tonot being able to perform her necessary workand cooking responsibilities.
CURRENT FUNCTIONAL ABILITIES &
LIMITATIONS (cont.)
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OCCUPATIONAL
THERAPY PROCESS
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Assessments
Goniometry- To assess range of motion.
Dynamometer- To assess grip strength.
Visual Analog Scale (VAS) - Used before and
after work related tasks as a self-perceived
measure of pain. A score of 0 would be no
pain at all and a score of 10 would be the
worst pain possible.
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Performance in Areas of Occupation
For Mrs. J these included: Instrumental Activities Of Daily Living (IADL):
meal preparation
Work: completing work tasks such as typing(Job Performance)
Leisure: participating in scrapbooking activity(Leisure Participation)
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Instrumental Activities Of Daily Living
(IADL)
Performance ObservedMrs. J was observed in doing a simulated cookingtask
Performance Patterns Identified
Mrs. J placed her right wrist in extreme extensionwhen cutting with a knife and when opening the
lid of the peanut butter jar and jelly jar.
Had difficulty manipulating the jar lids due todecreased grip strength.
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Hypothesis Refined
Mrs. Js decreased ability to perform tasks of
daily life was due to poor wrist positioningresulting in pain.
Mrs. Js work station was set up in a way that did
not promote proper upper positioning whichmay contribute to her overall discomfort when
performing work related tasks.
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Selected Outcome
1. Long term goal:
Mrs. J will cook a meal for herself with minimalassistance from her two children for their family
dinner.
2. Short term goals:
Mrs. J will complete a 3-5 step cooking task with a
reported VAS of less than 3/10.
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WORKPerformance Observed
Mrs. J was observed at a computer workstation in thetherapy room which was set up to stimulate herpersonal computer workstation.
Performance Patterns Identified
Mouse and mouse pad were placed 14 inches lateralto her monitor and keyboard which resulted in poorpostural mechanics.
Hypothesis Refined
Same as IADL
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Selected Outcome
1. Long term goal:
Mrs. J will be able to independently perform workactivities safely for an 8-hour day.
2. Short term goal: Mrs. J will demonstrate the set up at her home
based work station with moderate assistance and
will adhere to ergonomic instruction in order to
tolerate working a 3-hour work day.
She will demonstrate the ability to safely sustain a
5-hour work day using adaptive equipment.
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LEISUREPerformance Observed
Mrs. J was observed in the therapy room doingsimulated scrapbooking tasks.
Performance Patterns Identified
Mrs. J placed her wrist in extreme extension whencutting paper shapes and trimming pictures.
Frequently rested the proximal region of her palmarsurface on the table surface that she was working on.
Hypothesis Refined
Same as IADL
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Selected Outcomes
1. Long term goal:
Mrs. J will independently complete 5 pages outof her 20 page scrapbook for her fathers 70thbirthday.
2. Short term goals: Mrs. J will tolerate greater than 5 minutes using
the necessary scrapbooking tools with a reportedpain level of less than 3/10.
Mrs. J will tolerate greater than 10 minutes ofactivity with no more than one rest period.
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OCCUPATIONAL THERAPY
INTERVENTIONS
Guide to physical therapy practice:
Therapeutic Exercise
Functional training in self-care and home
management
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Therapeutic Exercise
Tendon Gliding Exercise
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Nerve Gliding Exercise
Therapeutic Exercise
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Functional Training In Self-care and
Home Management
Ergonomically Work Station The positioning of equipment was altered to become
more ergonomically correct, and certain equipmentwas added to support performance
Posture Proper postural positioning was promoted during
scrapbooking activities by having the participants in alarge room with adequate table space andergonomically-correct chairs.
Share home chores Mrs. J started giving her children daily kitchen chores
related to meal preparation.
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Learn new techniques
Learning new cooking strategies and techniques to
promote proper wrist positioning and prevent
pain
Functional Training In Self-care and
Home Management
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OUTCOME RELATED TO ASSESSMENTS
Upon completion of the assessment and
interventions, it was determined that the
three activities of work, meal preparation, and
scrapbooking were of greatest importance toMrs. J (importance scores of 10/10, 9/10 and
9/10, consecutively).
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ALTERNATIVE TREATMENT OPTION
If treatment is unsuccessful for severe CTS, areferral to their physician could lead to the
following options as seen in the literature:
Efficacy of surgical release of carpal tunnel
After 3 months: 80% success
rate for surgery, 54% for the
splinting group after 3 months.After 18 months: increased to
90% for surgery and 75% for
splinting (Gerritsen et al).
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STANDARDS AND REGULATIONS
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REFERENCES
Bruce Fisher, Ron Gorsche and Patricia Leake.May 2004. Diagnosis, Causation and Treatment
of Carpal Tunnel Syndrome: An Evidence-Based
Assessment
Arthritis Foundation, Malaysia
Dr. Grace Walker Gray. 2008. Carpal Tunnel
Syndrome and Occupational Therapy
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THANK YOU
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