case study: carpal tunnel syndrome

8/10/2019 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.


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.


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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Tendon Gliding Exercise


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Nerve Gliding 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

case study: carpal tunnel syndrome

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