Case Study: Carpal Tunnel Syndrome

CARPAL TUNNEL
SYNDROME :
A Patient Case
MUSLIHAH BINTI MOHD RAZALI (A139018)
ANIZAH BINTI LAMIRON (A137987)
INTRODUCTION
Carpal Tunnel Syndrome - arises from the
intermittent or continuous compression or
entrapment of the median nerve as it passes
through the carpal tunnel from the wrist to
the hand.
(Fisher et al 2004)
The median nerve

(yellow) can become
pinched as it runs
through the carpal
tunnel, the space
between the wrist bones
and the transverse carpal
ligament (white). This
leads to numbness or
pain and the loss of
function in parts of the
hand and fingers
associated with carpal
tunnel syndrome.
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.
CASE
INVESTIGATION
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 hours
per day, five days a week at her home-based
computer workstation, meal preparation, and
scrapbooking with friends.
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
CURRENT FUNCTIONAL ABILITIES &

LIMITATIONS
Unable to type for more than five consecutive
minutes without symptoms of pain and
paresthesia.
Uncertain of proper wrist positioning when
performing various tasks, including using her
computer keyboard, calculator and phone.
Had difficulty with several aspects of meal
preparation; opening jars, cutting food,
picking up heavy containers and preparing
meals.
CURRENT FUNCTIONAL ABILITIES &

LIMITATIONS (cont.)
Having the most difficulty with performing
certain scrapbooking tasks; cutting photos
with scissors into intricate shapes, using a
corner rounder tool, and cutting paper with
a trimmer.
Having a difficult time sleeping at night due to
wrist pain at night and the stress related to
not being able to perform her necessary work
and cooking responsibilities.
OCCUPATIONAL
THERAPY PROCESS
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.
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)
Instrumental Activities Of Daily Living

(IADL)
Performance Observed
Mrs. J was observed in doing a simulated cooking
task
Performance Patterns Identified

Mrs. J placed her right wrist in extreme extension
when cutting with a knife and when opening the
lid of the peanut butter jar and jelly jar.
Had difficulty manipulating the jar lids due to
decreased grip strength.
Hypothesis Refined
Mrs. Js decreased ability to perform tasks of
daily life was due to poor wrist positioning
resulting in pain.
Mrs. Js work station was set up in a way that did
not promote proper upper positioning which
may contribute to her overall discomfort when
performing work related tasks.
Selected Outcome
1. Long term goal:
Mrs. J will cook a meal for herself with minimal

assistance 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.
WORK
Mrs. J was observed at a computer workstation in the
therapy room which was set up to stimulate her
personal computer workstation.
Mouse and mouse pad were placed 14 inches lateral
to her monitor and keyboard which resulted in poor
postural mechanics.
Hypothesis Refined
Same as IADL
Selected Outcome
1. Long term goal:
Mrs. J will be able to independently perform work

activities 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.
LEISURE
Mrs. J was observed in the therapy room doing
simulated scrapbooking tasks.
Mrs. J placed her wrist in extreme extension when
cutting paper shapes and trimming pictures.
Frequently rested the proximal region of her palmar
surface on the table surface that she was working on.
Hypothesis Refined
Same as IADL
Selected Outcomes
1. Long term goal:
Mrs. J will independently complete 5 pages out

of her 20 page scrapbook for her fathers 70th
birthday.
2. Short term goals:
Mrs. J will tolerate greater than 5 minutes using

the necessary scrapbooking tools with a reported
pain level of less than 3/10.
Mrs. J will tolerate greater than 10 minutes of
activity with no more than one rest period.
OCCUPATIONAL THERAPY
INTERVENTIONS
Guide to physical therapy practice:
Therapeutic Exercise
Functional training in self-care and home
management
Tendon Gliding Exercise
Nerve Gliding Exercise
Functional Training In Self-care and

Home Management
Ergonomically Work Station
The positioning of equipment was altered to become
more ergonomically correct, and certain equipment
was added to support performance
Posture
Proper postural positioning was promoted during
scrapbooking activities by having the participants in a
large room with adequate table space and
ergonomically-correct chairs.
Share home chores

Mrs. J started giving her children daily kitchen chores
related to meal preparation.
Functional Training In Self-care and

Home Management
Learn new techniques
Learning new cooking strategies and techniques to
promote proper wrist positioning and prevent
pain
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 to
Mrs. J (importance scores of 10/10, 9/10 and
9/10, consecutively).
ALTERNATIVE TREATMENT OPTION

If treatment is unsuccessful for severe CTS, a
referral 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).
STANDARDS AND REGULATIONS
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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CARPAL TUNNEL

The median nerve

MRS JS SYMPTOMS & SIGNS

CURRENT FUNCTIONAL ABILITIES &

CURRENT FUNCTIONAL ABILITIES &

Performance in Areas of Occupation

Instrumental Activities Of Daily Living

Performance Patterns Identified

Mrs. J will cook a meal for herself with minimal

2. Short term goals:

Mrs. J will complete a 3-5 step cooking task with a

Mrs. J will be able to independently perform work

2. Short term goal:

Mrs. J will demonstrate the set up at her home

Mrs. J will independently complete 5 pages out

2. Short term goals:

Mrs. J will tolerate greater than 5 minutes using

Functional Training In Self-care and

Share home chores

Functional Training In Self-care and

OUTCOME RELATED TO ASSESSMENTS

ALTERNATIVE TREATMENT OPTION

STANDARDS AND REGULATIONS

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