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Posts Tagged ‘cts’

There was an article in the New York Times recently entitled Sports Injuries: When to tough it out.

The part of the article that stood out involved diagnostic testing. Here is a quote from the article:

“Sometimes going to a doctor for a diagnostic workup can be precarious, with scans that can show all sorts of apparent abnormalities and injuries that are not causing any problems.

For example, in a study reported at a recent meeting of the American Orthopedic Society, Dr. Matthew Silvis, an orthopedist in Palmyra, Pa., did M.R.I.’s of the hips of 21 professional hockey players and 21 college players. They showed abnormalities in 70 percent of the athletes, even though these hockey players had no pain or only minimal discomfort that did not affect their playing. More than half had labral tears, rips in the cartilage that stabilizes the hip.”

“M.R.I.’s are so sensitive,” Dr. Musahl said. “They frequently show little tears or fraying everywhere. And it is very, very common to have a small labral tear in your hip — it doesn’t mean you have to have the particular symptoms.”

The same is true for rotator-cuff tears, rips in the tendons that help stabilize the shoulder. Studies have found that about half of all middle-age people with no shoulder pain have these tears, although they are unaware of them and have no symptoms.

Testing certainly has it’s place but it is important to understand that testing is only one piece of the puzzle. The assessment, symptomatology, mechanism of injury, and experience also play a critical role because:

  • Hockey players are going to have hip labral tears
  • Baseball players are going to have labral fraying
  • Middle aged people are going to have degenerative changes
  • Assembly line workers are going to have tests positive for carpal tunnel and rotator cuff tears
  • Individuals over the ages of 50-60 are going to present with lumbar spine pathology
  • And so on…

And all of these test results could appear in someone who is completely asymptomatic.

It gets interesting when the individual reaches threshold – when symptomatology now presents itself.

Here are a couple of examples to consider from several years ago – both involved individuals diagnosed with carpal tunnel syndrome.

  • One individual fell on their wrist and aggravated their wrist. Within about a week of developing symptoms, an EMG was done and the test came back positive for CTS. So…in 1-2 weeks someone is going to go from not having CTS to now having it???
  • A individual was having significant wrist and shoulder pain – a recent flare-up. They were previously diagnosed with CTS via EMG (chronic case). With the latest flare-up in symptoms, another EMG was ordered since it had been awhile from the previous EMG.  Here this individual was in pretty severe pain and the new EMG results were…EMG results were improved from previous testing and were now within the “normal” range. A person who is in pretty severe pain now is being told that they no longer have CTS???
  • Add your own story or example here.

Everything is fine when 2 and 2 equal 4. It starts to get dicey when things don’t add up as easily. Again, the assessment – the symptoms- mechanism of injury – and your experience as a clinician play a significant role in bringing together the full picture.

As a young athletic trainer, I was under the impression that MRI and other diagnostic testing were the final determinant regarding someone’s injury status. Years of experience, research, professional discussion, and lots of “huh??? This doesn’t make sense” moments have changed that thought process over the years.

Diagnostic testing does have it’s place but it is important to keep testing in the proper perspective. It is a piece of the puzzle and requires putting the other pieces together as well. Diagnostic testing does not slam the door on the case necessarily – plenty of detective work needs to be done so that the entire case can be properly evaluated.

What are your thoughts? Have you had similar experiences when diagnostic testing and reality weren’t quite meshing?

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Have you recently considered if wrist positioning affects grip strength?

Well, in case you have, this post is going to discuss some facts related to grip strength and wrist positioning.

So lets go through this demonstration to see if wrist positioning does affect grip strength. Working in the industrial setting, this is a demonstration that I will use with patients and other individuals to stress the importance of a neutral grip whenever possible.

So let’s take a look at the first example of grip with the wrist held in the neutral position. A neutral grip was able to generate 105 pounds of force. The second example shows the wrist at approximately 30 degrees of wrist flexion. Pay attention to the grip strength that is generated. The grip strength generated in this position is 68 pounds of force. 35% less than in neutral grip. The grip strength generated near end-range of flexion is 39 pounds of force. This is 63% less strength than generated in neutral grip and 43% less grip strength than generated in ~30 degrees of wrist flexion.

The conclusion: Grip strength generated in the flexed position is significantly less than compared to grip in the neutral position. The greater degree of flexion, the less strength that is able to be generated.

So the answer to the question is yes, wrist positioning does affect grip strength. Now, let’s look at some related information. This is of particular interest with those who have or treat carpal tunnel syndrome.

Extremes of wrist flexion and wrist extension can cause compression of the carpal canal and negatively affect intraneural blood flow. In an average person, pressure within the carpal canal is approximately 2 mm Hg.

When pressures reach 20-30 mm Hg, venular blood flow is impacted. Axonal transport is affected at 30 mm Hg. Neurophysiologic changes such as motor and sensory dysfunction begins at 40 mm Hg. At 60-800 mm Hg, complete cessation of intraneural blood flow is noted. Average carpal canal pressure in carpal tunnel patients in neutral wrist position was 32 mm Hg as reported in the study: The carpal tunnel syndrome: A study of carpal canal pressures. The same study goes on to show that extreme ranges of wrist flexion and extension in those with carpal tunnel syndrome increased carpal canal pressure in excess of 90 mm Hg.

One more aside. In the study: Segmental Carpal Canal Pressure in Patients With Carpal Tunnel Syndrome, the greatest pressure in the carpal canal was found 10mm distal to the distal wrist crease.

So as we bring this to a conclusion. Grip performed in a neutral grip is the optimal position for strength and also presents an environment for minimal carpal canal pressure. Grip performed in the flexion and extension is a less efficient movement and does contribute to increased pressure within the carpal canal.

So this is some information that you can store and utilize the next time you encounter someone using inefficient technique for their task or perhaps someone with carpal tunnel syndrome.

What do you think? Any new information that you would like to share? Any similar experiences that you can speak about to the group.

Additional Source: Carpal Tunnel Syndrome by David A. Fuller, MD

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I came across an interesting study yesterday comparing the use of ultrasound vs. low level laser therapy in treating Carpal Tunnel Syndrome.  The study was published in 2004 and conducted by Amir H. Bakhtiary and Ali Rashidy-Pour, Rehabilitation Faculty in the Physiology Department at Semnan Medical Sciences University, Iran. The study, entitled Ultrasound and laser therapy in the treatment of carpal tunnel syndrome, was published in the Australian Journal of Physiotherapy.

5770147_aad5619c5f1It is important for continued research such as this to be done. Low level laser therapy and other forms of light therapy have burst onto the scene over the last several years, particularly in the United States and so continued study as to their efficacy is important. Furthermore, carpal tunnel syndrome can be a debilitating condition and further studies to help provide quality treatment for those with CTS is important.

This study is of particular interest to me because as an athletic trainer in the industrial setting, this is a condition I see plenty of. Secondly, this is of interest because I have extensively used both treatments in the past to treat carpal tunnel syndrome and I was interested to see the results. This particular study concluded:  “Our clinical trials showed that ultrasound treatment is more effective than low level laser treatment in patients with mild to moderate carpal tunnel syndrome.”

The study had a sample group of 50 patients and a total of 90 wrists were treated. Each wrist was treated exclusively with either ultrasound or laser treatment. Patients were treated daily over a three week period for a total of 15 treatments.

The part that I found most interesting however involved the treatment parameters and this is probably where I have the most questions with the study. Ultrasound was delivered at a dosage of 1.0 W/cm2 for a total of 15 minutes per treament. The low lever laser treatment on the other hand was delivered at a total of 9 Joules over 5 points along the median nerve. This dosage equates, according to the study, to 1.8 Joules per treatment point.

According to the study, the results overwhelmingly favored ultrasound as a superior treatment based upon pre and post-treatment measurements.

As someone who has treated CTS for over the last 15 years utilizing each of these modalities, I observed the following in regards to this study:

  • Ultrasound was delivered at an intensity of 1.0 W/cm2. This seems to be reasonable. I may tend to use a slightly higher intensity personally (1.25 W/cm2) but this is dependent upon several factors and for the sake of the study, this seems fair.
  • Ultrasound was delivered at a treatment time of 15 minutes per treatment. This treatment time seems to be on the excessive side. (Now, on the flip side – if this did have positive results, maybe we need to reexamine our treatment times regarding ultrasound – but that is for another discussion.) Typical treatment times for the administration of ultrasound is generally 5-10 minutes, wouldn’t you agree? So, using ultrasound for 15 minutes per treatment seems to be in excess of what would be considered normal.
  • According to the study, laser was delivered at 1.8 Joules x 5 treatment sites for a total of 9 Joules. While the treatment dosage of ultrasound may be excessive, the treatment dosage for the laser treatment seems to be extremely low. The laser that we use at our facility utilizes three infrared diodes that each deliver 1 Joule of energy per treatment cycle. So for every 33 second cycle that we administer treatment, 3 Joules of energy are delivered per site. We typically will treat each site with 3 treatments and then treat a total of 3-5 sites at the wrist and hand. (Treatment is based upon manufacturer’s recommendations). So each site will receive 9 Joules of energy and this would again be repeated at 3-5 sites. This is a significant contrast to the treatment dosages used in the study.

Studies in this vain are important and I applaud those who conducted this study. Having said that, I am not sure that you can make the conclusion that ultrasound is a more effective treatment in mild to moderate CTS cases based upon the above observations. I do find the results, particularly with the ultrasound, interesting and definitely worth more investigation. I am just not completely sure, based upon what I read in the study, that the treatment dosages were “equitable”.

Am I incorrect in my observations? What are your thoughts? I am interested to hear what you think.

Photo Credit,  mrebert

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In the industrial athletic training setting, one of the more common injuries or conditions that I come across is carpal tunnel syndrome. This can certainly be a challenge to treat. One stretch that can be added to your arsenal in treating this, and other upper extremity injuries for that matter, is a stretch of the brachial plexus. Brachial Plexus Stretch

One little success story to share with you (results not guaranteed) involved a woman with chronic CTS. Her symptoms had been at a relatively dull roar for a while until she started experiencing increased numbness and tingling that were not going away. The symptoms were probably present for a couple of weeks and when I finally showed her this stretch. Her symptoms were gone within a day and she continues to implement this stretch in her normal stretching routine.

Again – taking in the total context – this may be a stretch that you can implement as part of your treatment regime. This stretch is also certainly not just limited to CTS sufferers. This can be used with general upper extremity tightness and more. As always, exercise care when instructing your patients of this stretch and be mindful of any situations that may cause this stretch to be not used in the first place or discontinued.

A couple final thoughts. As you can see from the picture, a small swiss ball was used. I like using the ball because it gives the patient a little flexibility in how they position the hand in order to get the best stretch. The ball provides a little more alterationability (if that’s a word) than using the wall as an anchor. A patient can simply use a ball from around the house to replicate this stretch at home. If they don’t have a ball, try a plastic mixing bowl and placing this against the wall. This will give a similar effect.

Make sure to keep the shoulder at “shoulder level” or lower so as not to aggravate the shoulder or any additional conditions.

Finally, you’ll notice in the picture that I am turing away from the wall. This again is a tweak to the stretch that will allow you to feel this stretch a little bit more. Turn away as much or as little as you wish in order to customize this stretch to personal preference.

Quite honestly this was not a “standard stretch” that I always gave to CTS patients (although one may argue it should have been). The point is – I tried this out one day thinking that it may benefit the patient and sure enough it did. This stretch and others for that matter won’t benefit you gathering dust in the bottom of your “toolbox”. Give it a try – you might be pleased with the results.

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