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A 22-year-old college athlete had his cast removed 2 days ago. Eight weeks ago, he sustained a Colles' fracture of his dominant right wrist when he fell on an outstretched hand during a basketball game. He presents to an outpatient physical therapy clinic today for his initial evaluation. He reports some pain in his forearm and hand with numbness and tingling in his thumb, index, middle, and half of his ring finger. His right grip strength is 50% weaker than the left. There is observable atrophy in the right thenar eminence, and he describes a “pressure” sensation at his wrist. He notices that his right hand falls asleep sometimes when doing homework on the computer. Motion at end-range wrist flexion and extension increases his pain and neurologic symptoms. The patient has a positive Phalen's test and a positive Tinel's sign at the wrist. His signs and symptoms are consistent with carpal tunnel syndrome.

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Describe a physical therapy plan of care based on each stage of this health condition.

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What are the most appropriate physical therapy interventions?

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What examination signs may be associated with this suspected diagnosis?

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  • DOUBLE CRUSH SYNDROME: Type of peripheral nerve compression syndrome in which there is a central compression that impacts a nerve bundle (e.g., at the thoracic or pelvic outlet) and a second more peripheral compression (e.g., at the carpal or tarsal tunnel)
  • GANGLION CYST: Noncancerous fluid-filled lumps that most commonly develop along the tendons or joints in the hands or feet
  • RAYNAUD'S PHENOMENON: Intermittent ischemia of the fingers or toes usually caused by exposure to cold or due to emotional stimuli

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  1. Identify the contents and borders of the carpal tunnel.

  2. Discuss key steps of the examination that would lead the physical therapist toward a diagnosis of carpal tunnel syndrome.

  3. Describe lifestyle and environmental factors that could contribute to developing carpal tunnel syndrome.

  4. Discuss evidence-based treatment strategies and precautions for each stage of the condition (acute, subacute, chronic).

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PT considerations during management of the individual with progressive weakness and atrophy of the thenar muscles and first two lumbricals, sensory disturbances in the median nerve distribution, pain in the wrist and hand with repetitive use, and functional loss due to carpal tunnel syndrome:

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  • General physical therapy plan of care/goals: Assess muscle strength and sensation in the median nerve distribution distal to the carpal tunnel; ergonomic work space assessment; patient education on positioning and possible benefits of bracing or night splint; maximize function with repetitive work activities such as typing and gripping
  • Physical therapy interventions: Increase space and mobility of the carpal tunnel by stretching and manual therapy techniques; strengthen thenar muscles and first two lumbricals; stretches to increase flexibility of forearm flexor muscles; patient education on positioning and bracing; functional task training; home exercise program
  • Precautions during ...

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