Syndromes involving the various tunnels -- carpal, cubital, tarsal, etc. -- are irritative phenomena in which nerves are entrapped within an anatomical structure. The pathology of this entrapment commonly includes ischemic nerve pathology due to compression and congestion of the local arterial tree, with fibrous tissue reaction commonly accompanying these changes. This pathology is demonstrated clinically by positive Phalen, Tinel, and Allen signs, with nocturnal paresthesias, painful numbness and tingling relative to the involved nerve distribution.
The initial modality for use in this congestive phenomenon is cryotherapy, in the moist form. The cold pack should be applied over the moist covering and should be located directly over the lesion. This may be assisted by splinting of the part, if anatomically suitable, which should maintain the part in a neutral position both day and night. Of course, the patient must be instructed to avoid use of the appendage where the lesion exists until healed, if possible.
If a silicone gel pack is used, a moist covering is unnecessary. The cold pack should remain over the lesion for about 20 to 30 minutes at a time. The development of pallor in the area of application is to be expected. However, should cyanosis develop, the ice pack must be withdrawn immediately. This procedure may be effective providing the patient is faithful in avoiding use of the involved part. Reduction of the skin temperature by approximately five degrees Celsius commonly reduces nerve transmission velocity sufficiently to relieve pain perception.
If the syndrome persists, phonophoresis of low intensity with 0.5 percent corticosteroid and 2.5 percent lidocaine ointment combined with the coupling agent may be of value in reducing the effects of the pathology. The phonophoretic wave should be a pulsed form.
If the congestion begins to resolve but the pain persists, interferential current may be applied using the Davis Procedure (Dynamic Chiropractic dated 15 November 1988).
Should this management procedure be inadequate to resolve this pathology, or if there is muscle atrophy or appreciable reduction in muscle strength relative to motor innervation (reduction in grasp strength in carpal tunnel syndrome for example), the patient should be referred for an electomyograph, or somatosensory evoked potentials.
If the pathology is sufficiently advanced, and/or of appropriate character (encysted), referral to an orthopedic surgeon becomes appropriate for decompression.
Certain occupational demands predispose to such pathologies and include but are not limited to barbers, beauticians, dentists, electricians, and others in which grasp strength with wrist motion are virtually mandatory in performing their occupational duties. Additionally, the syndrome may involve a recurrent pathology in which the patient, even after having undergone surgical correction, may experience exacerbation with predisposition to loss of function sometime later. Since radical intervention is always available to the patient, unless clinical evaluation demands surgical decompression, conservative management is good prudent judgement in this author's opinion as an initial regimen of care.
References
Griffin, J.E.; Karselis, T.C. Physical Agents for Physical Therapists, 2nd ed. Springfield: Charles C. Thomas 1982.
Krusen; Kottke; Ellwood. Handbook of Physical Medicine & Rehabilitation. 2nd ed. Philadelphia: W.B. Saunders Company 1971.
Schriber, W.A. A Manual of Electrotherapy. 4th ed. Philadelphia: Lea & Feibiger 1975.
Davis, R.V. Therapeutic Modalities for the Clinical Health Sciences. 1st ed., 1983. Copyright -- Library of Congress TXU-389-661.
Cailliet, R. Soft Tissue Pain and Disability. F.A. Davis.
Savage. Interferential Therapy. Faber/Faber 1984.
Anderson, W.A.D. Pathology. Mosby, 3rd ed.
R. Vincent Davis, D.C., B.S.P.T., D.N.B.P.M.E.
Independence, Missouri
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