1. REHABILITATION FOR THE ELBOW AND WRIST CONNIE GEIGER PT/CHT Director of Hand Therapy Sport and Spine Clinic

2. CARPAL TUNNEL SYNDROME Evaluation Process Detailed history of symptoms Detailed history of symptoms Assess causative factors (what do they think is causing this???) Assess causative factors (what do they think is causing this???) Grip and pinch strength testing Grip and pinch strength testing Manual muscle testing-thenar/intrinsics. Check for balance. Manual muscle testing-thenar/intrinsics. Check for balance. Proximal factors Proximal factors Special tests (Phalen’s, Tinels’s, tendon and nerve gliding Special tests (Phalen’s, Tinels’s, tendon and nerve gliding

3. TREATMENTSTRATEGIES Modalities Modalities Splints Splints Exercise Programs Exercise Programs Patient Education- do they REALLY know what CTS is and isn’t? Take a critical look at everything Patient Education- do they REALLY know what CTS is and isn’t? Take a critical look at everything

4. MODALITES Ultrasound Ultrasound Electrical Stimulation Electrical Stimulation Iontophoresis Iontophoresis Heat/Cold/Contrast Therapy Heat/Cold/Contrast Therapy Soft tissue mobilization total arm- compare sides Soft tissue mobilization total arm- compare sides

5. SPLINTING FOR CARPAL TUNNEL Help maintain neutral position 0-15 degrees. Help maintain neutral position 0-15 degrees. Proper fit important. Proper fit important. Night vs. daytime splint schedule- does their job allow for splint? Night vs. daytime splint schedule- does their job allow for splint?

6. EXERCISE PROGRAMS Improve posture, flexibility and strength of upper quadrant. Improve posture, flexibility and strength of upper quadrant. Designed to include entire UE includes pectorals, neck musculature, shoulder capsule. Designed to include entire UE includes pectorals, neck musculature, shoulder capsule. Strengthening-entire limb stabilization Strengthening-entire limb stabilization Improve tendon and nerve gliding occupying thru CT to decrease compressive forces. Improve tendon and nerve gliding occupying thru CT to decrease compressive forces. Do “CHECKS” Do “CHECKS”

7. PATIENT EDUCATION Understand what CT really is Understand what CT really is Proactive approach-self management, compliance, motivation to improve Proactive approach-self management, compliance, motivation to improve Critically analyze all daily tasks Critically analyze all daily tasks General health considerations-stress, smoking, nutrition, exercise General health considerations-stress, smoking, nutrition, exercise

8. GRIP STENGTH AND WRIST ANGLES Think NEUTRAL in all you do. Think NEUTRAL in all you do.

9. CRITERIA FOR IMPROVEMENT Decreased pain-local and referred Decreased pain-local and referred Decreased paresthesias Decreased paresthesias Deceased use of meds Deceased use of meds Faster recovery after exacerbation episodes Faster recovery after exacerbation episodes Decreased need for splints Decreased need for splints Decreased fatigue with routine job tasks Decreased fatigue with routine job tasks Return to previous functional level with modifications as needed Return to previous functional level with modifications as needed

10. CMC OA OF THE THUMB Evaluation Considerations Detailed History of Symptoms Detailed History of Symptoms Grip and Pinch (3 point and key) Grip and Pinch (3 point and key) Assess balance of 9 muscles that have an action at the thumb Assess balance of 9 muscles that have an action at the thumb Assess deformity and altered mechanics (basilar prominence? web space contracture? MP hyperextension/IP flexion?) Assess deformity and altered mechanics (basilar prominence? web space contracture? MP hyperextension/IP flexion?)

11. TREATMENT APPROACH 4 PARTS Symptom management strategies Symptom management strategies Splinting options Splinting options Appropriate exercises for ROM/Strengthening Appropriate exercises for ROM/Strengthening Joint Protection and ergonomic concepts Joint Protection and ergonomic concepts Treat the Patient not the Radiograph Treat the Patient not the Radiograph

12. SYMPTOM MANAGEMENT Iontophoresis Iontophoresis Ultrasound Ultrasound Cold Packs/ Ice massage Cold Packs/ Ice massage Fluidotherapy/Home heat /paraffin Fluidotherapy/Home heat /paraffin Soft tissue mobilization/contracture release Soft tissue mobilization/contracture release

13. SPLINTING OPTIONS Hand based neoprene soft splint with molded abduction inset for lighter activity Hand based neoprene soft splint with molded abduction inset for lighter activity Custom thermoplastic hand based thumb spica splint with thumb IP supported in 30 degrees flexion for heavier demand Custom thermoplastic hand based thumb spica splint with thumb IP supported in 30 degrees flexion for heavier demand Will the patient actually WEAR it??? Will the patient actually WEAR it???

14. EXERCISE FOR CMC OA Thenar isometrics in position of function Thenar isometrics in position of function Extensor pollicus brevis “lifts” Extensor pollicus brevis “lifts” Resisted index finger abduction Resisted index finger abduction Wrist stabilization exercises in neutral Wrist stabilization exercises in neutral

15. JOINT PROTECTION CONCEPTS Use the proper tool/utensil for the job Use the proper tool/utensil for the job Modify grip and pinch technique (minimize forcible pinching as this is a HUGE force multiplier at the base joint of thumb Modify grip and pinch technique (minimize forcible pinching as this is a HUGE force multiplier at the base joint of thumb Avoid “hooking” items on thumb Avoid “hooking” items on thumb Avoid forcible turning/twisting actions Avoid forcible turning/twisting actions

16. DEQUERVAINS SYNDROME 1 ST DORSAL COMPARTMENT TENOSYNOVITIS Splint in FOREARM BASED thumb spica splint about 6 weeks Splint in FOREARM BASED thumb spica splint about 6 weeks Ice Ice Rest Rest AROM- gentle stretching in Finkelstein’s position AROM- gentle stretching in Finkelstein’s position TIME TIME

17. THANK YOU!!! THANK YOU!!!