Sensorimotor exercises with ReHand after surgical release of a Carpal Tunnel Syndrome | Clinical Case

A few months ago we received in the Hand Therapy Department a patient who had recently received an open surgical release of her Carpal Tunnel due to Median Nerve involvement.

After 5 days post-surgery, and its corresponding Surgeon review, she began her conservative treatment in order to return to work and ADL as soon as possible.

Surgical wound of our patient after release of her affected carpal tunnel.

Hand Therapy and Sensorimotor level in Carpal Tunnel Syndrome

Our main goal was to actively mobilise as early as possible, including motor control exercises, in order to induce changes at the level of the Central Nervous System (Somatosensory Cortex) and at the Peripheral level (the Median Nerve and the affected wrist). Of course, always monitoring the patient’s sensations during its performance.

We must remember that there is a large amount of scientific literature that highlights how patients affected by Carpal Tunnel Syndrome suffer a desinhibition or central hypersensitisation in their primary motor cortex (1), resulting in blurred and overlapping areas of the cortex, as shown in the following image (2).

Figure from Maeda Y et al 2014 (2). It can clearly observe that healthy subjects (HC) present well defined areas than those affected by Carpal Tunnel Syndrome (CTS)

Maeda Y et al concluded that “S1 neuroplasticity is indeed maladaptive in subjects with CTS, and it seems that this maladaptive neuroplasticity underlies the functional deficits seen in CTS”.

For all these reasons, it is necessary to include an approach focused on producing changes at the peripheral and central level in order to “re-draw” the cortical representation of the affected hand. Thus, ReHand is a more than viable and feasible option for this goal.

Carpal tunnel Syndrome Assessment

During the initial assessment, specific strength tests such as the Grip and Pinch tests were performed following the protocol proposed by Mathiowetz et al (3). During strength evaluation, we avoid any discomfort in the scar area. To this end, the patient is properly instructed about how to perform this test.

Grip and Pinch strength Tests according to Mathiowtz et al. (3)

In addition, manual dexterity was assessed using the “Nine Hole Peg Test”, the aim of which is to place all the Pegs into the holes in the board itself, and then remove them in the shortest possible time:

Nine Hole Peg Test

Exercises proposal with ReHand

1. Pinch Exercise for Thenar Muscle Activation: we include functional movements, such as the pinch movement, into ReHand digital tool, which the patient can perform on her Tablet. These exercises are always performed with a previous ROM calibration without pain, to avoid any discomfort during the exercise and to ensure that they performe it safely.

Below we clearly observe how the patient fails during the exercise in her attempt to control her thumb. However, this is a good sign initially. We must remember that these failures are NORMAL during the CNS “relearning” process in Motor Control exercises. The CNS is constantly receiving sensory and visual information to progressively improve its performance.

Pinch exercise onto a Tablet touchscreen with ReHand digital Tool

2. Wrist flexion-extension exercise: after removing the immobilisation cast, one of the main goals in this patient will be to restore motor control of the wrist and restore its mobility. We already know from previous studies that a period of immobilisation of the limb produces changes at a central level (4). Using an external visual focus (the grey guide on the screen), the patient must follow the proposed Flex-Ext movement. Again, a pain-free ROM calibration is performed before the exercise itself to ensure safe work.

We must be aware of the possible compensations that appear in the elbow or shoulder, as it is an exercise that is initially challenging for the patient. We could allow some of these compensations at the earliest stage of rehabilitation.

Flexo-extension exercise with the ReHand digital tool, on the first day of conservative work in Hand Therapy. Department

ReHand Clinical Trial in Carpal Tunnel Sydrome surgically released

This kind of approach in patients who underwent surgery for CTS was evaluated in a clinical trial, which led to great results in improving the function of patients treated with ReHand at an earlier stage (5). This work was published in the highest impact journal in the field of Physiotherapy and Rehabilitation; the Journal of Physiotherapy (Journal Q1 with Impact Factor 2019: 5.440).

ReHand´s Team publication in patients with CTS (5)

References

(1) Iwatsuki K, Hoshiyama M, Yoshida A, Shinohara T, Hirata H. A magnetoencephalographic study of longitudinal brain function alterations following carpal tunnel release. Sci Rep [Internet]. 2019;9(1):1–6.

(2) Maeda Y, Kettner N, Holden J, Lee J, Kim J, Cina S, et al. Functional deficits in carpal tunnel syndrome reflect reorganization of primary somatosensory cortex. Brain. 2014;137(6):1741–52. 

(3) Mathiowetz V, Weber K, Volland G, Kashman N. Reliability and validity of grip and pinch strength evaluations. J Hand Surg Am. 1984 Mar;9(2):222-6. doi: 10.1016/s0363-5023(84)80146-x. PMID: 6715829.

(4) Newbold DJ, Laumann TO, Hoyt CR, Hampton JM, Montez DF, Raut RV, Ortega M, Mitra A, Nielsen AN, Miller DB, Adeyemo B, Nguyen AL, Scheidter KM, Tanenbaum AB, Van AN, Marek S, Schlaggar BL, Carter AR, Greene DJ, Gordon EM, Raichle ME, Petersen SE, Snyder AZ, Dosenbach NUF. Plasticity and Spontaneous Activity Pulses in Disused Human Brain Circuits. Neuron. 2020 Aug 5;107(3):580-589.e6. doi: 10.1016/j.neuron.2020.05.007. Epub 2020 Jun 16. PMID: 32778224; PMCID: PMC7419711.

(5) Blanquero J, Cortés-Vega MD, García-Frasquet MÁ, Sánchez-Laulhé PR, Nieto Díaz de Los Bernardos MI, Suero-Pineda A. Exercises using a touchscreen tablet application improved functional ability more than an exercise program prescribed on paper in people after surgical carpal tunnel release: a randomised trial. J Physiother. 2019 Apr;65(2):81-87. doi: 10.1016/j.jphys.2019.02.008. Epub 2019 Mar 26. PMID: 30926400.