{
  "resourceType": "ActivityDefinition",
  "id": "nerve-tendon-gliding-cts",
  "url": "https://bodyiq.dev/fhir/ActivityDefinition/nerve-tendon-gliding-cts",
  "version": "1",
  "name": "NerveTendonGlidingCts",
  "title": "Nerve and Tendon Gliding Exercises (Carpal Tunnel)",
  "status": "draft",
  "experimental": true,
  "description": "Combined program of median nerve glides and tendon gliding for carpal tunnel syndrome. Nerve glides: sequential shoulder ABD → elbow extension → wrist/finger extension → cervical lateral flexion. Tendon glides: straight → hook fist → full fist → tabletop → straight fist. Proposed mechanisms include reducing intraneural pressure, improving nerve excursion, and preventing adhesion formation.",
  "useContext": [
    {
      "code": {
        "system": "http://terminology.hl7.org/CodeSystem/usage-context-type",
        "code": "user"
      },
      "valueCodeableConcept": {
        "text": "difficulty: beginner"
      }
    }
  ],
  "topic": [
    {
      "coding": [
        {
          "system": "https://bodyiq.dev/fhir/CodeSystem/exercise",
          "code": "nerve-tendon-gliding-cts",
          "display": "Nerve and Tendon Gliding Exercises (Carpal Tunnel)"
        }
      ]
    }
  ],
  "bodySite": [
    {
      "coding": [
        {
          "system": "https://bodyiq.dev/fhir/CodeSystem/exercise",
          "code": "wrist",
          "display": "Wrist"
        },
        {
          "system": "http://snomed.info/sct",
          "code": "74670003",
          "display": "Structure of radiocarpal joint"
        }
      ],
      "text": "Wrist"
    },
    {
      "coding": [
        {
          "system": "https://bodyiq.dev/fhir/CodeSystem/exercise",
          "code": "hand",
          "display": "Hand"
        },
        {
          "system": "http://snomed.info/sct",
          "code": "56103003",
          "display": "Structure of collateral ligaments of metacarpophalangeal joints"
        },
        {
          "system": "http://snomed.info/sct",
          "code": "725412007",
          "display": "Structure of distal interphalangeal joint"
        },
        {
          "system": "http://snomed.info/sct",
          "code": "371232006",
          "display": "Structure of proximal interphalangeal joint of finger"
        }
      ],
      "text": "Hand"
    }
  ],
  "kind": "ServiceRequest",
  "dosage": [
    {
      "text": "5-10 reps of each position, 3-5x daily, 6-12 weeks; combine with nighttime neutral wrist splinting [Akalin 2002, Baysal 2006]"
    }
  ],
  "usage": "Evidence: moderate. Historical studies show modest improvements when combined with splinting. May help delay or reduce need for surgical intervention in mild-moderate CTS.",
  "note": [
    {
      "text": "Quiet, sliding pattern — nerve and tendon move independently",
      "authorString": "focus:internal"
    },
    {
      "text": "Cycle through five hand shapes: straight, hook, fist, tabletop, straight fist",
      "authorString": "focus:external"
    },
    {
      "text": "Open the hand toward the ceiling, then close into a fist",
      "authorString": "focus:external"
    },
    {
      "text": "Tendons glide like ropes through a pulley",
      "authorString": "focus:imagery"
    }
  ],
  "relatedArtifact": [
    {
      "type": "citation",
      "label": "kisner-therapeutic-2017",
      "citation": "Kisner C, Colby LA, Borstad J. (2017). Therapeutic Exercise: Foundations and Techniques"
    },
    {
      "type": "citation",
      "label": "acsm-guidelines-2021",
      "citation": "American College of Sports Medicine. (2021). ACSM's Guidelines for Exercise Testing and Prescription",
      "document": {
        "url": "https://doi.org/10.4135/9781412994149.n165"
      }
    },
    {
      "type": "predecessor",
      "label": "If the combined nerve+tendon CTS program is symptom-provocative, drop the neural component and perform tendon gliding only (its named 'Tendon Glides Only' regression); tendon-gliding-sequence is the standard tendon-only post-CTR protocol. Advance back when neural tension is tolerated.",
      "display": "Tendon Gliding Sequence",
      "resource": "ActivityDefinition/tendon-gliding-sequence"
    }
  ],
  "extension": [
    {
      "url": "https://bodyiq.dev/fhir/StructureDefinition/muscle-involvement",
      "extension": [
        {
          "url": "muscle",
          "valueString": "Flexor Digitorum Superficialis"
        },
        {
          "url": "role",
          "valueCode": "primary"
        },
        {
          "url": "coding",
          "valueCoding": {
            "system": "http://snomed.info/sct",
            "code": "89895007"
          }
        }
      ]
    },
    {
      "url": "https://bodyiq.dev/fhir/StructureDefinition/muscle-involvement",
      "extension": [
        {
          "url": "muscle",
          "valueString": "Flexor Digitorum Profundus"
        },
        {
          "url": "role",
          "valueCode": "primary"
        },
        {
          "url": "coding",
          "valueCoding": {
            "system": "http://snomed.info/sct",
            "code": "423541009"
          }
        }
      ]
    },
    {
      "url": "https://bodyiq.dev/fhir/StructureDefinition/muscle-involvement",
      "extension": [
        {
          "url": "muscle",
          "valueString": "Extensor Digitorum"
        },
        {
          "url": "role",
          "valueCode": "synergist"
        },
        {
          "url": "coding",
          "valueCoding": {
            "system": "http://snomed.info/sct",
            "code": "50176000"
          }
        }
      ]
    }
  ]
}