Carpal Tunnel Syndrome
I. Definition: Carpal Tunnel Syndrome, also known as CTS, is the compression or pinch of a nerve in the carpal tunnel. The carpal tunnel is a narrow, rigid passageway of ligaments and bones located at the base of the hand. This nerve, called the median nerve, is housed inside the carpal tunnel which runs from the forearm to the hand. The median nerve is connected to the brain and spinal cord controlling different sensations to the palm side of the thumb and fingers, however not the little finger. It also controls impulses to some small muscles in the hand that allow the movement of the fingers and thumb. In some people, irritation from tendons causes thickening or swelling of the tunnel resulting in the compression or trauma of the median nerve. This will result in weakness, pain, or numbness in the wrist and hand, proceeding up the arm.
II. Etiology: Carpal Tunnel Syndrome is caused by a combination of many factors. These factors increase the pressure on the carpal tunnel, which then affects the median nerve. Factors can include sprains, fractures, or dislocations of the wrist which causes trauma or injury swelling the carpal tunnel. Consistent use of the pituitary gland, hypothyroidism, rheumatoid arthritis, and mechanical problems in the joint of the wrist are also factors. The repetitive use of the wrist, including typing, flexion and extension stress from occupations such as carpentry and carpet weaving, or use of mechanical tools like vibrating jackhammers are more factors. Infection, diseases, fluid retention during pregnancy and menopause, the development of cysts or tumors in the canal, or intraneural hemorrhages are also factors that may cause carpal tunnel syndrome. This is most common in women and workers requiring the use of the mechanical tools in the afore mentioned. Other occupations that may cause carpal tunnel syndrome include poultry and meat cutters, mechanics, truck drivers, key punch operators, hairdressers, clothing factory workers, journalist, and piano players. The age range of those people affected is usually around 40 to 60; however the syndrome may occur at any age.
III. Symptoms: Symptoms of carpal tunnel syndrome usually start gradually and work their way to more severe problems. Frequent burning, itching, tingling, and numbness in the palm of the hand and fingers, mainly focusing on the thumb, index, and middle fingers are the most common symptoms many patients complain of. These symptoms are most often felt during the night because most people sleep with their wrists flexed. When the wrist is flexed, tingling in the wrists become more aggressive and cause the complaints. Motor skills are affected in ways such as clumsiness in the hand affected, like dropping things from not being able to hold them, and difficulty in writing. Weakness of the muscle of the thumb and the loss of pinch, grip strength, and edema of the fingers are also symptoms associated with carpal tunnel syndrome. The sense of temperature is also lost in some cases.
IV. Social Symptoms/Manifestations: On an intrapersonal level, or inside the individual’s mind, many people affected with this syndrome fear losing their jobs because of not being able to perform certain tasks efficiently. They also fear becoming permanently disabled from carpal tunnel syndrome. On an interpersonal level, or the relations between persons, people may refuse social events because of the pain and embarrassment of being disabled. Manifestations of carpal tunnel syndrome may cause people to become unable to continue their jobs if those jobs are the cause or will make the disorder worse. As for leisure activities, patients of this disorder may be unable to continue certain activities.
V. Prognosis: If treated as early as possible, patients will demonstrate improvement.
VI. Diagnostic Evaluations/Assessments: Many different aspects are tested when trying to diagnose carpal tunnel syndrome. Such include range of motion, grip and pinch tests, strength of muscles in the hand, hand functions, fine motor coordination, manipulation, dexterity, work tolerance, habits, patterns, tactile sensation, daily living skills, and leisure interests and activities. Tests are also preformed to prove the complaints.
ï¶ Tinel’s Sign- This test is preformed by tapping the median nerve along the wrist. The test comes out positive when the tapping of the nerve causes the tingling to become worse in the fingers.
ï¶ Phalen’s Sign- This test is done by pushing the back of your hands together for about one minute. During this minute, the carpal tunnel is being compressed and comes out positive when it causes the same symptoms the patient experiences with the carpal tunnel syndrome.
ï¶ Moberg pick-up test- This test is designed to evaluate the level of sensation by measuring motor ability which is affected by sensation. The constant touch and constant pressure and how they affect the fine motor skills are what are being studies.
ï¶ Semmes-Weinstein Monofilaments- This test measures diminishing and returning cutaneous sensation. Cutaneous sensation defined is any feeling originating in sensory nerve endings of the skin, including pressure, warmth, cold, and pain. (http://www.answers.com)
ï¶ Jebsen Hand Function Test- This test is designed to test a broad range of everyday functions someone would use their hands for.
ï¶ Nerve Conduction Velocity Test (NVC)- This tests the speed of signals through a nerve. This is done by placing patches, similar to the kind used for ECG’s, on the patients skin over various locations of a nerve. The patch then gives off a small electrical impulse that will then stimulate the nerve. The results of the nerve are then recorded by other electrodes. The speed of the nerve signals are determined by the time it takes the electrical impulses to travel between electrodes and the distances they are at.
ï¶ EMG- This detects abnormalities in the nerve impulse conduction. These abnormalities are the cause for the carpal tunnel syndrome symptoms a patient would feel. This test does not necessarily need to be preformed; however it is used when symptoms that are not of carpal tunnel syndrome are present.
VII. Treatment (Non-surgical): Treatment for carpal tunnel syndrome starts with very minor adjustments to daily life. The first step would be to stabilize the wrist using a wrist brace. By doing this, the carpal tunnel is widest and the nerve is leased compressed. Usually worn at night, the splint causes the wrist to stay in place and not flex at night as previously mentioned above. Also, using a brace during other activities that would cause the wrist to bend less and stay in a position that is comfortable for the carpal tunnel. Another minor helper would be anti-inflammatory medications such as Advil or Motrin. These medications can cause a decrease in the swelling in the carpal tunnel as well as decrease the symptoms caused by carpal tunnel syndrome. In some studies that have been preformed, high doses of Vitamin B-6 has shown to decrease the symptoms. Evidence also suggests that exercise will help with the symptoms. Acupuncture and chiropractic care have also shown to benefit some patients. Yoga has been shown to reduce the pain in the wrist and improve grip strength.
VIII. Treatment (Surgical): There are many different surgical procedures that can be chosen to reduce carpal tunnel syndrome. There are a few different release procedures that can be preformed. Such procedures include:
• Carpal Tunnel Release: One of the most common surgical procedures in the United States, this surgery is recommended for 6 months. This surgery involved cutting the band of tissue around the wrist which will reduce the pressure on the median nerve. This procedure is done under a local anesthesia and is not an over night stay surgical procedure.
• Open Release Surgery: This surgery is a traditional procedure in which a 2 inch incision is cut in the wrist and then cut the carpal ligament which will enlarge the carpal tunnel. Unless there are other medical complications, this procedure is an outpatient surgery, which means that the patient will receive treatment but will not be hospitalized.
• Endoscopic Surgery: This surgery is done by making two incisions about ½ inch big, one in the wrist and the other in the palm. A camera attached to a tube is inserted into the incision observing the tissue on the screen and cutting the carpal ligament. This procedure allows for faster recovery and less postoperative discomfort. This surgery is very effective and minimizes scarring and the scarring tenderness. There is also a one-portal surgical procedure available.
Although these surgeries provide relief from carpal tunnel syndrome, the long term effects may take months to a full recovery. Patients may walk away from the surgeries from nerve damage, infection, or pain at the site of the scar. Sometimes, because the carpal ligament is cut, the wrist may lose strength. These procedures mentioned above should be followed up by physical therapy to restore the strength in the wrist. In some cases, patients may need to change jobs because of the needs of the wrist after the surgery.
VIIII. Preventions: There are ways in which to prevent carpal tunnel syndrome. If you feel the start of the symptoms, you should contact a doctor immediately. To prevent the start of carpal tunnel, exercises can be done at home. Warming up joints before using them in hands on work for an extensive period of time will help. Cushions will help when typing on a keyboard or moving a mouse, while wearing braces in sports related activities will support the wrist and prevent damage to the carpal tunnel.
X. Summary: Carpal Tunnel Syndrome is when the median nerve in the wrist gets pinched or compressed. This is caused by flexion of the wrist, most often during sleeping, serious injury and over usage. Although there are ways to prevent the disorder from appearing, sometimes minor injuries and leisure activities may cause symptoms to show and worsen. Typing, working with vibrating machinery, carpentry, and other stressful wrist activities can lead to carpal tunnel syndrome. To cure the disorder, there are non-surgical and surgical treatments that can be preformed. Sometimes these treatments may lead to some nerve damage, loss of sense of temperature, and pain, the overall outcome may in fact help treat the carpal tunnel syndrome.
• National Institute of Health – National Institute of Neurological Disorders and Stroke
• About.com: Orthopedics
• EMedicine from WebMD
• Former Carpal Tunnel Patient