Carpal Tunnel Syndrome

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What is Carpal tunnel syndrome?

Carpal Tunnel Syndrome is a common cause of wrist and hand pain along with pins and needles in the hand.

Anatomy:

The Carpal Tunnel is essentially a space in the wrist where tendons, blood vessels and nerves pass through, as they travel to the hand and the fingers. The space in between the carpal bones and the flexor retinaculum makes the carpal tunnel and it is very small. Essentially Carpal tunnel syndrome is when these structures get compressed.
Normal pressure in the Carpal Tunnel is less than 10mmHg, but in patients with Carpal Tunnel Syndrome this pressure rises to above 30mmHg and under movements it can rise to over 90mmHg.

So what causes the compression?

This can vary, but it is usually down to swelling, inflammation and thickening of structures within the carpal tunnel.
Carpal tunnel syndrome affects 3 to 6 percent of adults in the general population (Leblanc & Cestia et al 2011). People who use their hands a lot with repetitive activities in either their work or hobbies are more likely to get it.
It is more common in females and older age groups (Page et al 2012) and more likely if you suffer from diabetes, arthritis, hypothyroidism, have had a wrist fracture, are pregnant or on some medications. In pregnancy it often gets better within three months of the baby being born. However, in some women, symptoms can continue for more than a year and may need treatment.
It even affects us Physio’s too: Physio’s who treat 10 or more patients a day increased the risk of injury in the wrist & hand by 14 times (Campo et al (2008).

What are the exact signs and symptoms?

The compression of the Median nerve causes altered sensation in the wrist and the fingers nearest the thumb, as well as in the thumb itself. Commonly, there is burning, tingling and numbness in addition to pain in the wrist, hand or thumb. The symptoms are often worst during the night but as the condition progresses symptoms will eventually come in the day (Cleland & Koppenhaver 2011). In severe cases the muscle bulk at the base of the thumb can begin to waste, because the nerve supply to the muscles becomes compromised.

How do you diagnose it?

A physiotherapist can diagnose carpal tunnel syndrome but they also need to rule out the chance that the symptoms are coming from higher up such as your neck, shoulder or elbow. This is significant and some research has found that misdiagnoses are more often the rule than the exception. "By the time we've completely mutilated the person, maybe then we'll decide it's not carpal tunnel syndrome after all," says one epidemiologist. Barbara Silverstein, research director at the Washington State Department of Labor and Industries, Olympia, Washington.

Common tests for carpal tunnel syndrome are:

Phalens: 


The forearm is held vertically and the wrist is allowed to drop into 90 degrees of flexion under the influence of gravity. If stiffness of the wrist does not permit 90 degrees of flexion then the wrist should be allowed to fall as far as possible. Forced flexion, by the examiner grabbing the hand and deliberately bending it, or by asking the patient to press the backs of the hands together in front of them, should be avoided as this increases the number of false positive tests. An important element of the test is that it is only positive if the symptoms elicited are essentially the same as those of which the patient is complaining to begin with. The Phalen’s test is positive in about 70% of cases and has a false positive rate of about 30%.


Tinels:
Percussion over the palm side of the wrist to elicit tingling in the fingers. Some examiners use their own fingers to tap the wrist, others use a tendon hammer, Percussion can be over the carpal tunnel or may be proximal to it (closer to elbow rather than the hand). Comparisons with other methods of making the diagnosis suggest that Tinel’s sign may be unreliable with anything up to 50% false positive and false negative rates.

Failing diagnosis with these tests a nerve conduction study can be performed to test the nerve to see if it is being compressed. If the nerve impulse is slow then the nerve is being compressed.

How do you treat carpal tunnel syndrome?


Rest:
You need to essentially rest from your aggravating activities. For example typing, hammering or gripping activities, basically the repetitive use of your hands that causes the condition. 35% of patients with Carpal Tunnel Syndrome had spontaneous remission after an average time of 6 months (Padua et al 2001).

Wrist splint:
The use of a Wrist Support can help and as symptoms are worse during the night this can also be used to stop you from waking up with symptoms. The common splint type is called a futura splint and it stops you from flexing your wrist and compressing the carpal tunnel. Some evidence has actually found that 90% of Carpal Tunnel Syndrome patients who used a wrist brace had complete relief of symptoms. In this research the wrist brace was used 24 hours a day. It is best to try the splint for between 2 and 6 weeks but if after this time it is ineffective then another treatment option will be required.

However:

Another study found limited evidence that a night splint is more effective than no treatment in the short term in Carpal Tunnel Syndrome (Page et al 2012).

Medication:
Non Steroidal Anti Inflammatory Drugs (NSAIDs) can be effective for the relief of symptoms by reducing swelling and inflammation.

Heat or Ice:
Heat therapy is not among the options that should be used to treat patients with carpal tunnel syndrome but ice may be useful. If you apply ice then use a damp tea towel and have on for no longer than 10-15 minutes, also don’t re-apply ice again for at least 2 hours.

Physiotherapy:
A study looking at two manual therapy interventions for carpal tunnel syndrome in the Journal of Manipulative and Physiological Therapeutics (2007) presented data that substantiated the clinical efficacy of conservative treatment options for mild to moderate carpal tunnel syndrome.
Physiotherapy treatment is very important to regain range of wrist motion, rebuild thumb muscle strength and to resolve stiffness. Exercises using hand Therapy Balls and Therapeutic Putty can be very helpful to regain mobility. Grip and thumb Strengthening Devices can also be useful to restore normal hand and thumb strength.  However the current literature offers limited support for joint mobilisations of the wrist & hand (Heiser et al 2013).

Here are some common exercises for carpal tunnel syndrome from the CSP:

Carpal Tunnel Syndrome Exercises

Ultrasound is also an option when treating patients with carpal tunnel syndrome as ultrasound affects inflammation. O'Connor et al (2003) found ultrasound, yoga & wrist mobilisation to provide short-term relief from carpal tunnel syndrome.

Ergonomics:

Royal College of Physicians recommends:

Employers should consider offering computer operators with carpal tunnel syndrome the opportunity to trial different computer keyboards.

Injection:
In more long-standing cases, corticosteroid injections may be more effective. These are aimed at decreasing inflammation and swelling within the Carpal Tunnel and, in severe cases, several may be required before symptoms are resolved. Research show that steroid injection for carpal tunnel syndrome improves symptoms 1 month after injection better than placebo (Marshall et al 2009).

Surgery:
If conservative measures fail to solve the problem within 2 weeks to 7 weeks, then surgery may be required. However early surgery is an option when there is clinical evidence of median nerve denervation or the patient elects to proceed directly to surgical treatment.

Conventionally, surgery has been performed using an open technique, but more recently an arthroscopic technique has been developed.

The major advantage of the arthroscopic technique is that the procedure can be performed under local anaesthetic, meaning that it can be done on an out-patient basis. The arthroscopic technique requires two small incisions - one in the wrist and one in the palm of the hand - and a very small diameter camera is then inserted to allow the surgeon to see the Carpal Tunnel. Following the arthroscopic release, the wrist is usually supported in a Wrist Brace for between 4 and 6 weeks. But it is suggested that the wrist not be immobilised postoperatively after routine carpal tunnel surgery. This piece of evidence shows that Endoscopic carpal tunnel release surgery enables return to work or daily activities in on average approximately 1 week (Scholten et al 2007).

However:

Carpal tunnel surgery has about a 57% failure rate following patients from 1-day to 6-years. At least one of the following symptoms re-occurred during this time: Pain, Numbness, Tingling sensations (Nancollas et al 1995).
A study of patients having a second surgery, revealed that only 53% of the patients showed significant improvement in their symptoms.
But this one shows relief from pain was complete or modest in 86% of the patients. 67% were able to return to their old jobs whereas, 15% had to change jobs and the remainder did not return to work.
Multiple surgeries can cause complications ranging from excessive scar tissue overgrowth (re- compressing the nerve tunnel) to surgical injuries that leave the fingers totally devoid of sensation.

Also:

Surgical treatment of carpal tunnel syndrome relieves symptoms significantly better than splinting (Verdugo et al 2008).

How do you prevent Carpal tunnel syndrome?

Avoid sustained or repetitive grip and pinch gripping activities.
Maintain the wrist in a neutral (straight) position with activity.
Avoid leaning on or putting pressure against the front of the wrist of the base of the hand.
Stretch the wrist regularly and make sure you have enough recovery time from repetitive gripping activities.

So hopefully this helps you to understand more about carpal tunnel syndrome and the options open to you.
If you need any further information or would like to book an appointment then call Hawkes Physiotherapy on 01782 771861 or 07866195914


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