Carpal Tunnel Syndrome

Carpal Tunnel Syndrome (CTS) is the inflammatory disorder that is caused by a pinched nerve (median nerve) in the wrist, usually due to repetitive stress or traumatic injury.

SymptomsCauses | Exercises | Prevention | Treatment | Diagnosis

The actual carpal tunnel is a small canal or tunnel runs from the forearm through the wrist. Bones form three walls of the tunnel, which are bridged by strong, broad ligament. The median nerve passes through this tunnel, which actually supplies feeling to the thumb, index, and ring fingers, the nine tendons that flex the fingers and also provides function for the thenar muscles, which are actually the muscles at the base of the thumb.

When the protective lining of the tendons within the carpal tunnel inflamed and swell or when the ligament that forms the roof becomes thicker and broader leads to Carpal Tunnel Syndrome. The result is compression on median nerve fibers due to the swollen tendons and thickened ligaments; there will be slow down in the transmission of the nerve signals through this carpal tunnel.

The different Symptoms of Carpal Tunnel Syndrome (CTS):

  1. Interruption of Sleep with Hands Numbness and in Pain
  2. Frequent Pain in Hand and Wrist
  3. Neck or shoulder pain on same side as hand discomfort.
  4. Poor Circulation of blood in Hands there by Hands falling asleep
  5. Weakness in Hand and Wrist- Pain Radiating up the Forearm
  6. Cold Hands
  7. Forearms warm and loss of grip strength.
  8. Loss of Feeling in Fingers and Thumb
  9. Dropping Objects especially small objects.

Carpal Tunnel Symptoms maybe begin with pain in the wrist and hand or numbness and tingling of the fingers. Patients of Carpal Tunnel Syndrome may also experience a sense of weakness and a tendency to drop things.

They may experience the loss of hot and cold sensation to their hands or even feel that their hands are swollen though there is no visible swelling. Symptoms can be felt during both work and rest periods.

In fact, the Carpal Tunnel Syndrome may be distinguished from similar conditions by pain occurring at night after going to bed. In some cases, work associated Carpal Tunnel Syndrome Symptoms first occur outside of work, for these reason patients may fail to associate the symptoms with work associated activity.

Anyone who is experiencing the recurrent or persistent pain, numbness and tingling, or weakness of the hand should consult a physician for a diagnosis of Carpal Tunnel Syndrome.

Other Diseases, which show the same Symptoms as Carpal Tunnel Syndrome Symptoms:

Accompanying Diseases :

There are about 25% of patients who are having work associated repetitive stress disorders, which show similar symptoms as that of Carpal Tunnel Symptoms. A definitive diagnosis is often difficult to find. These disorders requires treatments similar to those that are used for treating CTS: rest, immobilization, steroid injections, and even surgery if the non-surgical methods are unsuccessful.

Nerve Entrapment Problems :

Repetitive work causes pressure on the median nerve in the locations other than the wrist and can also affect other nerves in the arm and hand. The branch of the median nerve that runs through the palm of the hand can be damaged directly by repeated pounding or by the use of certain tools that requires a strong grip using the palm, for example needle-nosed pliers. The median nerve can also be pinched up in the forearm.

Ulnar Tunnel Syndrome :

The ulnar nerve, which supplies sensation to the ring and little fingers, can also become trapped like the median nerve as a result of repetitive stress, with subsequent loss of sensation in these fingers and the outer half of the palm. This condition, known as ulnar tunnel syndrome. It can be a separate disorder or appear with Carpal Tunnel Syndrome. In the latter case, release surgery for CTS usually also relieves the ulnar nerve entrapment. The ulnar nerve can also be affected at the elbow.

Tendon-Related Problems :

Tenosynovitis, which means swelling of the tendon sheath in the hands and fingers, is also a repetitive stress injury and can effect various parts of the hand and fingers. One or more fingers may experience pain and stiff, especially in the morning when you wake up from bed and even the wrist may be swollen. When a tendon thickens, leaving the finger in a bent position, which is known as Trigger finger also called as snapping finger. This Trigger finger is a common complication of rheumatoid arthritis, which may even occur in diabetes or for some other unknown causes. De Quervain’s disease involves tenosynovitis at the base of the thumb. These disorders are often present with Carpal Tunnel Syndrome.

When there is contraction of the muscles adjoining the tendon or when the physician stretches the affected finger or part of the hand the patients experience a intensified pain in the involved area.

Thoracic Outlet Syndrome:

The nerves in the neck when pinched may also cause weakness in the hands. The thoracic outlet syndrome caused by compression of nerves and blood vessels running down the neck into the arm. This condition can cause symptoms, which are very similar to that of CTS. This compression occurs at the first rib in the front of the shoulder. The thoracic outlet syndrome can be diagnosed by detecting reducing blood flow in the arm as the patient raises the affected hand and turns his or her head toward the opposite side. Although the condition is not frequent, a correct diagnosis technique is important to differentiate it from CTS. Treatments, which are used for thoracic outlet syndrome, are useless for treating carpal tunnel syndrome.

Arthritic Conditions :

Arthritic conditions like the rheumatoid arthritis, gout, and osteoarthritis, can cause pain in the hands and fingers.

Raynaud’s Phenomenon :

Raynaud’s phenomenon patients experience numbness and tingling or pain in the fingers of one or both hands. This Raynaud’s phenomenon usually brought on by cold or stress and is treated with warmth or, in severe cases, medications that may open blood vessels. People with this problem, are actually at higher risk for carpal tunnel syndrome and there may be some relationship between the Raynaud’s phenomenon and Carpal Tunnel Syndrome.

Causes of Carpal Tunnel Syndrome

The Carpal Tunnel Syndrome causes are difficult to be determined as it is difficult to say that the primary cause of Carpal Tunnel Syndrome is due to work conditions or due to underlying medical problems.

In a study, obesity, diabetes, hypothyroidism, and arthritis occurred in the majority of people who are having work-associated Carpal Tunnel Syndrome. Such conditions are main causes of carpal tunnel disorder. In many cases of Carpal Tunnel Syndrome occur from a combination of factors, like predisposing medical condition exacerbated by work stress and psychological and social stressors.

Work-Associated

The main Carpal Tunnel Syndrome causes is the repetitive motion at workplace, which is increasing a lot. These cases contribute to half of the work associated illness and the Carpal Tunnel Syndrome They account for nearly half of all reported work-related illness, and Carpal Tunnel Syndrome is estimated to account for over 41% of the disorders caused due to repetitive motion. The key risk factors in the workplace that causes the Carpal Tunnel Syndrome.

  • Repetition
  • High force
  • Awkward joint posture
  • Direct pressure
  • Vibration, and
  • Prolonged constrained posture.

The main cause of the Carpal Tunnel Syndrome is the incorrect posture, especially in computer users. The rolling of the shoulders forward, rounding the lower back and thrusting the chin forward shortens the neck and the muscles of the shoulder, thereby compressing the nerves in the neck which ultimately have an effect on the wrist, fingers and the hand. But it is difficult to know the relation between these aspects and CTS.

The psychological factors like the deadlines, interpersonal factors and the job design at the workplace can also contribute for the inflammation of the carpal tunnel.

Medical Problems:

The medical problems such as fracture or dislocation of bone can narrow the carpal tunnel, which in turn exerts pressure on the median nerve. Some other medical problems, like the rheumatoid arthritis, diabetes, and hypothyroidism, can also cause the inflammation in the carpal tunnel, which exerts pressure on the median nerve.

Some experts believe that the initial stages of a number of auto-immune diseases may be carpal tunnel syndrome. A long-term hemodialysis and diseases such as multiple myeloma, Waldenstrom’s macroglobulinemia, and non-Hodgkin’s lymphoma, which cause a build-up of a waxy starch like protein called amyloid in the bone and joint tissues can also cause Carpal Tunnel Syndrome.

Acromegaly, a disease that causes abnormally long bones, can cause CTS. A virus known as “human parvovirus” can lead to developing CTS in both hands.

Some medications administered to cancer patients such as the interleukin-2, which effects the immune system, can cause CTS, as well as anti-clotting drugs such as Warfarin.

Hormonal Problems:

The preservation of fluid during pregnancy or hormonal changes associated with menopause can cause swelling and symptoms of carpal tunnel syndrome.

Genetically Inherited Problems:

The higher risk of the Carpal tunnel syndrome is reported in family having a history of this problem, which indicates that it is genetically inherited. Some researchers are particularly interested in abnormalities in certain genes that regulate myelin, a fatty substance that serves as insulation for nerve fibers. Some people may be born with abnormalities of the carpal bones.

Carpal Tunnel Prevention

There exists no single way of prevention method for Carpal Tunnel Syndrome. The ergonomic methods can help to minimize the risk of work associated Carpal Tunnel Syndrome or other cumulative trauma disorders.

Taking short breaks from can prevent Carpal Tunnel syndrome. A person does repetitive tasks should go for short warm-up period, take frequent break periods and thereby avoiding over effort on the finger muscles and hand.

The key cause of Carpal Tunnel Syndrome is poor posture so utmost care is to be taken to have perfect neutral posture especially for those who are in typing jobs and computer jobs. A keyboard user should sit in such a way that the spine should be against the back of the chair, the shoulders should be relaxed, the elbows should be along the sides of the body, the wrists should be straight and the feet be firmly placed on the floor or on a footrest. The keyboard should be placed within the eye level, so that the neck does not bend over the work. This will help to keep the neck flexible and head remains upright, which maintains circulation and nerve function to the arms and hands.

Another key cause of Carpal Tunnel Syndrome is Forceful usage of fingers and hands. The extra force exerted on the fingers, hands and wrist during repetitive tasks ultimately leads to Carpal Tunnel Syndrome. The tools and tasks should be designed in such a way that the wrist position is same as that when they are in relaxed position will avoid this risk. There should be no task such that the wrist for long periods stay deviated from side to side or to remain flexed or highly extended.

Treatment methods of Carpal tunnel Syndrome

Carpal Tunnel treatment usually falls into two general categories, surgical and non-surgical methods.

Carpal Tunnel Surgery Methods:

Carpal Tunnel Surgery method is also known as Release Surgical Procedures as this surgery is actually for release the pressure on carpal tunnel. There are four Carpal Tunnel Surgery methods

  • Open Release,
  • Mini Open Release,
  • Endoscopy,
  • Percutaneous Balloon Carpal Tunnel-Plastry.

Depending upon the trouble faced by patients suffering of CTS the doctor decides when exactly there is need of Carpal Tunnel Surgery. In a long-term study on CTS, most patients experienced symptoms of CTS for only an average period of six to nine months, but 22% of the patients had symptoms lasted for a period of eight or more years. There isn’t any test to determine whether the symptoms will get resolved or become worse in most people.

A number of experts believe that Carpal Tunnel Surgery is performed frequently and that CTS patients should opt for the non-surgical methods of treatment before going for a Carpal Tunnel Surgery and some experts argue that often the condition is progressive and will worsen over time without the Carpal Tunnel Surgery, which generally brings good results.

One study indicated performing Carpal Tunnel Surgery within three years of the diagnosis of CTS is more successful than waiting for long periods as actually waiting for long period can reduce the benefits of the surgery. The Electrodiagnostic tests for nerve conduction might be more helpful in determining who would most like to get benefited from the this type of Carpal Tunnel Surgery.

The results suggested that workers who had significantly slow nerve conduction and other abnormal results showed the most improvement after Carpal Tunnel Surgery and those who had normal or near-normal nerve conduction results before surgery were least likely to get benefited from the Carpal Tunnel Surgery. As said by a study patient who had less preoperative muscle weakness and whose symptoms were worse at night most likely to be satisfied with the Carpal Tunnel Surgery.

Patients suffering from CTS, which is an outcome of nerve damage due to medical conditions, like the diabetes, hypothyroidism, or rheumatoid arthritis, appear to have the same outcome as those without such conditions and so such disorders should not prevent the Carpal Tunnel Surgery.

It is generally Carpal Tunnel Surgery is recommended if symptoms of CTS continue to exist for four to six months and if muscles begin to atrophy in the base of the palm. The surgical procedure does not always cure all patients because it permanently cuts the carpal ligament, which might lead to loss of wrist strength.

Open Release Surgery:

Carpal Tunnel Surgery generally is an open surgical procedure performed in an outpatient facility. A local anesthetic is injected either into the hand or higher up the arm and wrist. A two-inch incision in made in the palm by the surgeon and he cuts the carpal ligament free from the underlying median nerve by which the ligament is literally released and therefore the pressure on the median nerve is relieved.

The risk of complications with this surgery is less than one percent. Although other techniques are being developed, this procedure is still the most cost effective. Carpal tunnel release is the most commonly performed hand surgery, with more than 100,000 procedures each year.

Mini-Open Release Surgery:

Mini open release technique is the more recent variation of Carpal Tunnel Surgery, in which an incision that is only about an inch and a half. With the help of only a local anesthetic the mini open release surgery can be performed in the doctor’s office itself and it takes just about 12 minutes.

A study on the results reported that there is no loss of finger mobility, recurrence of CTS after a year, and no infection, or no injury to the median nerve but it is more expensive than standard open release surgery.

Non-Surgical Treatment:

Wrist Splinting

Lightweight wrist splints that hold the wrist in a neutral position are more help for carpal tunnel syndrome when worn full time than when only worn overnight, according to a recent study.

Wearing the wrist splints full time will give the best improvements in nerve function, but this improvement did not translate into superior symptom relief or improved ability to perform daily activities.

Perhaps, researchers suggested, the lack of improvements in symptoms and day-to-day functioning resulted from full-time wearers being more likely to take off their splints. Only 27 percent of full-time wearers kept the wrist splints on all day or nearly all day.

One of the non-surgical methods is the Conservative Therapy. It is critical to begin treating early stages of carpal tunnel syndrome before the damage is severe. The patient should avoid if possible repetitive activities at work or home that may worsen the syndrome. Conservative treatment works best in men of age under 40 and least well in young women group.

The Carpal Tunnel Syndrome affected hand and wrist is to be given rest for at least two weeks, which this allows to shrink and release the pressure on the median nerve which is swollen, inflamed tissues. For this Ice may provide relief. It is been reported some patients that alternating warm and cold soaks have been more beneficial. If hot applications relieve pain, it is most likely that the problem might not be caused by CTS but by some other condition producing similar sought of symptoms.

The wrist splints or brace also work for some people, which are worn at nights or during sports, which helps to keep the wrist from bending. The splint is used for several weeks or months depending on the severity of the problem. Except for anecdotal reports, no evidence exists that these supports actually help to reduce the pain. Some experts even believe that wrist supports may actually intensify the problem by reducing blood circulation and restricting the movement of hand by which the shoulder muscles tense up.

Physical Therapy

Another kind of non-surgical method is the Physical Therapy. If symptoms are less active, then the patient may go for the supervised hand and wrist strengthening exercise program, which is usually offered by physical or occupational therapists. One study found that with this Physical Therapy that included exercises to improve balance and posture, most people with CTS felt improvement after two months.

NSAIDs (Ibuprofen and Aspirin)

One of the non-surgical treatments is the Drug treatment. The non-steroidal anti-inflammatory drugs (NSAIDs), like the ibuprofen or the aspirin, can help to reduce the swelling and pain. The doctor may inject an anesthetic or a corticosteroid like the cortisone into the carpal tunnel to reduce the swollen tissues and relieve pressure on the nerve, if the painkillers don’t work. Just three injections of cortisone should be given to avoid abrasion of the tendon.

It is important to note that the pain may increase for a day or two after the injection and even the skin color may change. Diuretics, like the trichlormethiazide, which reduce fluid in the body, can be used. In one study, a short-term regimen of low doses of the oral corticosteroid prednisolone was more effective than either the diuretic trichlormethiazide or an NSAID (tenoxicam).

In fact, a placebo (a “sugar” pill) is more effective than the NSAID or the diuretic. If used for long periods the Oral corticosteroids can have serious side effects, however, and the study did not continue beyond one month, so long-term risks and benefits of this treatment for CTS are unknown. The naftidrofuryl (Praxilene) drug dilates the bloods vessels, which increases oxygen transport, and appears to have some ability for nerve regeneration.

It was used after surgery to treat the atrophied palm of the hand due to carpal tunnel syndrome in Europe. All patients who were treated in the study showed total or partial recovery. High doses of this drug have side effects like causing kidney problems.

Light Therapy

Laser Light Therapy is also one kind of non-surgical treatment for carpal tunnel syndrome. One recent study found that cold laser light treatment method had greater improvement in grip strength and range of wrist movement than those engaged in physical therapy for the automobile workers with CTS. The process uses low-energy laser light that penetrates, but does not cut the skin and stimulates cells activity in the injured areas.

Ultrasound is another type of non-surgical treatment methods, which is considered to be a safe procedure that bombards the wrist with sound waves. The ultrasound reduces the symptoms and relief lasted for at least six months.

B6 Vitamins

Some studies, have reported that vitamin B6 (pyridoxine) deficiency is associated with CTS. Which is been supported by a recent study, furthermore, the recent study reported that high levels of vitamin B6 show fewer CTS symptoms. The same study also reported that high levels of vitamin C relatives to the low levels of vitamin B6 were associated with a higher existence and greater frequency of symptoms. It should be noted that taking higher doses of vitamin B6 could be toxic and can even cause nerve damage.

 

Carpal Tunnel Diagnosis

The different diagnosis techniques for CTS are:

  1. Self-Assessment Tests,
  2. Physical Examination Tests,
  3. Imaging Test,
  4. Electrodiagnostic Tests,
  5. Investigative Tests.

Self-Assessment Tests:

A diagram of hand and wrist which is divided in six regions is shown by some doctors, in which the patients are told to indicate where exactly are they experiencing the symptoms like numbness, pain, tingling and even they are asked to rate the severity of symptoms of Carpal Tunnel Syndrome.

Self-Assessment is a good first step to determining whether one is suffering from CTS.

Physical Examination Testing Technique:

The doctors will perform small maneuvers called the “Provocative Tests” during the Physical examination. This test is mainly for distinguishing between Carpal Tunnel Syndrome and other disorders. In one kind of test the median nerve is tapped over to produce a tingling sensation or mild shock sensation called the Tinel’s sign by the doctor.

Another type of technique is the Phalen’s test in which, the patient’s elbow is rested on a table and lets the wrists dangle with fingers pointing downwards and the backs of the hands pressed together which looks like backward praying. Within a minute if the symptoms are developed then Carpal Tunnel Syndrome is indicated.

The weakness of the muscles is also may be tested by the doctor by pressing on the thumb as the patient holds it and the little finger together. The using wrist-flexion tests, the doctor may even ask the patient to try and reproduce symptoms of Carpal Tunnel syndrome.

Imaging Techniques:

The Imaging Techniques like the Magnetic resonance imaging (MRI) (as well as basic X-rays tests) are very accurate in determining the severity of carpal tunnel syndrome. Other imaging techniques like the Ultrasound Imaging are useful in revealing the abnormalities in the wrist.

Electrodiagnostic Tests :

If the Carpal tunnel syndrome cannot be identified by the simple Self-assessment testing technique or by Physical Assessment testing techniques or by Medical history, then it is best to go for this Electrodiagnostic Tests. Electrodiagnostic tests are of two types:

  • Nerve Conduction Studies and
  • Electromyographies.

These two detect the median nerve compression in the carpal tunnel by analyzing the electric waveforms of nerves and muscles. In the Nerve conduction studies, the surface electrodes are first fastened to the wrist and hand and small shocks are applied to nerves of the forearms, wrists and fingers to measure the speed of conduction of sensory and motor nerve fibers. In the electromyography, the electrical activity of the muscles into which a fine sterile, wire electrode is inserted is viewed.

The conduction time of Women and the elderly normally is slower than the younger adult men. The nerve conduction speed is generally get effected by certain things like the obesity, anxiety and temperature and skew the results. These two techniques are more effective than other techniques as they detected 84% of effected people and also eliminated 95% cases that are not true carpal tunnel syndrome. The other disorders like the pinched nerves in the neck or elbow or thoracic outlet syndrome can also be detected by these two Techniques.

Investigative Tests :

As reported by some researchers an accurate and consistent tool for diagnosis of Carpal Tunnel Syndrome is the computer-assisted device that measures pinch and grip strength and finger pressure.

 Exercises for Carpal Tunnel