Carpal Tunnel Syndrome

Written by Giovanni Bruno

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What is Carpal Tunnel Syndrome?

Carpal Tunnel syndrome is a musculoskeletal condition that causes pain, tingling, numbness and weakness into the hand. This happens because one of the nerves which passes through the carpal tunnel is compressed. The carpal tunnel is a fibrous canal composed of a deep carpal arch and a superficial flexor retinaculum. The superficial flexor retinaculum is a thick connective tissue which forms the floor of the carpal tunnel.

The nerve which is compressed in carpal tunnel syndrome is called the median nerve. The median nerve runs from your forearm through a passageway in your wrist (carpal tunnel) to your hand. It originates from the brachial plexus, a nerve network which originates from the lower cervical nerves and the first thoracic nerve.

The median nerve provides sensation to the palm side of your thumb and fingers, except the little finger (sensory function). Also median nerve provides nerve impulses to move the muscles around the base of your thumb (motor function).

What are the symptoms of Carpal Tunnel Syndrome?

The symptoms of carpal tunnel syndrome typically start gradually and worsen as time goes on. Symptoms include:

  • Burning, tingling and numbness in the hand. The location of altered sensation in the hand corresponds to the way the median nerve is distributed through the hand. This includes the thumb, index, middle or ring fingers. The little finger is innervated by another nerve called the ulnar nerve.
  • Weakness in the hand. This occurs because of numbness but also due to the reduction of the nerve impulses that run through the median nerve due to the nerve being repetitively compressed. As carpal tunnel syndrome gets worse, individuals may experience a reduction in strength for holding and grasping objects. This is due to the muscles in the hand starting to diminish. Increases in pain and muscle cramping may also be experienced.
  • Symptoms usually occur and can increase due to specific, maintained positions such as:
    • holding a steering wheel, phone or newspaper
    • repetitive work movements like cleaning, packaging and typing on a keyboard

What are the common causes of Carpal Tunnel Syndrome?

Carpal tunnel syndrome is caused by compression on the median nerve. Any action that squeezes or irritates the median nerve in the carpal tunnel space can cause carpal tunnel syndrome. Repetitive motions, wrist movements that you do over and over play a crucial role in the development of carpal tunnel syndrome.

A number of factors have been associated with carpal tunnel syndrome. Although these ones are not considered as a direct cause of carpal tunnel syndrome, they may increase the risk of damage to the median nerve:

  • Anatomical aspects. Fractures or dislocations (wrist), or degenerative changes due to arthritis that deforms the small bones in your wrist, can alter the space around the carpal tunnel and put pressure on the median nerve. People who have smaller carpal tunnels may be more likely to have carpal tunnel syndrome.
  • Sex. Carpal tunnel syndrome is more common in women. This is because the carpal tunnel area is relatively narrower in women than in men.
  • Nerve-damaging conditions. Some chronic illnesses, such as diabetes, generally increase the risk of nerve damage inside your body. Diabetes is directly related to glucose metabolism. Excess levels of glucose in the bloodstream typically causes damage to the nerve structures. This includes the median nerve.
  • Inflammatory conditions. Rheumatoid arthritis and other conditions that have an inflammatory aspect can affect the inner laying of the wrist’s tendon. This may result in an increased pressure on the median nerve.
  • Conditions related to fluid changes. Fluid retention increases the pressure within the joints especially the distal ones. In relation to the wrist and carpal tunnel, fluid retention can increase the pressure on the median nerve. This is common during pregnancy and the menopause. Obesity is also a cause for increased fluid accumulation.
  • Daily and occupational factors. Prolonged or repetitive motion of the wrist, especially wrist flexion, can create harmful pressure on the median nerve or aggravate existing nerve damage. However, scientific evidence that proves a direct relationship between these factors and developing carpal tunnel syndrome haven’t yet been established.

How is Carpal Tunnel Syndrome diagnosed?

Your healthcare practitioner will take an in-depth case history along with an examination of your hands, arms, shoulders, and neck to determine the cause of your pain and symptoms. The practitioner will assess your hand and wrist searching for any signs of swelling, tenderness and skin discoloration. They will test each finger to see if there is any loss of sensibility, mobility or strength. Orthopedic tests will then be used to diagnose carpal tunnel syndrome and rule out other causes of hand and wrist pain. The assessment will be aimed at testing your median nerve, to exclude or confirm any damage or irritation to the nerve.

Orthopedic test for carpal tunnel syndrome include:

Tinel’s Sign. The median nerve will be pressed with a reflex hammer. If your fingers tingle or if you feel an electric-shock-like sensation, the test is considered positive.

Phalen’s Maneuver or wrist-flexion test

The healthcare practitioner will tell you to press the backs of your hands and fingers together with your wrists flexed and your fingers pointed down. You’ll keep that position with your wrist for a couple of minutes. It is considered a positive test if your fingers start tingling or get numb

What are the treatment options for Carpal Tunnel Syndrome?

From manual to surgical therapy, there are several options when it comes to treating carpal tunnel syndrome. A combination of different approaches may be needed in order to get the relief you need, and as usual it is best to discuss the options with your local doctor or healthcare practitioner.

Self-management

Hot and Cold therapy. To help reduce the symptoms of carpal tunnel syndrome, you can use ice on your wrist. Apply a cold compress or for 10-15 minutes over the wrist. Repeat 3-4 times a day. You can also try using heat to relieve muscle and tendon tension around your wrist.

Rest. You can put at rest your wrist avoiding all the movements which trigger the symptoms.
Some movements relieve and discharge your carpal tunnel from pressure such as gently shaking your wrist.
Pain Relief Medication. Some pain relief may be achieved with over-the-counter medications such as aspirin, ibuprofen, or naproxen. Remember that these medications will help you ease the pain, but won’t address or cure the cause of carpal tunnel syndrome.

Wrist Brace. Your healthcare practitioner may suggest you wearing a wrist brace. Braces are generally useful when you have mild to moderate symptoms. It does not always work, but there are no side effects either. You will have to wear the brace at least for 3-4 weeks to see any improvements. The wrist brace is a support for your joints so make sure to wear it even during the day while you’re doing any activities that may flare up the pain.

How Can a Wrist Brace Help?

Most people put their wrists in flexed or awkward positions during sleep, resulting in a lot of pressure on the median nerve. A brace can help because it keeps your wrist in a neutral and comfortable position. You may also find it helpful to wear a brace during the day, especially during activities that trigger flare-ups.
After you take the wrist brace off, be sure to keep moving your wrist in order to maintain your flexibility at a good level. This will help you keep your muscles flexible and active.

Conservative treatment

Physiotherapy. A physiotherapy is a qualified medical professional who works to reduce your pain and help you regain strength and mobility. A physical therapist may suggest exercises called “gliding exercises”. These focus on the nerves and tendons mobility inside the joint passages. With the aim to improve the mobility and flexibility of the tendons and nerves inside the carpal tunnel, encouraging smooth movement and a reduction or median nerve irritation.
In the study of Fernandez et al 2015 has been found that surgery and physical manual therapies including desensitization maneuvers of the central nervous system were similarly effective at medium-term and long-term follow-ups for improving pain and function but that physical therapy led to better outcomes in the short term.

Osteopathic Therapy. Osteopathy is a manual treatment approach that uses several manual techniques to improve posture, reduce tension in your muscles and improve motion in your joints. Burnham et al 2015 showed that osteopathic treatment has some positive effects on the management of carpal tunnel syndrome. Results from the study showed transverse carpal ligament length was improved, and after 6 weeks treatment all the symptoms were improved including wrist functionality.

Massage Therapy. In the study of Elliot et al 2013 Massage therapy has shown to be an effective way to treat Carpal Tunnel Syndrome , in fact massage can relieve the symptoms and help you prevent the recurrence of the pain. Massage reduces muscle tension, lengthen muscle fascia which causes lack of flexibility and mobility in your arm and hand .

Massage therapy increases the blood flow to your joints and your muscles helping the inner healing process of our body structures.

Surgical interventions

If symptoms are ongoing for a prolonged period of time or you start to feel constant weakness in your muscles, tingling and pins and needles, then your GP may refer you for surgical intervention. There are a few different surgical interventions for carpal tunnel syndrome and these will be discussed with you by your surgeon. This will include risk and benefits for each procedure.

Usually the surgical operations which are performed are open and endoscopic. In both of them, your doctor cuts the ligament around the carpal tunnel to reduce the pressure on the median nerve and relieve your symptoms. After the surgery, the ligament will heal by itself, but with more space for the median nerve sliding.

Open surgery: during open carpal tunnel release surgery, the transverse carpal ligament is cut. This relieves pressure on the median nerve and in theory helps to reduce the symptoms of carpal tunnel syndrome.

With this type of surgery you do not need to stay in the hospital for the night and you can go home on the same day. During the operation local anaesthetic will be used so you will be wide awake.

Endoscopic surgery: with the help of a tiny little camera your surgeon will be guided when cutting the ligament. Typically to insert the camera, the surgeon will make small incisions in your wrist and sometimes also your arm. The cuts are really small, about a half-inch each.

After surgery you may be suggested to start doing physiotherapy to restore mobility of your wrist and to reduce your muscle tension around the muscles of your forearm and your hand.

How long does Carpal Tunnel Syndrome last?

In some cases, if carpal tunnel syndrome is mild and it is caught early, it may go away on its own with strict rest. If carpal tunnel syndrome is not treated, permanent nerve and muscle damage may occur. Early diagnosis and treatment always offer the best results. It may last for months or last for years, and is always dependent on the cause. If you think that you may have carpal tunnel syndrome, talk with your doctor as soon as possible.

Can Carpal Tunnel Syndrome be prevented?

Prevention of carpal tunnel syndrome is always dependent on the cause of the symptoms. In some cases it cannot be prevented. However there are a few things that can be done to reduce your symptoms:

  1. Avoid any stressful movements, maintain pressure on your wrist or any awkward twisted positions. This will help to minimize stress on your hands and wrists.
  2. Relax the grip on the objects and reduce the force that you use at work. For example with prolonged handwriting, use a pen with a comfortable grip for your hand.
  3. Be sure to take regular breaks at work and gently stretch and bend your hands and wrists. This is especially important if you use equipment that vibrates or that requires you to apply a great amount of strength.
  4. Avoid bending your wrist all the way up or down. A relaxed middle position is the best one. If you’re working with a computer, make sure to adjust your posture: make sure that your mouse is in a comfortable position and also keep your keyboard at elbow height. Pay attention to your general posture and how you’re sitting. Poor posture will have an effect on your carpal tunnel syndrome.
  5. Keep your hands warm: A cold environment will affect your hands, making you develop more pain and stiffness. If you don’t work in a warm environment, try wearing gloves to keep your wrists and hands warm.

What are the best exercises for Carpal Tunnel Syndrome?

Wrist bend. Rest your elbow on a table, with your wrist straight and your arm pointing up. Gently bend your wrist forward at an angle that is not painful for you and hold for 5- 7 seconds. Move Your wrist back into its starting position. Gently bend your wrist backwards and hold for 5-7 seconds. If this exercise causes too much discomfort, reduce the holding time and the repetitions.

Wrist lift. Place your palm on a surface (like a kitchen table) and lift your fingers up, excluding the thumb.Place your other hand on the knuckles at an angle of 90 degrees. push down to increase the resistance for your fingers as you lift them up. You should feel your forearm contracting.Repeat 8 times. If this exercise causes too much discomfort, reduce the holding time and the repetitions.

Wrist flex. Hold your arm out straight in front of you, with your palm facing down. Gently bend your wrist down. Use the opposite hand to increase your wrist’s flexion and stretch your hand back in the direction of your body. Hold for 25 seconds.Relax your wrist and gently straighten it. Gently bend the affected hand backwards and use the opposite one to pull your fingers back and hold for 10 up to 25 seconds. Do 3 sets each side If this exercise causes too much discomfort, reduce the holding time and the repetitions.

Wrist stretch with weight. Holding a light weight (e.g a small bottle of water, a small towel, a small tin of beans ), then stretch your arm out (do this movement slowly) with your palm facing downwards. Slowly bend your wrist up, and then return to a neutral position. Do 4 sets of 8 repetitions. According to your symptoms you can increase the weight that you’re holding, do this gradually.If this exercise causes too much discomfort, reduce the holding time and the repetitions.

References

Burnham, Taylor & Higgins, Derek & Burnham, Robert & Heath, Deborah. (2015). Effectiveness of Osteopathic Manipulative Treatment for Carpal Tunnel Syndrome: A Pilot Project. The Journal of the American Osteopathic Association. 115. 138-48.

Elliott, Rex & Burkett, Brendan. (2013). Massage therapy as an effective treatment for carpal tunnel syndrome. Journal of bodywork and movement therapies. 17. 332-8.

Fernández-de-Las Peñas C, Ortega-Santiago R, de la Llave-Rincón AI, Martínez-Perez A, Fahandezh-Saddi Díaz H, Martínez-Martín J, Pareja JA, Cuadrado-Pérez ML. Manual Physical Therapy Versus Surgery for Carpal Tunnel Syndrome: A Randomized Parallel-Group Trial. J Pain. 2015 Nov;16(11):1087-94.

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