McGovern Physical Therapy Associates - The Personal Care Professionals

CARPAL TUNNEL SYNDROME

What is carpal tunnel syndrome?

Carpal tunnel syndrome occurs when the median nerve, which runs from the forearm into the hand, becomes pressed or squeezed at the wrist. The median nerve controls sensations to the palm side of the thumb and fingers (although not the little finger), as well as impulses to some small muscles in the hand that allow the fingers and thumb to move. The carpal tunnel - a narrow, rigid passageway of ligament and bones at the base of the hand houses the median nerve and tendons. Sometimes, thickening from irritated tendons or other swelling narrows the tunnel and causes the median nerve to be compressed. The result may be pain, weakness, or numbness in the hand and wrist, radiating up the arm. Although painful sensations may indicate other conditions, carpal tunnel syndrome is the most common and widely known of the entrapment neuropathies in which the body's peripheral nerves are compressed or traumatized.

What are the symptoms of carpal tunnel syndrome?

Symptoms usually start gradually, with frequent burning, tingling, itching or numbness in the palm of the hand and the fingers, especially the thumb and the index and middle fingers. Some carpal tunnel sufferers say their fingers feel useless and swollen, even though little or no swelling is apparent. The symptoms often first appear in one or both hands during the night, since many people sleep with flexed wrists. A person with carpal tunnel syndrome may wake up feeling the need to "shake out" the hand or wrist. As symptoms worsen, people might feel tingling during the day. Decreased grip strength may make it difficult to form a fist, grasp small objects, or perform other manual tasks. Some people are unable to tell between hot and cold by touch.

What are the causes of carpal tunnel syndrome?

Carpal tunnel syndrome is often the result of a combination of factors that increase pressure on the median nerve and tendons in the carpal tunnel, rather than a problem with the nerve itself. Most likely the disorder is due to a congenital predisposition - the carpal tunnel is simply smaller in some people than in others. Other contributing factors include trauma or injury to the wrist that cause swelling, such as sprain or fracture; over activity of the pituitary gland; hypothyroidism; rheumatoid arthritis; mechanical problems in the wrist joint; work stress; repeated use of vibrating hand tools; fluid retention during pregnancy or menopause; or the development of a cyst or tumor in the canal. In some cases no cause can be identified.

There is little clinical data to prove whether repetitive and forceful movements of the hand and wrist during work or leisure activities can cause carpal tunnel syndrome. Repeated motions performed in the course of normal work or other daily activities can result in repetitive motion disorders such as bursitis and tendonitis. Writer's cramp - a condition in which a lack of fine motor skill coordination and ache and pressure in the fingers, wrist, or forearm is brought on by repetitive activity - is not a symptom of carpal tunnel syndrome.

Who is at risk of developing carpal tunnel syndrome?

Women are three times more likely than men to develop carpal tunnel syndrome, perhaps because the carpal tunnel itself may be smaller in women than in men. The dominant hand is usually affected first and produces the most severe pain. Persons with diabetes or other metabolic disorders that directly affect the body's nerves and make them more susceptible to compression are also at high risk. Carpal tunnel syndrome usually occurs only in adults.

The risk of developing carpal tunnel syndrome is not confined to people in a single industry or job, but is especially common in those performing assembly line work - manufacturing, sewing, finishing, cleaning, and meat, poultry, or fish packing. In fact, carpal tunnel syndrome is three times more common among assemblers than among data-entry personnel. A 2001 study by the Mayo Clinic found heavy computer use (up to 7 hours a day) did not increase a person's risk of developing carpal tunnel syndrome.

During 1998, an estimated three of every 10,000 workers lost time from work because of carpal tunnel syndrome. Half of these workers missed more than 10 days of work. The average lifetime cost of carpal tunnel syndrome, including medical bills and lost time from work, is estimated to be about $30,000 for each injured worker.

How is carpal tunnel syndrome diagnosed?

Early diagnosis and treatment are important to avoid permanent damage to the median nerve. A physical examination of the hands, arms, shoulders, and neck can help determine if the patient's complaints are related to daily activities or to an underlying disorder, and can rule out other painful conditions that mimic carpal tunnel syndrome. The wrist is examined for tenderness, swelling, warmth and discoloration. Each finger is tested for sensation, and the muscles at the base of the hand are examined for strength and signs of atrophy. Routine laboratory tests and X-rays can reveal diabetes, arthritis and fractures.

Physical therapists can use specific tests to try to produce the symptoms of carpal tunnel syndrome. In the Tinel test, the therapist taps on or presses on the median nerve in the patient's wrist. The test is positive when tingling in the fingers or a resultant shock-like sensation occurs. The Phalen, or wrist-flexion, test involves having the patient hold his or her forearms upright by pointing the fingers down and pressing the backs of the hands together. The presence of carpal tunnel syndrome is suggested if one or more symptoms, such as tingling or increasing numbness, are felt in the fingers within 1 minute.

How is carpal tunnel syndrome treated?

Treatments for carpal tunnel syndrome should begin as early as possible, under a trained physical therapist’s direction. Initial treatment generally involves resting the affected hand and wrist, avoiding activities that may worsen symptoms, and immobilizing the wrist in a splint to avoid further damage from twisting or bending. It is then best to begin a supervised hand and wrist strengthening exercise program. One study found that most people with CTS felt improvement after two months of physical therapy that included exercises to improve balance and posture.

Physical therapy techniques, such as ultrasound, stretching and range-of-motion exercises are proven to be the most effective for the relief of symptoms. Ultrasound therapy uses high-pitched sound waves to create heat, which may help decrease pain in the soft tissues (such as the tendons), and increase circulation. Stretching the wrists and hands may help prepare the carpal tunnel nerve for repetitive movements. One study found that range-of-motion exercises, when compared with splinting, brought faster pain relief and helped people return to work sooner. In mild cases of carpal tunnel syndrome, wearing a wrist splint does relieve symptoms. Wrist splints keep the wrist from bending and minimize or prevent pressure on the median nerve. Wrist splints are designed for different purposes such as for particular jobs or for wearing at night. Splints are most effective if they are used as soon as symptoms are noticed, in conjunction with a supervised exercise program. Retraining (learning new ways of doing things), and ergonomic considerations (such as having your body in the correct posture and position and using equipment that is right for your strength and ability) may also help. Retraining and ergonomic considerations may not only relieve the symptoms of carpal tunnel syndrome but also may prevent them from coming back. Drugs, acupuncture and chiropractic care have benefited some patients but their effectiveness remains unproved. An exception is yoga, which has been shown to reduce pain and improve grip strength among patients with carpal tunnel syndrome.

How Physical Therapists Can Help Outside the Clinic

Physical therapists with specialized training in cumulative trauma disorders have been working in industrial and corporate settings for many years to meet the health care needs of America's workforce. They work closely with employers to educate employees about CTS- what causes it and how to avoid it through proper use of the musculoskeletal system. Physical therapists can target and correct poor work habits and improper work designs, such as tools, furniture, equipment, and work space. They also can assess the risk potential of an individual and determine if that person is physically unsuited for a particular job.

Among their many responsibilities, physical therapists teach health awareness and job safety. A typical education program includes exercises employees can do at work and at home, adjustments to the overall work environment and individual work stations, plus early detection of symptoms to avoid painful and costly surgery.

Physical therapists also work with employers and their engineering departments to design and modify the work environment, helping to remove the causal factors of CTS.

If you or anyone you know has symptoms of carpal tunnel syndrome, consult a physical therapist or other qualified health care practitioner for an evaluation and individualized treatment.

McGovern Physical Therapy Associates, the personal care professionals, is a multispecialty provider of outpatient physical therapy care. Voted “Best PT Practice 2004” by ADVANCE for Directors in Rehabilitation magazine, our clinicians offer personalized manual therapy and exercise expertise, including a variety of customized treatment options. Combining innovation, experience and excellence, our staff of clinicians, as well as dedicated office personnel, work as a team to provide caring, convenient and professional service for total patient recovery.

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