carpal tunnel syndrome

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Medical Encyclopedia: Carpal Tunnel Syndrome

More about Carpal Tunnel Syndrome:
Causes and symptoms
Diagnosis
Treatment
Prognosis
Prevention
Resources

Definition

Carpal tunnel syndrome is a disorder caused by compression at the wrist of the median nerve supplying the hand, causing numbness and tingling.

Description

The carpal tunnel is an area in the wrist where the bones and ligaments create a small passageway for the median nerve. The median nerve is responsible for both sensation and movement in the hand, in particular the thumb and first three fingers. When the median nerve is compressed, an individual's hand will feel as if it has "gone to sleep."

Women between the ages of 30 and 60 have the highest rates of carpal tunnel syndrome. Research has demonstrated that carpal tunnel syndrome is a very significant cause of missed work days due to pain. In 1995, about $270 million was spent on sick days taken for pain from repetitive motion injuries.

— Rosalyn Carson-DeWitt, MD

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Dictionary: carpal tunnel syndrome

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A condition characterized by pain and numbing or tingling sensations in the hand and caused by compression of a nerve in the carpal tunnel at the wrist.

Neurological Disorder:

Carpal tunnel syndrome

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Definition

Carpal tunnel syndrome is an entrapment neuropathy of the wrist. It occurs when the median nerve, which runs through the wrist and enervates the thumb, pointer finger, middle finger and the thumb side of the ring finger, is aggravated because of compression. Symptoms include numbness, tingling and pain in the fingers the median nerve sensitizes. Some people have difficulty grasping items and may have pain radiating up the arm. Carpal tunnel syndrome is common in people who work on assembly lines, doing heavy lifting and packing involving repetitive motions. Other repetitive movements such as typing are often implicated in cause carpal tunnel syndrome, however some clinical evidence contradicts this association. Additional causes of the syndrome include pregnancy, diabetes, obesity or simply wrist anatomy in which the carpal tunnel is narrow. Treatment includes immobilization with a splint or in severe cases surgery to release the compression of the median nerve.

Description

Carpal tunnel syndrome (CTS) is caused by a compression of the median nerve in the wrist, a condition known as nerve entrapment. Nerve entrapments occur when a nerve that travels through a passage between bones and cartilage becomes irritated because a hard edge presses against it. In almost every case of nerve entrapment, one side of the passage is moveable and the repetitive rubbing exacerbates the injury.

Three sides of the carpal tunnel are made up of three bones that form a semicircle around the back of the wrist. The fourth side of the carpal tunnel is made up of the transverse carpal tunnel ligament also called the palmar carpal ligament, which runs across the wrist on the same side as the palm. This ligament is made of tissue that cannot stretch or contract, making the cross sectional area of the carpal tunnel a fixed size. Running through the carpal tunnel are nine tendons that assist the muscles that move the hand and the median nerve. The median nerve enervates the thumb, forefinger, middle finger, and the thumb side of the ring finger. The ulnar nerve that serves the little finger side of the ring finger and the little finger runs outside of the transverse carpal tunnel ligament and is therefore less likely to become entrapped in the wrist.

The tendons that run through the carpal tunnel are encased in a lubricating substance called tensynovium. This substance can become swollen when the tendons rub quickly against one another, as occurs when the finger muscles are used repeatedly. When this happens, there is less space within the carpal tunnel for the median nerve and it becomes compressed or pinched.

When a nerve is compressed, the blood supply to the nerve is interrupted. In an attempt to alleviate the problem, the body's immune system sends new cells called fibroblasts to the area to try to build new tissue. This eventually results in scar tissue around the nerve. In an area that cannot expand this only worsens the situation and puts more pressure on the nerve. A compressed nerve can be likened to an electrical wire that has been crimped. It cannot transmit electrical signals to the brain properly and the result is a feeling of numbness, tingling or pain in the areas that the nerve enervates.

Compression of the median nerve causes tingling and numbness in the thumb, forefinger, middle finger and on the thumb-side of the fourth finger. It may also cause pain in the forearm and occasionally into the shoulder. Some persons have a difficult time gripping and making a fist.

People who suffer from CTS range from those who are mildly inconvenienced and must wear a splint at night to relieve pressure on the median nerve to those who are severely debilitated and lose use of their hands. Problems associated with CTS can invade a person's life making even simple tasks such as answering the phone, reading a book or opening a door extremely difficult. In severe cases, surgery to release the median nerve is often suggested by an orthopedist. The carpal tunnel ligament is cut, relieving the pressure within the carpal tunnel. Rates of success are quite high with the surgical procedure.

Demographics

Carpal tunnel syndrome is more common in women than in men, perhaps because the carpal tunnel generally has a smaller cross section in women than in men. The ratio of women to men who suffer from CTS is about three to one. CTS is most often diagnosed in people who are between 30 and 50 years old. It is more likely to occur in people whose professions require heavy lifting and repetitive movements of the hands such as manufacturing, packing, cleaning and finishing work on textiles.

Causes and symptoms

Carpal tunnel syndrome may occur when anything causes the size of the carpal tunnel to decreases or when anything puts pressure on the median nerve. Often the cause is simply the result of an individual's anatomy; some people have smaller carpal tunnels than others. Trauma or injury to the wrist, such as bone breakage or dislocation can cause CTS if the carpal tunnel is narrowed either by the new position of the bones or by associated swelling. Development of a cyst or tumor in the carpal tunnel will also result in increased pressure on the median nerve and likely CTS. Systemic problems that result in swelling may also cause CTS such as hypothyroidism, problems with the pituitary gland, and the hormonal imbalances that occur during pregnancy and menopause. Arthritis, especially rheumatoid arthritis, may also cause CTS. Some patients with diabetes may be more susceptible to CTS because they already suffer from nerve damage. Obesity and cigarette smoking are thought to aggravate symptoms of CTS.

Much evidence suggests that one of the more common causes of CTS involves performing repetitive motions such as opening and closing of the hands or bending of the wrists or holding vibrating tools. Motions that involve weights or force are thought to be particularly damaging. For example, the types of motions that assembly line workers perform such as packing meat, poultry or fish, sewing and finishing textiles and garments, cleaning, and manufacturing are clearly associated with CTS. Other repetitive injury disorders such as data entry while working on computers are also implicated in CTS. However, some clinical data contradicts this finding. These studies show that computer use can result in bursitis and tendonitis, but not CTS. In fact, a 2001 study by the Mayo Clinic found that people who used the computer up to seven hours a day were no more likely to develop CTS than someone who did not perform the type of repetitive motions required to operate a keyboard.

The two major symptoms of carpal tunnel syndrome include numbness and tingling in the thumb, forefinger, middle finger and the thumb side of the fourth finger and a dull aching pain extending from the wrist through the shoulder. The pain often worsens at night because most people sleep with flexed wrists, which puts additional pressure on the median nerve. Eventually the muscles in the hands will weaken, in particular, the thumb will tend to lose strength. In severe cases, persons suffering from CTS are unable to differentiate between hot and cold temperatures with their hands.

Diagnosis

Diagnosis of carpal tunnel syndrome begins with a physical exam of the hands, wrists and arms. The physician will note any swelling or discoloration of the skin and the muscles of the hand will be tested for strength. If the patient reports symptoms in the first four fingers, but not the little finger, then CTS is indicated. Two special tests are used to reproduce symptoms of CTS: the Tinel test and the Phalen test. The Tinel test involves a physician taping on the median nerve. If the patient feels a shock or a tingling in the fingers, then he or she likely has carpal tunnel syndrome. In the Phalen test, the patient is asked to flex his or her wrists and push the backs of the hands together. If the patient feels tingling or numbness in the hands within one minute, then carpal tunnel syndrome is the likely cause.

A variety of electronic tests are used to confirm CTS. Nerve conduction velocity studies (NCV) are used to measure the speed with which an electrical signal is transferred along the nerve. If the speed is slowed relative to normal, it is likely that the nerve is compressed. Electromyography involves inserting a needle into the muscles of the hand and converting the muscle activity to electrical signals. These signals are interpreted to indicate the type and severity of damage to the median nerve. Ultrasound imaging can also be used to visualize the movement of the median nerve within the carpal tunnel. X rays can be used to detect fractures in the wrist that may be the cause of carpal tunnel syndrome. Magnetic resonance imaging (MRI) is also a useful tool for visualizing injury to the median nerve.

Treatment team

Treatment for carpal tunnel syndrome usually involves a physician specializing in the bones and joints (orthopedist) or a neurologist, along with physical and occupational therapists, and if necessary, a surgeon.

Treatment

Lifestyle changes are often the first type of treatment prescribed for carpal tunnel syndrome. Avoiding activities that aggravate symptoms is one of the primary ways to manage CTS. These activities include weight-bearing repetitive hand movements and holding vibrating tools. Physical or occupational therapy is also used to relieve symptoms of CTS. The therapist will usually train the patient to use exercises to reduce irritation in the carpal tunnel and instruct the patient on proper posture and wrist positions. Often a doctor or therapist will suggest that a patient wear a brace that holds the arm in a resting position, especially at night. Many people tend to sleep with their wrists flexed, which decreases the space for the median nerve within the carpal tunnel. The brace keeps the wrist in a position that maximizes the space for the nerve.

Doctors may prescribe non-steroidal anti-inflammatory medications to reduce the swelling in the wrist and relieve pressure on the median nerve. Oral steroids are also useful for decreasing swelling. Some studies have shown that large quantities of vitamin B-6 can reduce symptoms of CTS, but this has not been confirmed. Injections of corticosteroids into the carpal tunnel may also be used to reduce swelling and temporarily provide some extra room for the median nerve.

Surgery can be used as a final step to relieve pressure on the median nerve and relieve the symptoms of CTS. There are two major procedures in use, both of which involve cutting the transverse carpal tunnel ligament. Dividing this ligament relieves pressure on the median nerve and allows blood flow to the nerve to increase. With time, the nerve heals and as it does so, the numbness and pain in the arm are reduced.

Open release surgery is the standard for severe CTS. In this procedure, a surgeon will open the skin down the front of the palm and wrist. The incision will be about two inches long stretching towards the fingers from the lowest fold line on the wrist. Then next incision is through the palmar fascia, which is a thin connective tissue layer just below the skin, but above the transverse carpal ligament. Finally, being careful to avoid the median nerve and the tendons that pass through the carpal tunnel, the surgeon carefully cuts the transverse carpal ligament. This releases pressure on the median nerve.

Once the transverse carpal tunnel ligament is divided, the surgeon stitches up the palma fascia and the skin, leaving the ends of the ligament loose. Over time, the space between the ends of the ligament will be joined with scar tissue. The resulting space, which studies indicate is approximately 26% greater than prior to the surgery, is enlarged enough so that the median nerve is no longer compressed.

A second surgical method for treatment of CTS is endoscopic carpal tunnel release. In this newer technique, a surgeon makes a very small incision below the crease of the wrist just below the carpal ligament. Some physicians will make another small incision in the palm of the hand, but the single incision technique is more commonly used. The incision just below the carpal ligament allows the surgeon to access the carpal tunnel. He or she will then insert a plastic tube with a slot along one side, called a cannula, into the carpal tunnel along the median nerve just underneath the carpal ligament. Next an endoscope, which is a small fiber-optic cable that relays images of the internal structures of the wrist to a television screen, is fed through the cannula. Using the endoscope, the surgeon checks that the nerves, blood vessels and tendons that run through the carpal tunnel are not in the way of the cannula. A specialized scalpel is fed through the cannula. This knife is equipped with a hook on the end that allows the surgeon to cut as he or she pulls the knife backward. The surgeon positions this knife so that it will divide the carpal ligament as he pulls it out of the cannula. Once the knife is pulled through the cannula, the carpal ligament is severed, but the palma fascia and the skin are not cut. Just as in the open release surgery, cutting the carpal ligament releases the pressure on the median nerve. Over time, scar tissue will form between the ends of the carpal ligament. After the cannula is removed from the carpal tunnel, the surgeon will stitch the small incision in patient's wrist and the small incision in the palm if one was made.

The two different surgical techniques for treating CTS have both positive and negative attributes and the technique used depends on the individual case. In open release, the surgeon has a clear view of the anatomy of the wrist and can make sure that the division of the transverse ligament is complete. He or she can also see exactly which structures to avoid while making the incision. On the other hand, because the incision to the exterior is much larger than in endoscopic release, recovery time is usually longer. While the symptoms of CTS usually improve rapidly, the pain associated with the incision may last for several months. Many physicians feel that the recovery time associated with endoscopic release is faster than that for open release because the incision in the skin and palma fascia are so much smaller. On the other hand, endoscopic surgery is more expensive and requires training in the use of more technologic equipment. Some believe that are also risks that the carpal ligament may not be completely released and the median nerve may be damaged by the cannula, or the specialized hooked knife. Research is ongoing in an attempt to determine whether open or endoscopic release provides the safest and most successful results.

Success rates of release surgery for carpal tunnel syndrome are extremely high, with a 70–90% rate of improvement in median nerve function. There are complications associated with the surgery, although they are generally rare. These include incomplete division of the carpal ligament, pain along the incisions and weakness in the hand. Both the pain and the weakness are usually temporary. Infections following surgery for CTS are reported in less than 5% of all patients.

Recovery and rehabilitation

One day following surgery for carpal tunnel syndrome, a patient should begin to move his or her fingers, however gripping and pinching heavy items should be avoided for a month and a half to prevent the tendons that run through the carpal tunnel from disrupting the formation of scar tissue between the ends of the carpal ligament.

After about a month and a half, a patient can begin to see an occupational or physical therapist. Exercises, massage and stretching will all be used to increase wrist strength and range of motion. Eventually, the therapist will prescribe exercises to improve the ability of the tendons within the carpal tunnel to slide easily and to increase dexterity of the fingers. The therapist will also teach the patient techniques to avoid a recurrence of carpal tunnel syndrome in the future.

Clinical trials

There are a variety of clinical trials underway that are searching for ways to prevent and treat carpal tunnel syndrome. The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) supports this research on CTS. Their website is .

One trial seeks to determine which patients will benefit from surgical treatments compared to non-surgical treatments using a new magnetic resonance technique. The study is seeking patients with early, mild to moderate carpal tunnel syndrome. Contact Brook I. Martin at the University of Washington for more information. The phone number is (206) 616–0982 and the email is bim@u.washington.edu.

A second trial compares the effects of the medication amitriptyline, acupuncture, and placebos for treating repetitive stress disorders such as carpal tunnel syndrome. The study is located at Harvard University. For information contact Ted Kaptchuk at (617) 665–2174 or tkaptchu@caregroup.harvard.edu.

A third study is evaluating the effects of a protective brace for preventing carpal tunnel syndrome in people who use tools that vibrate in the workplace. The brace is designed to absorb the energy of the vibrations while remaining unobtrusive. For information on this study contact Prosper Benhaim at the UCLA Hand Center. The phone number is (310) 206–4468 and the email address is pbenhaim@mednet.ucla.edu.

Prognosis

Persons with carpal tunnel syndrome can usually expect to gain significant relief from prescribed surgery, treatments, exercises, and positioning devices.

Resources

BOOKS

Johansson, Phillip. Carpal Tunnel Syndrome and Other Repetitive Strain Injuries. Brookshire, TX: Enslow Publishers, Inc. 1999.

Shinn, Robert, and Ruth Aleskovsky. The Repetitive Strain Injury Handbook. New York: Henry Holt and Company. 2000.

OTHER

"Carpal Tunnel Syndrome." American Association of Orthopaedic Surgeons. (February 11, 2004). http://orthoinfo.aaos.org/brochure/thr_report.cfm?Thread_ID=5&topcategory=Hand.

"Carpal Tunnel Syndrome Fact Sheet." National Instititute of Neurological Disorders and Stroke. (February 11, 2004). http://www.ninds.nih.gov/healt_and_medical/disorders/carpal_tunnel.htm.

ORGANIZATIONS

American Chronic Pain Association (ACPA). P.O. Box 850, Rocklin, CA 95677. (916) 632-0922 or (800) 533-3231. ACPA@pacbell.net. http://www.theacpa.org.

National Chronic Pain Outreach Association (NCPOA). P.O. Box 274, Millboro, VA 24460. (540) 862-9437; Fax: (540) 862-9485. ncpoa@cfw.com. http://www.chronicpain.org.

National Institute of Arthritis and Musculoskeletal and Skin Dieseases (NIAMS). National Institutes of Health, Bldg. 31, Rm. 4C05, Bethesda, MD 20892. (301) 496-8188; Fax: (540) 862-9485. ncpoa@cfw.com. http://www.niams.nih.gov/index.htm.

Juli M. Berwald, Ph.D.

Sci-Tech Encyclopedia: Carpal tunnel syndrome

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A condition caused by the thickening of ligaments and tendon sheaths at the wrist with consequent compression of the median nerve at the palm. Affected individuals report numbness, tingling, and pain in the hand; the discomfort often becomes worse at night or after use of the hand. A physical examination of the injured hand during the early stages of the syndrome often reveals no abnormality. With more severe nerve compression, the individual experiences sensory loss over some or all of the digits innervated by the median nerve (thumb, index finger, middle finger, and ring finger) and weakness of thumb movement.

The incidence of carpal tunnel syndrome is greater among electronic-parts assemblers, frozen-food processors, musicians, and dental hygienists. Highly repetitive wrist movements, use of vibrating tools, awkward wrist positions, and movements involving great force seem to be correlated with the disorder. Awkward and repetitive wrist motions occur in many office tasks, such as typing and word processing.

Carpal tunnel syndrome probably accounts for a minority of the cases of overuse syndrome (cumulative trauma syndrome), which is a common problem in occupational settings. Overuse syndrome symptoms include muscle pain, tendinitis, fibrositis (inflammation of connective tissue in a joint region), and epicondylitis (inflammation of the eminence on the condyle of a bone). Although the causative relationship between the two disorders has not been conclusively proven, the incidence of both carpal tunnel syndrome and overuse syndrome appears to increase in tandem in individuals who are at risk.

The increase in pressure within the carpal canal is usually caused by nonspecific inflammation of flexor tendon sheaths. Diabetes, pregnancy, rheumatoid arthritis, and hypothyroidism are the most common medical conditions associated with carpal tunnel syndrome. A reduction in the flow of blood to the nerve can account for the intermittent tingling that occurs at night or with wrist flexion. See also Amyloidosis; Arthritis; Diabetes.

Nonsurgical treatment includes avoidance of the use of the wrist, use of a splint to keep the wrist in a neutral position, and anti-inflammatory medications. These treatments are especially useful in individuals with an acute flare-up and in those with minimal and intermittent symptoms. Surgical treatment may be used if conservative approaches fail. The procedure is usually done on an outpatient basis with prognoses of good to excellent in 80% of the cases. Although 40% of the individuals regain normal function, the condition of 5% may worsen.

Computer Desktop Encyclopedia: carpal tunnel syndrome

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A disorder that causes numbness in the hand and pain in the wrist due to the compression of the median nerve, which runs down the arm to the fingers. The pain can extend all the way to the neck and be extremely severe. People may have a genetic predisposition to this malady and those who suffer with thyroid problems, diabetes and rheumatoid arthritis are believed to be more susceptible.

Short, Repetitive Movement

Carpal tunnel syndrome is caused by short, repetitive movement, such as typing, knitting, and using vibrating tools for hours on end. The lack of rest in between these motions irritates and inflames the flexor tendons that travel with the median nerve to the hand through an area in the wrist called the "carpal tunnel," which is surrounded by bones and a transverse ligament. The inflamed tendons squeeze the nerve against the ligament.

The Treatments

The prescription for typists may be as simple as wrist exercises and the use of a wrist rest or ergonomic glove. The more severe remedy is surgery, in which the transverse ligament is cut to relieve pressure. See RSI and medical conditions.

It's the Median Nerve

There is so little space in the carpal tunnel that when the tendons get inflamed, the median nerve is pressed against the transverse ligament. (Image courtesy of www.carpal-tunnel.com.)

Rest the Wrist

Wrist rests help to avoid carpal tunnel syndrome by keeping the wrists elevated above the keyboard.

An Ergonomic Glove

IMAK Products' Smart Glove uses a removable splint (upper cutout) to keep the wrist in the proper position. The ergoBeads (bottom cutout) massage the area to increase blood circulation and promote healthy muscle tissue. (Image courtesy of IMAK Products Corporation, www.imakproducts.com)

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Food and Nutrition: carpal tunnel syndrome

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Painful disorder of wrist and hand due to compression of the median nerve in the carpal tunnel. Claimed to be relieved by high intakes of vitamin B₆, some 50-100 times the reference intake, but there is little evidence. See also tenosynovitis.

Food and Fitness: carpal tunnel syndrome

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A condition characterized by pins and needles, pain, and numbness in the thumb and first three fingers of the hand. It arises when a nerve in the carpal tunnel is compressed. The carpal tunnel is a narrow tunnel at the base of the palm, through which tendons and a major nerve (the median nerve) pass from the wrist to the hand. Carpal tunnel syndrome is quite common among middleaged and pregnant women. It is also probably the most common over-use sports injury involving the wrist. Long-distance cyclists who maintain a constant grip on the handlebars, weight-lifters, racket players, and golfers are all susceptible. The first step in treatment is to remove the cause. Most cases respond well to rest and hydrocortisone treatment, but sometimes surgical relief is needed. In the case of cyclists, wearing padded cycling gloves and regularly changing the grip on the handlebars can prevent the condition from arising.

Dental Dictionary: carpal tunnel syndrome

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An irritation and inflammation of the synovials surrounding the tendons controlling the fingers. Carpal tunnel syndrome is a disabling condition for persons who work with their hands, particularly those engaging in keyboard activities in music, typing, and data management.

Alternative Medicine Encyclopedia: Carpal Tunnel Syndrome

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Definition

Carpal tunnel syndrome is a disorder caused by compression at the wrist of the median nerve supplying the hand, causing numbness and tingling.

Description

Women between the ages of 30 and 60 have the highest rates of carpal tunnel syndrome. Research has demonstrated that carpal tunnel syndrome is a significant cause of missed work days due to pain. In 1995, about $270 million was spent on sick days taken for pain from repetitive motion injuries.

Causes & Symptoms

Compression of the median nerve in the wrist can occur during a number of different conditions, particularly those conditions which lead to changes in fluid accumulation throughout the body. Because the area of the wrist through which the median nerve passes is very narrow, any swelling in the area will lead to pressure on the median nerve. This pressure will ultimately interfere with the nerve's ability to function normally. Pregnancy, obesity, arthritis, certain thyroid conditions, diabetes, and certain pituitary abnormalities all predispose to carpal tunnel syndrome. Other conditions that increase the risk for carpal tunnel syndrome include some forms of arthritis and various injuries to the arm and wrist (including fractures, sprains, and dislocations). Furthermore, activities which cause a person to repeatedly bend the wrist inward toward the forearm can predispose to carpal tunnel syndrome. Certain jobs that require repeated strong wrist motions carry a relatively high risk of carpal tunnel syndrome. Injuries of this type are referred to as "repetitive motion" injuries, and are more frequent among secretaries who do a lot of typing, people working at computer keyboards or cash registers, factory workers, and some musicians.

Symptoms of carpal tunnel syndrome include numbness, burning, tingling, and a prickly pin-like sensation over the palm surface of the hand, and into the thumb, forefinger, middle finger, and half of the ring finger. Some individuals notice a shooting pain which goes from the wrist up the arm, or down into the hand and fingers. With continued median nerve compression, an individual may begin to experience muscle weakness, making it difficult to open jars and hold objects with the affected hand. Eventually, the muscles of the hand served by the median nerve may begin to grow noticeably smaller (atrophy), especially the fleshy part of the thumb. Untreated, carpal tunnel syndrome may eventually result in permanent weakness, loss of sensation, or even paralysis of the thumb and fingers of the affected hand.

Diagnosis

The diagnosis of carpal tunnel syndrome is made in part by checking to see whether the patient's symptoms can be brought on by holding his or her hand with the wrist bent for about a minute. Wrist x rays are often taken to rule out the possibility of a tumor causing pressure on the median nerve. A physician examining a patient suspected of having carpal tunnel syndrome will perform a variety of simple tests to measure muscle strength and sensation in the affected hand and arm. Further testing might include electromyographic or nerve conduction velocity testing to determine the exact severity of nerve damage. These tests involve stimulating the median nerve with electricity and measuring the resulting speed and strength of the muscle response, as well as recording the speed of nerve transmission across the carpal tunnel. In 2002, a report stated that three medical organizations had concluded that electrodiagnostic studies were the preferred methods of diagnosing carpal tunnel syndrome, offering the highest degrees of sensitivity and specificity.

Treatment

Carpal tunnel syndrome is initially treated with splints, which support the wrist and prevent it from flexing inward into the position that exacerbates median nerve compression. Some people get significant relief by wearing such splints to sleep at night, while others will need to wear the splints all day, especially if they are performing jobs that stress the wrist.

The activity which caused the condition should be avoided whenever possible. Also, the actions of making a fist, holding objects, and typing should be reduced. The patient's work area should be modified to reduce stress on the body. This may be achieved by correct positioning and with ergonomically designed furniture. Performing hand and wrist exercises periodically throughout the day can be beneficial.

Researchers found that the carpal ligament can be lengthened or released without surgery through osteopathic manipulation and weight loading. Combining the two gives additional benefit because manipulation lengthens the ligament at one end and weight loading increases the length at the other end. Patients can be taught a stretching exercise for self-manipulation of the ligament.

A National Institute of Health (NIH) panel concluded that traditional acupuncture may be a useful alternative or complementary treatment for carpal tunnel syndrome. Studies have shown that both laser acupuncture and microamp transcutaneous electrical nerve stimulation (TENS) can significantly reduce the pain associated with carpal tunnel syndrome. Both of these therapies are painless. Greater than 90% of the patients treated reported no pain or pain that had been reduced by more than half. Patients in this study were also using Chinese herbal medicines, deep acupuncture (including needle acupuncture), moxibustion, and omega-3 fish oil capsules. All patients were able to return to work and the pain of most patients remained stable for up to two years. Persons over the age of 60 years had a poorer response.

Some studies have shown that persons with carpal tunnel syndrome are deficient in vitamin B₆ (pyridoxine) and that supplementation with this vitamin is beneficial. Carpal tunnel syndrome should improve within two to three months by taking 100 mg three times daily. The patient should consult with his or her physician when taking high doses of this vitamin.

Chinese and homeopathic remedies include:

arnica; 30c dose
astra essence
Rhus toxicodendron; 6c dose
Ruta graveolens; 6c dose

Allopathic Treatment

Ibuprofen or other nonsteroidal anti-inflammatory drugs may be prescribed to decrease pain and swelling. Diuretics may be used if the syndrome is related to the menstrual cycle. When carpal tunnel syndrome is more advanced, steroids may be injected into the wrist to decrease inflammation.

The most severe cases of carpal tunnel syndrome may require surgery to decrease the compression of the median nerve and restore its normal function. Such a repair involves cutting that ligament that crosses the wrist, thus allowing the median nerve more room and decreasing compression. This surgery is done almost exclusively on an outpatient basis and is often performed without the patient having to be made unconscious. Careful injection of numbing medicines (local anesthesia) or nerve blocks (the injection of anesthetics directly into the nerve) create sufficient numbness to allow the surgery to be performed painlessly, without the risks associated with general anesthesia. Recovery from this type of surgery is usually quick and without complications.

In 2002, researchers in the Netherlands reported that after studying about 80 patients over two years, surgery proved more successful than nighttime splints in freeing up compressed nerves of patients with carpal tunnel syndrome. Many patients in the splint group ended up choosing the surgery option after several months of wearing splints.

Expected Results

Without treatment, continued pressure on the median nerve puts the patient at risk for permanent disability in the affected hand. Alternative medicines have been shown to reduce pain. Most people are able to control the symptoms of carpal tunnel syndrome with splinting and anti-inflammatory agents. For those who go on to require surgery, about 95% will have complete cessation of symptoms.

Prevention

Avoiding or reducing the repetitive motions that put the wrist into a bent position may help to prevent carpal tunnel syndrome. People who must work long hours at a computer keyboard, for example, may need to take advantage of recent advances in ergonomics and position the keyboard and computer components in a way that increases efficiency and decreases stress. Early use of a splint may also be helpful for persons whose jobs put them at risk of carpal tunnel syndrome.

Resources

Books

Asbury, Arthur K. "Carpal Tunnel Syndrome." In Harrison's Principles of Internal Medicine. edited by Anthony S. Fauci, et al. New York: McGraw-Hill, 1998.

Crouch, Tammy. Carpal Tunnel Syndrome and Repetitive Stress Injuries. Berkeley, CA: Frog, 1995.

Periodicals

Branco, Kenneth, and Margaret A. Naeser. "Carpal Tunnel Syndrome: Clinical Outcome After Low-Level Laser Acupuncture, Microamps Transcutaneous Electrical Nerve Stimulation, and Other Alternative Therapies-An Open Protocol Study." The Journal of Alternative and Complementary Medicine 5 (1999):5-26.

Brody, Jane E. "Experts on Carpal Tunnel Syndrome Say that Conservative Treatment is the Best First Approach." The New York Times. 119 (February 28, 1996): B9+.

"Carpal Tunnel Syndrome." Postgraduate Medicine 98 no. 3 (September 1995): 216.

Glazer, Sarah. "Repetitive Stress Injury: A Modern Malady." The Washington Post 110 (March 12, 1996): WH12.

"Guidelines Promote Electrodiagnostic Studies for CTS." Case Management Advisor (August 2002): S1.

Lucas, B. "Nonsurgical Technique for Carpal Tunnel Syndrome." Patient Care 33 (March 15, 1999):12.

Seiler, John Gray. "Carpal Tunnel Syndrome: Update on Diagnostic Testing and Treatment Options" Consultant. 37 no. 5 (May 1997):1233+.

"Surgery Beats Splints for Wrist Syndrome." Science News (September 28, 2002): 205.

Organizations

Association for Repetitive Motion Syndromes. P.O. Box 514, Santa Rosa, CA 95402. (707) 571-0397.

[Article by: Belinda Rowland; Teresa G. Odle]

Encyclopedia of Public Health: Carpal Tunnel Syndrome, Cumulative Trauma

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Among the most common problems currently seen in the workplace are those injuries due to cumulative trauma from repetitive motion. Repetitive activities are found in many occupational settings, including traditional manufacturing. Examples include work on an automobile assembly line or in food processing plants, such as a chicken processing facility. Repetitive activities are also found in the office environment, where repetitive trauma results from the prolonged use of keyboards. Repetitive trauma and carpal tunnel syndrome can also be seen in nonemployment situations due to underlying disease processes such as diabetes, or to repetitive activities such as knitting and sewing.

Cumulative trauma problems tend to effect joint surfaces or the neurological system. Joint surfaces may be worn to the point of causing pain. Carpal tunnel syndrome, a common problem, arises because the nerve, artery, and vein supplying the hand all travel through a narrow space in the wrist (the carpal tunnel), which can become irritated and swollen from regular and repetitive use. The most likely structure to be affected is the nerve, and pain is the most common presenting symptom. Other joints which may be affected from cumulative trauma are the elbow, shoulder, knee, and ankle. Repetitive activities or professional athletics are frequent causes.

There are several ways that cumulative trauma problems can be managed. Ideally, the repetitive activities causing the difficulty should be altered. This can be done in workplace settings, such as on an automobile assembly line, where workers can shift specific job activities every few hours and rest certain body parts while using others. For other settings or tasks that do not allow for such rotation, such as keyboarding, workers should be given regular rest breaks from these activities. When there is no possibility of altering the specific nature of the job there are supportive items that can be used. The use of splints, wrist rests, or other devices to optimize the positioning of the hand, and the adjustment of furniture height, may help in preventing and ameliorating carpal tunnel syndrome. Medication is sometimes used, as well, with variable results.

Should the problem persist, or worsen to the point where nerve damage can be documented by electrophysiological testing, then surgery may be necessary to open up the carpal tunnel space to relieve pressure on the nerve involved.

Congressional restrictions on collecting data about these difficulties has made it difficult to determine how widespread carpal tunnel syndrome and other cumulative trauma problems may be. There also has been a delay in the implementation of workplace regulations to help relieve these problems. After many years of planning and discussion, ergonomic regulations were put in place by the federal government, but quickly taken back, with additional plans made for further study of these issues.

Bibliography

Weebs, J. L.; Levy, B. S.; and Wagner, G. R. (1997). Preventing Occupational Disease and Injury. Washington, DC: American Public Health Association.

— ARTHUR L. FRANK

Britannica Concise Encyclopedia: carpal tunnel syndrome

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Painful condition caused by repetitive stress to the wrist over time. The median nerve and the tendons that bend the fingers pass through the carpal tunnel on the inner side of the wrist, between the wrist (carpal) bones on three sides and a ligament on the fourth. Repetitive finger and wrist movements rub the tendons against the walls of the carpal tunnel and may make the tendons swell, squeezing the nerve. Numbness, tingling, and pain in the wrist and hand may progress to loss of muscle control. CTS is most common in assembly-line workers and computer keyboard users. Treatment may include avoidance of the causative activity, ergonomic workplace design, anti-inflammatory drugs, brace or splint use, and surgery.

For more information on carpal tunnel syndrome, visit Britannica.com.

Sports Science and Medicine: carpal tunnel syndrome

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A disorder caused by a swelling that compresses the median nerve as it passes through the carpal tunnel in the palm of the hand. Symptoms include pain, pins-and-needles, and numbness in the thumb and first three fingers. It can be associated with arthritis, an acute injury, or a chronic injury. Activities that involve repeated forceful wrist flexions can cause the syndrome. If the compression is not relieved, the muscles supplied by the median nerve can weaken and atrophy. Most cases respond to rest and hydrocortisone treatment, but sometimes surgical relief is required.

Science Q&A: What is carpal tunnel syndrome?

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Carpal tunnel syndrome occurs when a branch of the median nerve in the forearm is compressed at the wrist as it passes through the tunnel formed by the wrist bones (or carpals), and a ligament that lies just under the skin. The syndrome occurs most often in middle age and more so in women than men. The symptoms are intermittent at first, then become constant. Numbness and tingling begin in the thumb and first two fingers; then the hand and sometimes the whole arm becomes painful. Treatment involves wrist splinting, weight loss, control of edema; treatments for arthritis may help also. If not, a surgical procedure in which the ligament at the wrist is cut can relieve pressure on the nerve. Those who work continuously with computer keyboards are particularly vulnerable to carpal tunnel syndrome. To minimize the risk of developing this problem, operators should keep their wrists straight as they type, rather than tilting the hands up. It is also best to place the keyboard at a lower position than a standard desktop.

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Health Dictionary: carpal tunnel syndrome

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A repetitive stress injury to the wrist and hands often caused by typing on an ergonomically unsound keyboard. In this case, pain is thought to occur when swelling and scarring from the repetitive motion of typing compresses the nerves in the wrist. It is an example of an occupational disease.

Blogs: Related blogs on: carpal tunnel syndrome

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Dr Davis' Back and Wrist Pain Blog Treatment insights from a modern day San Francisco chiropractor.

Wikipedia: Carpal tunnel syndrome

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Carpal tunnel syndrome
Classification and external resources
Transverse section across the wrist and digits. (The median nerve is the yellow dot near the center. The carpal tunnel is not labeled, but the circular structure surrounding the median nerve is visible.)
ICD-10	G 56.0
ICD-9	354.0
OMIM	115430
DiseasesDB	2156
MedlinePlus	000433
eMedicine	orthoped/455 pmr/21 emerg/83 radio/135
MeSH	D002349

This article is about the medical condition. For the anatomical structure, see Carpal tunnel. For the Kid Koala album, see Carpal Tunnel Syndrome (album).

Carpal tunnel syndrome (CTS), or median neuropathy at the wrist, is a medical condition in which the median nerve is compressed at the wrist, leading to paresthesias, numbness and muscle weakness in the hand. The diagnosis of CTS is often misapplied to patients who have activity-related arm pain.

Most cases of CTS are idiopathic (without known cause); genetic factors determine most of the risk, and the role of arm use and other environmental factors is disputed.

Night symptoms and waking at night—the hallmark of this illness—can be managed effectively with night-time wrist splinting in most patients. The role of medications, including corticosteroid injection into the carpal canal, is unclear. Surgery to cut the transverse carpal ligament is effective at relieving symptoms and preventing ongoing nerve damage, but established nerve dysfunction in the form of static (constant) numbness, atrophy, or weakness are usually permanent and do not respond predictably to surgery.

History

Although the condition was first noted in medical literature in the early 20th century, the first use of the term “carpal tunnel syndrome” was in 1939.^[1] The pathology was identified by physician Dr. George S. Phalen of the Cleveland Clinic after working with a group of patients in the 1950s and 1960s.^[1] CTS became widely known among the general public in the 1990s because of the rapid expansion of office jobs.^[2]

Anatomy

Main article: Carpal tunnel

The median nerve passes through the carpal tunnel, a canal in the wrist that is surrounded by bone on three sides, and a transverse carpal ligament on the fourth. Nine tendons—the flexor tendons of the hand—pass through this canal.^[3] The median nerve can be compressed by a decrease in the size of the canal, an increase in the size of the contents (such as the swelling of lubrication tissue around the flexor tendons), or both. Simply bending the wrist at 90 degrees will decrease the size of the canal.

Compression of the median nerve as it runs deep to the transverse carpal ligament (TCL) causes wasting of the thenar eminence, weakness of the flexor pollicis brevis, opponens pollicis, abductor pollicis brevis, as well as sensory loss in the distribution of the median nerve distal to the transverse carpal ligament, sparing the superficial sensory branch given that its branch point is normally proximal to the TCL and travels superficially thus avoiding compression.

Symptoms

Mind Map Showing Summary of Carpal tunnel Contents and Carpal tunnel syndrome

Many people who have carpal tunnel syndrome have gradually increasing symptoms over time. The first symptoms of CTS may appear when sleeping and typically include numbness and paresthesia (a burning and tingling sensation) in the thumb, index, and middle fingers, although some patients may experience symptoms in the palm as well.^[3] These symptoms appear at night because people tend to bend their wrists when they sleep, which further compresses the carpal tunnel.

Patients may note that they "drop things". It is unclear if carpal tunnel syndrome creates problems holding things, but it does decrease sweating, which decreases friction between an object and the skin.

In early stages of CTS individuals often mistakenly blame the tingling and numbness on restricted blood circulation. They may also be at ease and accepting of the symptoms and believe their hands are simply “falling asleep”. In chronic cases, there may be wasting of the thenar muscles (the body of muscles which are connected to the thumb), weakness of palmar abduction of the thumb (difficulty bringing the thumb away from the hand).

Unless numbness or paresthesia are among the predominant symptoms, it is unlikely the symptoms are primarily caused by carpal tunnel syndrome. In effect, pain of any type, location, or severity with the absence of significant numbness or paresthesia is not likely to fall under this diagnosis.

People who have CTS often have a difficult time getting a proper diagnosis. The EMG Nerve Conduction Study can be one of the best ways to confirm if you have the problem or not. Neurologist, Orthopedists, Hand Surgeons, Chiropractic Neurologists, Physical Therapists, Chiropractors, Acupuncturists, Refloxologists, and many other specialties can be consulted for CTS.

Causes

Most cases of CTS are idiopathic.^[2] CTS is sometimes associated with trauma, pregnancy, multiple myeloma, amyloidosis, rheumatoid arthritis, acromegaly, mucopolysaccharidoses, or hypothyroidism.

Genetic

The most important risk factors for carpal tunnel syndrome are structural and biological rather than environmental or activity-related.^[4] The strongest risk factor is genetic predisposition.^[5]

Work related

The international debate regarding the relationship between CTS and repetitive motion in work is ongoing. The Occupational Safety and Health Administration (OSHA) has adopted rules and regulations regarding cumulative trauma disorders. Occupational risk factors of repetitive tasks, force, posture, and vibration have been cited. However, the American Society for Surgery of the Hand (ASSH) has issued a statement that the current literature does not support a causal relationship between specific work activities and the development of diseases such as CTS.

The relationship between work and CTS is controversial; in many locations workers diagnosed with carpal tunnel syndrome are entitled to time off and compensation.^[6] Carpal tunnel syndrome results in billions of dollars of workers compensation claims every year.^{[citation needed]}

Some speculate that carpal tunnel syndrome is provoked by repetitive grasping and manipulating activities, and that the exposure can be cumulative. It has also been stated that symptoms are commonly exacerbated by forceful and repetitive use of the hand and wrists in industrial occupations,^[7] but it is unclear if this refers to pain (which may not be due to carpal tunnel syndrome) or the more typical numbness symptoms.

A review of available scientific data by the National Institute for Occupational Safety and Health (NIOSH) indicated that job tasks that involve highly repetitive manual acts or specific wrist postures were associated with incidents of CTS, but causation was not established, and the distinction from work related arm pains that are not carpal tunnel syndrome was not clear. It has been proposed that repetitive use of the arm can affect the biomechanics of the upper limb or cause damage to tissues. It has also been proposed that postural and spinal assessment along with ergonomic assessments should be included in the overall determination of the condition. While addressing these factors has been found to improve comfort in some studies,^[8] there is no evidence that they affect the natural history of carpal tunnel syndrome.

Psychosocial factors

Studies have related activity-related upper extremity pain with psychological and social factors, but most such pains are nonspecific but commonly mislabeled as carpal tunnel syndrome. Psychological distress correlates with increased pain at work, as do other psychosocial stressors such as job demands, poor support from colleagues, and work dissatisfaction.^[9]

As mentioned elsewhere on this page, carpal tunnel is characterized by numbness, not pain. Therefore, any associations between stress and carpal tunnel syndrome are debatable.

Trauma related

Fractures of one of the arm bones, particularly a Colles' fracture.
Dislocation of one of the carpal bones of the wrist.
Strong blunt trauma to the wrist or lower forearm, incurred for example by using arm extremity to cushion a fall or protecting oneself from falling heavy objects.
Hematoma forming inside the wrist, because of internal hemorrhaging.
Deformities from abnormal healing of old bone fractures.
Electrical burns may cause acute carpal tunnel syndrome.

Carpal tunnel syndrome associated with other diseases

Non-traumatic causes generally happen over a period of time, and are not triggered by one certain event. Many of these factors are manifestations of physiologic aging.^[10]

Examples include:

Rheumatoid arthritis and other diseases that cause inflammation of the flexor tendons can create median nerve compression at the carpal tunnel.
With pregnancy and hypothyroidism, fluid is retained in tissues, which swells the tenosynovium.
Acromegaly, a disorder of growth hormones, compresses the nerve by the abnormal growth of bones around the hand and wrist.
Tumors (usually benign), such as a ganglion or a lipoma, can protrude into the carpal tunnel, reducing the amount of space. This is exceedingly rare (less than 1%).
Obesity also increases the risk of CTS: individuals who are classified as obese (BMI > 29) are 2.5 times more likely than slender individuals (BMI < 20) to be diagnosed with CTS.^[11].
Double crush syndrome is a speculative and debated theory which postulates that when there is compression or irritation of nerve branches contributing to the median nerve in the neck or anywhere above the wrist, this then increases the sensitivity of the nerve to compression in the wrist. There is little evidence, however, that this syndrome really exists.^[12]

Diagnosis

The reference standard for the diagnosis of carpal tunnel syndrome is electrophysiological testing. Patients with intermittent numbness in the distribution of the median nerve and positive Phalen's and Durkan's tests, but normal electrophysiological testing have—at worst—very mild carpal tunnel syndrome. A predominance of pain rather than numbness is unlikely to be due to carpal tunnel syndrome no matter the result of electrophysiological testing.

Clinical assessment by history taking and physical examination can support a diagnosis of CTS.

Phalen's maneuver is performed by flexing the wrist gently as far as possible, then holding this position and awaiting symptoms.^[13] A positive test is one that results in numbness in the median nerve distribution when holding the wrist in acute flexion position within 60 seconds. The quicker the numbness starts, the more advanced the condition.

Tinel's sign, a classic, though less specific test, is a way to detect irritated nerves. Tinel's is performed by lightly tapping the area over the nerve to elicit a sensation of tingling or "pins and needles" in the nerve distribution.

Durkan test, carpal compression test, or applying firm pressure of the palm over the nerve for up to 30 seconds to elicit symptoms has also been proposed.^[14]^[15]

Other conditions may also be misdiagnosed as carpal tunnel syndrome. Thus, if history and physical examination suggest CTS, patients will usually be tested electrodiagnostically with nerve conduction studies and electromyography. The goal of electrodiagnostic testing is to compare the speed of conduction in the median nerve with conduction in other nerves supplying the hand. When the median nerve is compressed, as in CTS, it will conduct more slowly than normal and more slowly than other nerves. There are many electrodiagnostic tests used to make a diagnosis of CTS, but the most sensitive, specific and reliable test is the Combined Sensory Index (also known as Robinson index)^[16]

The role of MRI or ultrasound imaging in the diagnosis of carpal tunnel syndrome is unclear.^[17]^[18]^[19]

Prevention

Some think that the current best evidence suggests that carpal tunnel syndrome is an inherent, structural disease determined primarily by one's genes.[2] Therefore, carpal tunnel syndrome is probably not preventable. However, others think it is preventable by developing healthy habits like avoiding repetitive stress, practicing healthy work habits like using ergonomic equipment and taking proper breaks, and early passive treatment like taking tumeric (anti-inflammatory), omega 3 fatty acids, and B vitamins. Those who favor activity as a cause of carpal tunnel syndrome speculate that activity-limitation might limit the risk of developing carpal tunnel syndrome, but there is little or no data to support these concepts[3] and they stigmatize arm use in way that risks increasing illness.[4][5]

Recommendations for preventing carpal tunnel syndrome have poor scientific support[6]. Several are listed here:

Take frequent breaks from repetitive movement such as computer keyboard usage or use of browser-based games that encourage the user for excessive finger movement. Free software programs such as Workrave and Xwrits are available to remind users to take breaks and stretch their wrists.

Reduce your force and relax your grip. Most people use more force than needed to perform many tasks involving the hands. If your work involves a cash register, for instance, hit the keys softly. For prolonged handwriting, use a big pen with an oversized, soft grip adapter and free-flowing ink. This way you won't have to grip the pen tightly or press as hard on the paper.

Take frequent breaks. Every 15 to 20 minutes give your hands and wrists a break by gently stretching and bending them. Alternate tasks when possible. If you use equipment that vibrates or that requires you to exert a great amount of force, taking breaks is even more important.

Watch your form. Avoid bending your wrist all the way up or down. A relaxed middle position is best. If you use a keyboard, keep it at elbow height or slightly lower.

Improve your posture. Incorrect posture can cause your shoulders to roll forward. When your shoulders are in this position, your neck and shoulder muscles are shortened, compressing nerves in your neck. This can affect your wrists, fingers and hands.

Keep your hands warm. You're more likely to develop hand pain and stiffness if you work in a cold environment. If you can't control the temperature at work, put on fingerless gloves that keep your hands and wrists warm.

Treatment

There have been numerous scientific papers evaluating treatment efficacy in CTS. It is important to distinguish treatments that are supported in the scientific literature from those that are advocated by any particular device manufacturer or any other party with a vested financial interest. Generally accepted treatments, as described below, may include splinting or bracing, steroid injection, activity modification, physical or occupational therapy (controversial), medications, and surgical release of the transverse carpal ligament.

Immobilizing braces

A rigid splint can keep the wrist straight.

A wrist splint helps limit numbness by limiting wrist flexion. Night splinting helps patients sleep. There is no evidence that wrist splinting is disease modifying.

The importance of wrist braces and splints in the carpal tunnel syndrome therapy is known, but many people are unwilling to use braces. In 1993, The American Academy of Neurology recommend a non-invasive treatment for the CTS at the beginning (except for sensitive or motor deficit or grave report at EMG/ENG): a therapy using splints was indicated for light and moderate pathology.^[20] Current recommendations generally don't suggest immobilizing braces, but instead activity modification and non-steroidal anti-inflammatory drugs as initial therapy, followed by more aggressive options or specialist referral if symptoms do not improve.^[21]^[22]^[23]

Many health professionals suggest that, for best results, one should wear braces at night and, if possible, during the activity primarily causing stress on the wrists.^[24]^[25]

Localized steroid injections

Steroid injections can be quite effective for temporary relief from symptoms of CTS for a short time frame while a patient develops a longterm strategy that fits with his/her lifestyle.^[26] In certain patients, an injection may also be of diagnostic value. This treatment is not appropriate for extended periods, however. In general, medical professionals only prescribe to localized steroid injections until other treatment options can be identified. For most patients, permanent relief requires surgery.^[27]

Physiotherapy

There is little evidence to support physiotherapy or occupational therapy as disease modifying treatments. They seem to be oriented primarily towards non-specific activity related pain rather than the numbness of carpal tunnel syndrome. The following comments regarding physical therapy seem to apply more to such chronic activity related pains than to verifiable idiopathic median nerve compression at the carpal tunnel.

Physiotherapy offers several ways to treat and control carpal tunnel syndrome. This procedure should be directed specifically towards the pattern of pain / symptoms and dysfunction assessed by the therapist. As such, it may include a range of modalities ranging from soft tissue massage, conservative stretches and exercises and techniques to directly mobilize the nerve tissue. It can also include the aforementioned immobilizing braces.

Clinically, sometimes a patient will present with a hand that is very inflamed and swollen with severe symptoms of pain, tingling and numbness and almost a fear of use because of the pain. In these cases a physiotherapist may focus on techniques to reduce the pain and inflammation, and exercises to encourage improved circulation. A comprehensive review of effectiveness of hand therapies in carpal tunnel management demonstrates that there is some valid scientific evidence for a range of therapeutic modalities.^[28] For instance, Body Awareness Therapy such as the Feldenkrais method has positive effects in relation to fibromyalgia and chronic pain.^[29] Structured exercise programs using these therapies to reduce wrist pain have been developed.

Occupational therapy

The comments provided in this section appear more suited to nonspecific activity related arm pains that to true carpal tunnel syndrome (verifiable idiopathic median nerve compression at the carpal tunnel).

Occupational therapy offers ergonomic suggestions to prevent worsening of the symptoms and occupational therapist facilitates hand functions through functional activities and helps to regain the functions which are necessary for the functional living through remedial adaptive approaches.

Any forceful and repetitive use of the hands and wrists can cause upper extremity pain. More frequent rest can be useful if it can be orchestrated into one's schedule. It has been shown that taking multiple mini breaks during the stressful activity is more effective than taking occasional long breaks.^{[citation needed]} There are computer applications that aid users in taking breaks. All of these applications have recommended defaults, following the most effective average break configuration, which is a 30 sec. pause every 3 to 5 minutes (the more severe the pain, the more often one should take this break). There are also programs that automatically click the mouse. Before investing in these types of programs, it's best to consult with a doctor and research whether computer use is causing or contributing to the symptoms, as well as getting a formal diagnosis.

More pro-active ways to reducing the stress on the wrists which will alleviate wrist pain and strain involve adopting a more ergonomic work and life environment. Switching from a QWERTY computer keyboard layout to a more optimised ergonomic layout such as Dvorak was commonly cited as beneficial in early CTS studies, however some meta-analyses of these studies claim that the evidence that they present is limited.^[30]^[31]

It is also important that one's body be aligned properly with the keyboard. This is most easily accomplished by bending ones elbows to a 90 degree angle and making sure the keyboard is at the same height as the elbows. Also it is important not to put physical stress on the wrists by hanging the wrist on the edge of a desk, or exposing the wrists to strong vibrations (e.g. manual lawn mowing). Position the computer monitor directly in front of your seat, so the neck is not twisted to either side when viewing the screen.^{[citation needed]}

Exercises that relax and strengthen the muscles of the upper back can reduce the risk of a double crush of the median nerve.

Massage is one of the most overlooked methods for treatment of the symptoms of CTS. The use of myofascial release and active stretch release can erase the pain, numbness, tingling and burning in minutes. Then following up with the stretches and exercises afore mentioned will lengthen the relief attained by these release techniques.

Medication

Using an over-the-counter anti-inflammatory such as aspirin, ibuprofen or naproxen can be effective as well for controlling symptoms. Pain relievers like paracetamol will only mask the pain, and only an anti-inflammatory will affect inflammation. Non-steroidal anti-inflammatory medications theoretically can treat the root swelling and thus the source of the problem. Oral steroids (prednisone) do the same, but are generally not used for this purpose because of significant side effects. Use of non-steroidal anti-inflammatory drugs may worsen asthma symptoms in some with a history of asthma, making the use of steroids such as prednisone the safer option for treating CTS. The most common complications associated with long-term use of anti-inflammatory medications are gastrointestinal irritation and bleeding. Also, some anti-inflammatory medications have been linked to heart complications. Use of anti-inflammatory medication for chronic, long-term pain should be done with doctor supervision.

A more aggressive pharmaceutical option is an injection of cortisone, to reduce swelling and nerve pressure within the carpal tunnel. Methylcobalamin (vitamin B12) has been helpful in some cases of CTS. ^[32]

Carpal tunnel release surgery

Release of the transverse carpal ligament ("carpal tunnel release" surgery) is recommended when there is static (everpresent, not just intermittent numbness), weakness of palmar abduction, or atrophy, and when night-splinting no longer controls intermittent symptoms.^[33] In general, milder cases can be controlled for months to years, but severe cases are unrelenting symptomatically and are likely to result in surgical treatment.^[34]

Procedure

In carpal tunnel release surgery, the goal is to divide the transverse carpal ligament in two. This is a wide ligament that runs across the hand, from the scaphoid bone to the hamate bone and pisiform. It also forms the roof of the carpal tunnel, and when the surgeon cuts across it (i.e., in a line with the ring finger) it no longer presses down on the nerves inside, relieving the pressure.^[35]

There are several carpal tunnel release surgery variations: each surgeon has differences of preference based on their personal beliefs and experience. All techniques have several things in common, involving brief outpatient procedures; palm or wrist incision(s); and cutting of the transverse carpal ligament.

The two major types of surgery are open carpal tunnel release and endoscopic carpal tunnel release. Most surgeons historically have performed the open procedure, widely considered to be the gold standard. However, a growing number of surgeons now are offering endoscopic carpal tunnel release. Which has been available since the 1990s. Open surgery involves an incision somewhere on the palm about an inch or two in length. Through this incision the skin and subcutaneous tissue is divided followed by the palmar fascia and ultimately the transverse carpal ligament. Endoscopic techniques involve one or two smaller incisions (less than half inch each) through which instrumentation is introduced including a synovial elevator, probes, knives and an endoscope used to fully visualize the underside of the transverse carpal ligament. The endoscopic methods do not divide the subcutaneous tissues or the palmar fascia to the same degree as the open method does..

Many studies have been done to determine whether the perceived benefits of a limited endoscopic or arthroscopic release are truly significant. Brown et al. did prospective, randomized, multi-center study and found no significant differences between the two groups with regard to the secondary quantitative outcome measurements. However the open technique resulted in more tenderness of the scar than did the endoscopic method. A prospective randomized study done in 2002 by Trumble revealed that good clinical outcomes and patient satisfaction are achieved more quickly when the endoscopic method of carpal tunnel release is used. Single-portal endoscopic surgery is a safe and effective method of treating carpal tunnel syndrome. There was no significant difference in the rate of complications or the cost of surgery between the two groups. However the open technique resulted in greater scar tenderness during the first three months after surgery as well as a longer time until the patients could return to work http://www.ejbjs.org/cgi/content/abstract/84/7/1107

Some surgeons have suggested that in their own hands endoscopic carpal tunnel release has been associated with a higher incidence of median nerve injury, and for this reason it has been abandoned at several centers in the United States. For example, at the 2007 annual meeting of the American Society for Surgery of the Hand, during the "Journal of Retraction" event, one former advocate of endoscopic carpal tunnel release, Thomas J. Fischer, MD, publicly retracted his advocacy of the technique, based on his assessment that the benefit of the procedure (slightly faster recovery) did not outweigh the risk of injury to the median nerve. Despite these views many other surgeons have embraced limited incision methods and it is considered to be the procedure of choice for many of these surgeons with respect to idiopathic carpal tunnel syndrome. Supporting this are the results of some of the previously mentioned series which cite no difference in the rate of complications for either method of surgery. Thus there has been broad support for either surgical procedure: open or endoscopic carpal tunnel release using a variety of devices or incisions with the knowledge that the primary goal of any carpal tunnel release surgery is to divide the transverse carpal ligament and the distal aspect of the volar ante brachial fascia thereby decompressing the median nerve. http://orthoinfo.aaos.org/topic.cfm?topic=A00005

All of the surgical options (when performed without complication) typically have relatively rapid recovery profiles (weeks to a few months depending on the activity and technique), and all usually leave a cosmetically acceptable scar.

Efficacy

Surgery to correct carpal tunnel syndrome has a high success rate. Up to 90% of patients were able to return to their same jobs after surgery.^[36]^[37]^[38] In general, endoscopic techniques are as effective as traditional open carpal surgeries,^[39]^[40] though the faster recovery time typically noted in endoscopic procedures is felt by some to possibly be offset by higher complication rates.^[41]^[42] Success is greatest in patients with the most typical symptoms. The most common cause of failure is incorrect diagnosis, and it should be noted that this surgery will only mitigate carpal tunnel syndrome, and will not relieve symptoms with alternative causes. Recurrence is rare, and apparent recurrence usually results from a misdiagnosis of another problem. Complications can occur, but serious ones are infrequent to rare.

Carpal tunnel surgery is usually performed by a hand surgeon, orthopaedic or plastic surgeon; some neurosurgeons and general surgeons also perform the procedure.

Long term recovery

Most people who find relief of their carpal tunnel symptoms with conservative or surgical management find minimal residual or "nerve damage".^[43] Long-term chronic carpal tunnel syndrome (typically seen in the elderly) can result in permanent "nerve damage", i.e. symptoms of numbness, muscle wasting and weakness.

While outcomes are generally good, certain factors can contribute to poorer results that have little to do with nerves, anatomy, or surgery type. One study showed that mental status parameters, alcohol use, yield much poorer overall results of treatment.^[44]

Many mild carpal tunnel syndrome sufferers either change their hand use, pattern, or posture at work or find a conservative, non-surgical treatment that allows them to return to full activity without hand numbness or pain, and without sleep disruption. Some find relief by adjusting their repetitive movements, the frequency with which they do the movements, and the amount of time they rest between periods of performing the movements. Other people end up prioritizing their activities and possibly avoiding certain hand activities so that they can minimize pain and perform the essential tasks. Keyboard re-mapping software can help people whose condition is aggravated by one-handed key strokes involving a combination of the Control, Shift, or Alt keys and an alpha-numeric key. Programs such as Autohotkey allow a person to disable key combinations while they train themselves to use two hands to perform the offending key strokes.

While recurrence after surgery is a possibility, true recurrences are uncommon to rare.^[45] Such recurrence can also be non-CTS hand pain. Such hand pain may have existed prior to the surgery, which is one reason it is very important to get a proper diagnosis.

References

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