CARPAL TUNNELSYNDROME

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.1,2,3

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; overactivity of the pituitary gland;

hypothyroidism; rheumatoid arthritis; mechanical problems in

the wrist joint; work stress; repeated use of vibrating hand

tools, which causes thickening from the irritated tendons ;

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. 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.

Symptoms of carpal tunnel syndrome are:2,3

'Pins and needles'. This is tingling or burning in part,

or all, of the shaded area shown above. The index and middle

fingers are usually first to be affected.

Pain in the same fingers may then develop. The pain may

travel up the forearm.

Numbness of the same finger(s), or in part of the palm,

may develop if the condition becomes worse.

Dryness of the skin may develop in the same fingers.

Weakness of some muscles in the fingers and/or thumb

occurs in severe cases. This may cause poor grip and

eventually lead to muscle wasting at the base of the thumb

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.1,2 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.

Causes of Carpal Tunnel Syndrome3:

Inflammatory causes: Rheumatoid arthritis

Wrist osteoarthritis

Post-traumatic causes: Bone thickening after a Colles’ fracture.

Endocrine causes: Myxoedema

Acromegaly

Idiopathic: The commonest causes

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.4 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.

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

should be tested for sensation, and the muscles at the base of

the hand should be examined for strength and signs of atrophy.

Routine laboratory tests and X-rays can reveal diabetes,

arthritis, and fractures.

Physicians can use specific tests to try to produce the

symptoms of carpal tunnel syndrome. In the Tinel test, the

doctor 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.2,5 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.2,5 The presence of carpal tunnel

syndrome is suggested if one or more symptoms, such as

tingling or increasing numbness, is felt in the fingers within

1 minute. Doctors may also ask patients to try to make a

movement that brings on symptoms.

Often it is necessary to confirm the diagnosis by use of

electrodiagnostic tests. In a nerve conduction study,

electrodes are placed on the hand and wrist. Small electric

shocks are applied and the speed with which nerves transmit

impulses is measured. In electromyography, a fine needle is

inserted into a muscle; electrical activity viewed on a screen

can determine the severity of damage to the median nerve.

Ultrasound imaging can show impaired movement of the median

nerve. Magnetic resonance imaging (MRI) can show the anatomy

of the wrist but to date has not been especially useful in

diagnosing carpal tunnel syndrome.

How is Carpal Tunnel

Syndrome treated?

Treatments for carpal tunnel syndrome should begin as early as

possible, under a doctor's direction. Underlying causes such

as diabetes or arthritis should be treated first. Initial

treatment generally involves resting the affected hand and

wrist for at least 2 weeks, avoiding activities that may

worsen symptoms, and immobilizing the wrist in a splint to

avoid further damage from twisting or bending. If there is

inflammation, applying cool packs can help reduce swelling.

NON-SURGIC AL

GENERAL MEASURES

Patients with carpal tunnel syndrome should avoid repetitive

wrist and hand motions that may exacerbate symptoms or make

symptom relief difficult to achieve. If possible, they should

not use vibratory tools (e.g., jackhammers, floor sanders),

because the motion of these tools can make their symptoms

worse. 6

Ergonomic measures to relieve symptoms depend on the motion

that needs to be minimized. Patients who work on computers,

for example, may benefit from improved wrist positioning or

the use of wrist supports, although the latter is

controversial. Wrist splints may be helpful for patients in

other professions that require repetitive wrist motion.

In addition to wrist splinting, conservative treatments

include oral corticosteroid therapy and local corticosteroid

injections. Approximately 80 percent of patients with carpal

tunnel syndrome initially respond to conservative treatment;

however, symptoms recur in 80 percent of these patients after

one year. 7

General Exercise Program. Some experts have reported that people who

are physically fit, including athletes, joggers, and swimmers,

have a lower risk for cumulative trauma disorders. Although

there is no evidence that exercise can directly improve CTS, a

regular exercise regimen using a combination of aerobic and

resistance training techniques strengthens the muscles in the

shoulders, arms, and back, helps reduce weight, and improves

overall health and well-being.

WRIST SPLINTS

Splinting the wrist at a neutral angle helps to decrease

repetitive flexion and rotation, thereby relieving mild soft

tissue swelling or tenosynovitis. Splinting is probably most

effective when it is applied within three months of the onset

of symptoms.8

The optimal splinting regimen depends on the patient's

symptoms and preferences. Nightly splint use is recommended to

prevent prolonged wrist flexion or extension.9 When worn at

night for four weeks, a specially designed wrist brace was

found to be more effective than no treatment in relieving the

symptoms of carpal tunnel syndrome (Figure 3).10This brace has

not yet been compared with traditional splints.

Some patients choose to wear a wrist splint all of the time.

Compared with nighttime-only splint use, full-time use has

been shown to provide greater improvement of symptoms and

electrophysiologic measures; however, compliance with full-

time use is more difficult. 11

ORAL MEDICATIONS

Diuretics, nonsteroidal anti-

inflammatory drugs (NSAIDs),

pyridoxine (vitamin B6), and

orally administered

corticosteroids have been used with varying degrees of success

FIGURE 3.Manu hand brace

for the conservative

treatment of carpal

tunnel syndrome (palmar

and dorsal views). This

specially designed brace

provides gentle pressure

to the heads of the

metacarpal bones while

stretching the third and

fourth fingers.

in patients with carpal tunnel syndrome. Unfortunately, few

high-quality trials have evaluated these treatments.

Orally administered corticosteroids have been shown to be more

effective than NSAIDs or diuretics in the short-term treatment

of carpal tunnel syndrome. The optimal corticosteroid dosage

remains to be determined. In one prospective, randomized,

double-blind, placebo-controlled trial (73 patients), global

symptom scores for carpal tunnel syndrome were significantly

improved at two weeks and four weeks in patients randomized to

receive prednisolone in a dosage of 20 mg per day for two

weeks, followed by 10 mg per day for two weeks. 12 No major

adverse effects were noted.

LOCAL INJECTION

Combined injection of a corticosteroid (methylprednisonlone

acetate) and a local anesthetic into or proximal to the carpal

tunnel can be used in patients with mild to moderate carpal

tunnel syndrome. Such injections can be diagnostic as well as

therapeutic. 13,14 It can be injected directly into the carpal

tunnel or proximal to the carpal tunnel.

ULTRASOUND THERAPY

Ultrasound therapy may be beneficial in the longer term

management of carpal tunnel syndrome. A double-blind,

randomized trial found that compared with “sham ultrasound”

treatment (control), 20 sessions of carpal tunnel ultrasound

therapy administered over approximately seven weeks resulted

in significantly greater improvement of symptoms at two weeks,

seven weeks, and six months.15 However, a smaller study showed

no benefit for this treatment. 16More studies are needed to

confirm the usefulness of ultrasound therapy for carpal tunnel

syndrome.

LASER THERAPY

Laser Light Therapy is also one kind of non-surgical treatment

for carpal tunnel syndrome. One recent study found that cold

laser light treatment method had greater improvement in grip

strength and range of wrist movement than those engaged in

physical therapy for the automobile workers with CTS. The

process uses low-energy laser light that penetrates, but does

not cut the skin and stimulates cells activity in the injured

areas.17

Alternative Therapies

Many alternative therapies are offered to sufferers of carpal

tunnel syndrome and other repetitive stress disorders. Few,

however, have any proven benefit. People should carefully

educate themselves about how alternative therapies may

interact with other medications or impact other medical

conditions, and should check with their doctor before trying

any of them.

YOGA.

Yoga can help to reduce symptoms of carpal tunnel syndrome. A

study by the University of Pennsylvania looked at the

effectiveness of yoga for 42 people with carpal tunnel

syndrome. People in the yoga group did 11 yoga postures twice

weekly for 8 weeks and had a significant improvement in grip

strength and pain reduction compared to people in the control

group, who wore wrist splints. Yoga postures are designed to

stretch, strengthen, and balance upper body joints.18

AYURVEDIC TREATMENT

Vitamin B6 18,19,20

Naturopaths suggest getting 40 to 80 milligrams of vitamin B6

twice a day to treat CTS. In one study of people with this

condition, two-thirds of those using this amount of B6 reported

improvement.

Foods high in B6 include cauliflower, watercress, spinach,

bananas and okra. It would be difficult to get enough B6 to

treat CTS solely from food. If you have this condition, you

might consider a supplement. The Daily Value is only 2

milligrams, however, and getting too much of this vitamin has

been linked to nerve disorders.

Herb – Wort 19,20

Widely known for its ability to treat depression, St.John’s

wort also helps nerves recover when they are damaged,

inflamed, or strained. Thousands of years before doctors

coined the term carpal tunnel syndrome, the relaxing herb was

used to heal nerve pain and tingling.

For the squeezed median nerve, St.John’s wort helps in two

ways. Its sedative effect helps to reduce pain, while its

anti-inflammatory activity can help shrink swollen tendons.42

Don’t expect the kind of quick pain relief that comes from

popping a pharmaceutical like aspirin or ibuprofen, though;

St. John’s wort typically takes a few weeks to start working.

While St. John’s wort is generally very safe, pregnant women

should not take it without a doctor’s okay.

Pineapple 18,19,20

When it comes to inflammation, sometimes your body just

doesn’t know when to stop. With CTS, you need to reduce the

inflammation in the swollen tendons and synovium in order to

relieve the pain. Pharmaceutical anti-inflammatories like

aspirin or ibuprofen might be all you need, but some people

find that they experience side effects from these drugs,

particularly upset stomach and ringing in the ears.

For relief with fewer side effects, you have the option of

trying some supplements that can be very effective. One of

these is bromelain, an enzyme found in pineapple that is

nature’s anti-inflammatory medicine.18 This hungry enzyme can

take a bite out of pain and swelling and help you heal

faster.19 Just be sure you don’t blunt its effect by taking it

with meals. If you do, all of its enzymatic energy is just

digested. If you take it between meals, however, it goes to

work digesting the products of inflammation.

When the tingling pain of CTS strikes, take two 500-milligram

tablets or capsules of bromelain between meals two or three

times a day. Bromelain is measured in milk-clotting units

(mcu) or gelatin-dissolving units (gdu). The higher the

number, the greater its potency. Look for a supplement with a

strength between 1,800 and 2,400 mcu or 1,080 and 1,440 gdu in

each capsule.

Flaxseed Oil 19,20

You can also soothe the inflamed nerve and tissues with

flaxseed oil, a supplement rich in omega-3 essential fatty

acids, says Ellen Potthoff, D.C., N.D., a chiropractor and

naturopathic doctor in Pleasant Hill, California. Any type of

inflammation responds well to essential fatty acids because no

matter where it hurts, they interrupt the process of

inflammation early.

One should feel better in two to four weeks if one starts

taking one tablespoon of flaxseed oil every day.

Turmeric 18,19,20

Turmeric is an herb that contains a powerful anti-inflammatory

chemical called curcumin. The herb has traditionally been used

in India’s Ayurvedic medicine to treat pain and inflammation.

The effect of turmeric has been compared to that of cortisone,

the pharmaceutical sometimes used to treat CTS symptoms.

Although turmeric’s pain-fighting power is not as strong as

cortisone’s, the herb is a lot easier on our system.

Turmeric’s action is similar to that of bromelain. For some

relief, patient should opt for capsules of the standardized

extract.Unlike the turmeric on our spice shelf, the capsules

contain 95 percent pure curcumin( 250 to 500 milligrams

curcumin).

ACUPUNCTURE.

A randomized, controlled study was carried out in 2009 to

investigate the efficacy of acupuncture compared with steroid

treatment in patients with mild-to-moderate carpal tunnel

syndrome as measured by both nerve conduction studies and

symptom assessment surveys.

The results showed that acupuncture was just as effective as

the corticosteroid for pain, numbness, tingling and weakness. 

For the symptoms of night time awakening and motor function,

the acupuncture group had better results.

The researchers concluded that acupuncture is a safe and

effective treatment option for CTS for those who experience

side effects to oral steroids or for those who do not opt for

early surgery. 18, 21

CHIROPRACTIC THERAPIES.

Chiropractic techniques have been useful for some people whose

condition is produced by pinched nerves. Significant increase

in grip strength and normalization of motor and sensory

latencies were noted and symptoms dissipated. 18,22

MAGNETS.

Magnets are a popular but an unproven therapy for pain

relief.23

BOTULINUM TOXIN TYPE A.

Efficacy of intracarpal injections of botulinum toxin type A

(Botox) to relieve symptoms of carpal tunnel syndrome is being

studied. At present, it has not been proven to bring

significant relief to the CTS symptoms.24

SURGERY

Carpal tunnel release is one of the most common surgical

procedures in the United States. Generally recommended if

symptoms last for 6 months, surgery involves severing the band

of tissue around the wrist to reduce pressure on the median

nerve. Surgery is done under local anesthesia and does not

require an overnight hospital stay. Many patients require

surgery on both hands. The following are types of carpal

tunnel release surgery:

Open release surgery, the traditional procedure used to correct

carpal tunnel syndrome, consists of making an incision up to 2

inches in the wrist and then cutting the carpal ligament to

enlarge the carpal tunnel. 25The procedure is generally done

under local anesthesia on an outpatient basis, unless there

are unusual medical considerations.

Endoscopic surgery may allow faster functional recovery and less

postoperative discomfort than traditional open release

surgery.25 The surgeon makes two incisions (about ½" each) in

the wrist and palm, inserts a camera attached to a tube,

observes the tissue on a screen, and cuts the carpal ligament

(the tissue that holds joints together). This two-portal

endoscopic surgery, generally performed under local

anesthesia, is effective and minimizes scarring and scar

tenderness, if any. One-portal endoscopic surgery for carpal

tunnel syndrome is also available.

Although symptoms may be relieved immediately after surgery,

full recovery from carpal tunnel surgery can take months. Some

patients may have infection, nerve damage, stiffness, and pain

at the scar. Occasionally the wrist loses strength because the

carpal ligament is cut. Patients should undergo physical

therapy after surgery to restore wrist strength. Some patients

may need to adjust job duties or even change jobs after

recovery from surgery.

Recurrence of carpal tunnel syndrome following treatment is

rare. The majority of patients recover completely.

PREGNANCY

Alterations in fluid balance may predispose some pregnant

women to develop carpal tunnel syndrome. Symptoms are

typically bilateral and first noted during the third

trimester. Conservative measures are appropriate, because

symptoms resolve after delivery in most women with pregnancy-

related carpal tunnel syndrome. 26

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