Carpal tunnel syndrome (CTS) has been a hot topic in the news for some time, and cases are increasing nationwide. People are working longer hours on computers and using more agile workforce technologies, such as laptops, cell phones, and handheld electronics, which empower them to work just about anytime, anywhere, often without breaks. While some may hail this trend of always being in touch as a useful convenience, members of the American Society of Hand Therapists (ASHT) have been raising warnings that these habits may contribute to an increase in hand ailments like CTS for Americans.

A Growing Concern
The number of CTS diagnoses continues to increase as patients approach physicians and therapists complaining of hand, finger, and wrist pain and numbness. It is probable that more CTS cases are being reported now because there is greater public and physician awareness of CTS symptoms and how hand therapists can help.

CTS is a painful, progressive condition caused by the compression of the median nerve, a key nerve that travels through the carpal tunnel—the area between a ligament and the carpal bones in the wrist. This constriction, caused by factors including swelling or positional changes, disturbs conduction of the nerve as it passes through the carpal tunnel. The nerve is like an electric cord in that it supplies power to many of the small muscles in the hand and provides feedback of touch. Patient-detected symptoms usually start gradually with pain or numbness in the hand and fingers, often initially at night, as well as pain traveling up through the arm. As the condition progresses, patients often feel a consistent tingling, pain, and numbness, or note decreased grip and pinch strength, and difficulty in using the hand for coordination or manual tasks. This leads to clumsiness and dropping of items. Given enough time, CTS can lead to muscle atrophy and permanent damage in the hand.

Few direct causes of CTS have been determined or identified. In some people, the carpal tunnel is simply smaller, which can cause stress to the median nerve in the carpal tunnel area. Hand traumas and injuries, such as wrist fractures or sprains, can also lead to CTS. Correlations are present with many other possible causes, but the true cause of the syndrome is not always clear.

Repetitive overuse of handheld electronics, long periods of time on the computer, or extended video game play appear to have a hand in the inflammation and strain of tendons and muscles. The ASHT has released several consumer-education alerts to build awareness of these CTS threats. Visit www.asht.org to view these alerts.

Posture can be a major factor. Many people work in a “forward head posture” when using some small electronic devices, which may contribute to risk factors in cumulative trauma disorders, including CTS. As the head shifts forward, its weight forces the neck and upper back muscles to work harder. Furthermore, the structural integrity of muscle groups in these regions can become imbalanced, which often compromises proper biomechanical activity and can cause compression on nerves or vessel structures throughout the upper extremity. Some hand therapists perform job-site evaluations and ergonomic assessments to determine whether a person’s work setting could be adjusted to help decrease the incidence of awkward postures and positions that may contribute to CTS. It is also important to note that a correlation has been demonstrated between obesity and some medical conditions such as rheumatoid arthritis and diabetes with CTS and other upper-extremity disorders.

According to the US Department of Labor, Occupational Safety and Health Administration, repetitive strain injuries are the nation’s most common and costly occupational health problem, affecting hundreds of thousands of American workers and costing more than $20 billion per year in workers’ compensation. The Bureau of Labor and Statistics and the National Institute for Occupational Safety and Health have found that CTS accounts for about 50% of all work-related injuries. More than 8 million people are affected by CTS each year, with women being twice as likely to develop CTS as opposed to their male counterparts.

One of the ways women are more likely than men to develop CTS is during pregnancy. While most women come to expect swollen ankles, lower back pain, and general discomfort with pregnancy, most do not realize that nearly one in four pregnant women and new moms endure CTS. Water retention during pregnancy not only causes inflated fingers and ankles but may also lead to pain and numbness in the hands and arms. Symptoms can appear at any time, but most often begin in the second half of pregnancy when women begin to retain more fluid, and are usually experienced at night or first thing in the morning. Fluid retention causes swelling to occur, often increasing pressure in the narrow and inflexible canal formed by the wrist bones. This pressure on the median nerve can cause the symptoms of CTS, including numbness and tingling, in addition to pain, dull ache, or burning in the fingers, hand, and wrist. Pain can even extend up the arm to the shoulders.

For many, the best option is to wait until the symptoms resolve after giving birth, but others may need to seek medical help due to severe discomfort during and after pregnancy. Expectant moms cannot prevent water retention but can manage the effects—and the pain—in their hands, wrists, and arms by tailoring their workload, making small adjustments in the way they do things, performing nerve-gliding exercises, and using splints. Proper positioning of the wrists as well as modifications of provocative types of activities can help with the symptoms.

CTS Assessment and Treatment
Innovative methods for evaluating and treating CTS have come about in conjunction with rising awareness and concern among hand therapists, insurers, employers, and the public. Hand therapists have been exploring new techniques to address the increasing incidence of this common workforce ailment and have been working to develop new treatments and interventions for CTS.

Patients with CTS experience a variety of symptoms. However, no comprehensive scale exists to systematically and concretely quantify and assess these CTS indicators. The CTS3 Scale was designed and introduced to professional hand therapists at the September 2005 combined Annual Meeting of the ASHT and the American Society for Surgery of the Hand. CTS3 methodically measures the severity of symptoms as perceived by patients. This scale may someday become the “gold standard” by which the severity of symptoms can be assessed, and may lead to better delineation of the best treatment options for each individual.

Traditionally, resting the wrist in a splint has helped to decrease symptoms by minimizing further stress of provocative positions such as extremes of wrist flexion or extension, and by allowing the wrist and nerve to rest in a neutral position overnight. For many, this in effect allows the nerve to partially heal itself. Hand therapists have been fabricating custom wrist orthoses for patients with CTS for years. Splints are definitely not a one-size-fits-all-patients type of therapy. Hand therapists often tailor the splint to the individual patient’s needs and the characteristics of their condition and treatment.

A research study unveiled at the ASHT National Meeting in 2005 showed that a slightly different style of orthosis—a full-hand resting splint that placed the wrist in a neutral position and the metacarpal joints in slight flexion—minimizes the pressure in the carpal tunnel. It has been shown to help decrease the severity of CTS symptoms and increase function in patients suffering from the condition, possibly better than the traditional wrist splint. Outpatients reported improved hand, wrist, and arm function and less severity of their symptoms after 6 weeks of wearing a full-hand resting splint at night.

More patients are looking into the specialized practice of hand therapy to treat their painful CTS conditions. Services provided by hand therapists in collaboration with physician care can streamline, expedite, and customize a patient’s healing process. Conservative, nonsurgical treatment is an option for people whose symptoms are of relatively recent onset, or whose symptoms are very transient and mild. Hand therapists may evaluate the status of the nerve by performing a test of sensibility in the hands, and further assess hand health by measuring range of motion in the hand and wrist, grip and pinch strength, and other tests as indicated. Prescribed treatment may include fabrication of the aforementioned splints, instruction in range-of-motion and/or nerve-gliding exercises, use of various treatments to decrease pain and swelling, and assessment and modification of problem-causing movements and habits. Hand therapists are familiar with the variety of options available and are able to assess each individual situation and then apply the best interventions. Also, job-site or ergonomic analysis may be used to determine if workplace factors may be modified to decrease symptoms.

Many patients prefer to avoid surgical treatment. However in severe CTS cases, if pain continues for several months, physicians may recommend surgery to release the transverse carpal ligament—the band of tissue over the carpal tunnel—to relieve the pressure and give the affected tendons and median nerve room to expand without compression.

During postoperative rehabilitation, hand therapists can assist patients with wound care and the management of scar and pain. They also may help people regain movement in the fingers and wrists, and help strengthen hands and wrists with tendon and nerve glides and other customized exercises. Rehabilitation timing depends on the procedure, the condition of the patient, and physician protocol. A hand therapist will work closely with the surgeon and the patient to plan and implement the rehabilitation process. Some patients can begin postoperative therapy very quickly after the surgery. Others will have to wait a longer time period as prescribed by their physician.

ASHT issues preventive tips (available at www.asht.org) to address the high incidence of hand and wrist injuries that may result from overuse of handheld electronics and other workforce technologies. Our ongoing awareness campaign includes informing patients and physicians about the potential for these problems and offering exercises, stretches, and strategies to minimize their occurrence and impact. Hand therapists may also work with the employer, patient, and physician to investigate work habits, determine probable contributing factors to CTS, and provide treatment and direction to prevent further injury incidence.

Professional hand therapists strive to help decrease people’s pain and symptoms related to CTS through a variety of interventions. They also strive to help patients be productive workers while developing healthier work routines and lifestyles, which may help decrease the overall occurrence of CTS cases.

Christine Muhleman, OTR, CHT, is the 2006 president of the Chicago-based American Society of Hand Therapists, a nonprofit organization whose goal is to advance the science of hand therapy. For more information on hand therapy, visit www.asht.org.

Recommended Reading
Carpal Tunnel Syndrome Information Page; Condensed from Carpal Tunnel Syndrome Fact Sheet. National Institute of Neurological Disorders and Stroke (NINDS). Available at: www.ninds.nih.gov/disorders/carpal_tunnel/carpal_tunnel.htm Accessed July 28, 2006.