Carpal tunnel syndrome (CTS) is a common problem affecting the hand and wrist. Symptoms begin when the median nerve gets squeezed inside the carpal tunnel of the wrist, a medical condition known as nerve entrapment. The carpal tunnel is an opening through the wrist to the hand that is formed by the bones of the wrist on the bottom and the transverse carpal ligament on the top. The median nerve rests on top of the tendons—just below the transverse carpal ligament—and passes through the carpal tunnel into the hand.
Any condition that decreases the size of the carpal tunnel or enlarges the tissues inside the tunnel can produce CTS symptoms. Although painful sensations may indicate other conditions, CTS is the most common and widely known of the entrapment neuropathies in which the body's peripheral nerves are compressed or traumatized.
CTS can also be the result of a combination of factors including trauma or injury to the wrist that cause swelling, such as a sprain, fracture, or dislocation if the bone pushes into the tunnel. Fractured wrist bones may later cause CTS if the healed fragments result in abnormal irritation on flexor tendons.
Various types of arthritis can also cause swelling and pressure in the carpal tunnel. When pressure builds on the median nerve, the blood supply to the outer covering of the nerve slows down and may even be cut off. At first, only the outside covering of the nerve is affected. But if the pressure keeps building up, the inside of the nerve will start to become thickened. New cells, called fibroblasts, form within the nerve and create scar tissue. This is thought to produce the feelings of pain and numbness in the hand. If pressure is taken off right away, the symptoms will go away quickly. Pressure that is not eased right away can slow or even stop the chances for recovery.
DIAGNOSING CTS
Symptoms usually start gradually, with frequent burning, tingling, or itching numbness in the palm of the hand and the fingers, especially the thumb and the index and middle fingers. As symptoms worsen, people might feel tingling during the day. Decreased grip strength may make it difficult to form a fist, grasp small objects, or perform other manual tasks. In chronic and/or untreated cases, the muscles at the base of the thumb may weaken and deteriorate.
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| Graston Technique® (GT) is comprised of stainless-steel instruments that are effective in the treatment of CTS symptoms. Using GT, PTs are able to get deeper into the soft tissue, releasing the adhesions and stress from the area around the carpal tunnel and resulting in relief from pain and numbness. |
Early diagnosis and treatment are important to avoid permanent damage to the median nerve. A physical examination of the hands, arms, shoulders, and neck 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 CTS. 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.
CTS TREATMENTS
A wrist brace will sometimes decrease the symptoms in the early stages on CTS. A brace keeps the wrist in a resting position. When the wrist is in this position, the carpal tunnel is as big as it can be—so the nerve has as much room as possible inside the carpal tunnel. A brace can be especially helpful for easing the numbness and pain felt at night and can keep the hand from curling under as one sleeps. The wrist brace can also be worn during the day to calm symptoms and rest the tissues in the carpal tunnel.
If conservative treatment, such as the use of wrist braces, is successful, patients may see improvement in 4 to 6 weeks. Patients may need to continue wearing the wrist splints at night to control symptoms and keep the wrists from curling under as they sleep. Patients should be encouraged to do activities using healthy body and wrist alignment. Limit activities that require repeated motions, heavy grasping, and vibration in the hand.
If patients have surgery, they will take longer to recover. Pain and symptoms generally begin to improve after surgery, but patients may have tenderness in the incision area for several months. During the recovery time after surgery, heavy gripping and pinching should be avoided for up to 6 weeks to keep the tendons from pushing out against the healing transverse ligament. After 6 weeks, you should be safe to resume gripping and pinching without irritating the wrist.
Physical therapy might take up to 6 to 8 weeks. You'll begin doing active hand movements and range-of-motion exercises. Therapists use ice packs, soft-tissue massage, and hands-on stretching to help with the range of motion. Treatment may begin with carefully strengthening the patient's hand by simple squeezing and stretching exercises.
As patients progress, their therapists should guide them through exercises to help strengthen and stabilize the muscles and joints in the hand. Additional exercises can be used to improve fine motor control and dexterity, and get the hand working in ways that are similar to the patient's work tasks and sports activities.
Low-level laser (also known as "cold laser") therapy has been proposed as a treatment for CTS. Because of the low absorption by human skin, it is hypothesized that the laser light can penetrate deeply into the tissues where it has a photobiostimulative effect. Some physicians recommend low-intensity laser light directed through the skin at the median nerve as a safe, cost-efficient alternative to surgery, especially when used within the first year that the symptoms appear. The laser beam is directed at several points along the median nerve during the course of several treatments. Some studies report that laser therapy gives some people significant long-term relief from symptoms.
Iontophoresis is another treatment for CTS. Iontophoresis is a transdermal delivery system in which a substance bearing a charge is propelled through the skin by a low electrical current. This technique works through electrodes that are used to move the molecules of the medication through the skin down to the carpal tunnel. This may work with tendons that are inflamed and close to the surface of the skin.
Whether the patient needs conservative treatment, such as a wrist brace, or more involved treatment with pain-relieving modalities, such as low-level laser, therapists should emphasize a number of ways to avoid future problems before the patient's therapy sessions end.
Jennifer Bowman, OTR/L, specializes in hand therapy at Lakeshore Physical Therapy in Chicago. For more information, contact .
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