If you think about it, carpal tunnel syndrome (CTS) has been around a long time. The condition was first noted in medical literature in the early 1900s, but the actual term wasn't used until 1938. It later became more widely known during the 1950s and ‘60s, but not among the general public until the 1990s, when it was linked to repetitive tasks performed at the workplace.

As occupational and physical therapists, most of us are familiar with the symptoms and causes of CTS. For the purposes of this article, we will be focusing on assessment, pain management, current treatment trends, and the products/technologies available on the market, as well as recovery.

ASSESSMENT

"Typically, I receive a script from an MD for treatment of hand pain, weakness, and/or numbness and tingling," notes Cynthia Boccia, OTR/L at Montgomery Physical Therapy and Wellness in Montgomery, NY, and Port Jervis Physical Therapy and Wellness in Port Jervis, NY. If the patient has seen a hand orthopedic, a diagnosis of CTS has probably already been determined, according to Boccia. "During initial intake, patients may describe nocturnal pain in which their sleep patterns are disturbed, secondary to feelings of heaviness of the hand in which they get relief by shaking their hand," Boccia says. In addition, many report dropping things, such as breaking dishes while washing them.

Upon initial assessment, she observes the patient's physical appearance, including signs of edema, especially wrist and thumb circumference and thenar atrophy. "I perform provocative tests such as Phalen's and Tinel's sign," she explains. Phalen's maneuver is performed by flexing the wrist gently as far as possible, then holding this position and awaiting symptoms. A positive test is one that results in numbness in the median nerve distribution when holding the wrist in the acute flexion position within 60 seconds. The quicker the numbness starts, the more advanced the condition. Tinel's sign is a way to detect irritated nerves and is performed by lightly tapping the area over the nerve to elicit a sensation of tingling or "pins and needles" in the nerve distribution.

"I also assess for nerve involvement to determine the functional sensibility deficit using the Semmes Weinstein Monofilament test, which seems quite consistent to EMG (electromyography) findings which show denervation potentials in those muscles innervated by the median nerve," Boccia states. Following this, she will take patients' grip and pinch measurements using a pinch meter, and a dynamometer to their strength, since CTS greatly decreases hand strength and AROM measurements.

For more than 10 years, Boccia has been providing occupational therapy to a diversified population. She began as an OT working in a rehabilitation center in a local hospital treating patients with orthopedic and neurological disorders. She then later became interested in hand, wrist, and elbow injuries, and specialized in this area for several years.

From his paper, "Carpal Tunnel Syndrome," by David A. Fuller, MD (March 2008), other tests that are commonly used in the workup include vibratory sensibility—where "a 256-cycle-per-second tuning fork is struck against an object, causing it to vibrate, and the fork's prong is then placed against the patient's fingertips. The median and ulnar fingers of both hands are tested, and it's considered positive if decreased sensation is perceived. Static and moving two-point discrimination is the minimum separation between two points (either static or moving) that can be perceived. Failure to discriminate more than 6 mm (static) or 5 mm (moving) is a positive finding," according to Fuller.

"Carpal compression tests are direct applications of pressure of 150 mm Hg or even pressure from both thumbs of the examiner [when] exerted on the patient's carpal canal and maintained for 30 seconds. The test is positive if pain, numbness, or paresthesia develops in the radial-sided digits," he writes.

X-rays might be taken to check for bone problems caused by past injury, arthritis, recently broken or dislocated bones, or tumors. X-rays are not used to diagnose CTS, but they can be helpful for identifying signs of arthritis or an old or new wrist or neck injury that may be contributing to the symptoms. Ultrasound is uncommon for diagnosis but is sometimes used to look at the size of the median nerve. For swelling of the median nerve, narrowing of the carpal tunnel, or problems with circulation of blood through the carpal tunnel, a MRI might also be done.

PAIN MANAGEMENT

Over-the-counter anti-inflammatories such as aspirin, ibuprofen, or naproxen can be effective for managing pain and controlling symptoms. Recently, the natural anti-inflammatory and antioxidant Bioastin has been shown to lessen and sometimes even eliminate the symptoms of CTS altogether; however, clinical studies are limited, and results last only with continued use. Pain relievers like paracetamol tend to mask the pain, but only an anti-inflammatory will affect inflammation. Nonsteroidal 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 due to significant side effects. A more aggressive pharmaceutical option is an injection of cortisone to reduce swelling and nerve pressure within the carpal tunnel.

"The majority of the patients I treat have developed CTS due to repetitive tasks at the workplace," Boccia says. Computer and mouse use, long-distance driving (truckers)—these patients remain in a stationary position or at their desks for approximately 6 to 8 hours per day engaged in repetitive tasks. "Most of them have underlying tendinitis of wrist and elbow as well," she adds. "In addition, I've treated patients s/p wrist fractures who developed CTS as a result of decreased tunnel size resulting from their trauma."

The majority of physicians send their patients for conservative treatment by an OT or PT for CTS before considering surgery. Goals of therapy include:

• decrease pain and paresthesia;
• decrease edema;
• increase AROM; and
• increase grip and pinch strength and independence with a home exercise program that includes tendon gliding exercises (TGEs) performed three times per day.

Boccia instructs her patients to start their day with the TGEs and to do them immediately before going to bed. She educates them on positions and tasks that may place them at risk during daily activities while at work or during leisure time. She's developed the 20-minute rule with her patients. "I encourage them to change their tasks every 20 minutes, and if they are unable to do so, I have them perform tendon-gliding exercises along with neck and wrist stretches right at their desks," she says. Additionally, she provides them with illustrations that they can conveniently hang at their workstations. Some of her patients actually have timers at their computers as reminders.

CURRENT PREVENTION/TREATMENT TRENDS

Patients can rest their wrist or change how they use their hand to help alleviate the pain of CTS, especially at night. Putting ice on the wrist, massaging the area, and doing stretching exercises can be beneficial. Propping the arm with pillows when lying down, avoiding the use of the hand too much, finding a new way to use the hand by using a different tool, using the other hand more often, and avoiding bending the wrist down for long periods of time are all fairly common measures taken to relieve CTS. Other things to consider:

• lose weight if the patient is over weight;
• get treatment for any underlying condition that may be causing CTS;
• do not bend, extend, or twist the hands for long periods;
• do not work with the arms too close or too far from the body;
• do not rest the wrists on hard surfaces for extended periods;
• use the other hand while performing work tasks;
• make sure work tools aren't too big for the hands;
• take regular breaks from repeated hand movements to give the hands and wrists time to rest;
• do not sit or stand in the same position all day; and
• adjust the height of the work chair so that the forearms are level with the keyboard and the wrists don't have to be flexed to type.

Boccia always incorporates the entire upper extremity during treatment of CTS. She begins with paraffin wax along with a hot pack to improve circulation and muscle extensibility. "This really helps those patients with moderate to severe compression who present with moderate to severe paresthesia of the digits," she notes. "After eight to 10 minutes in paraffin, I perform a retrograde massage of the affected extremity from distal to proximal."

Ultrasound therapy is another option. It uses high-pitched sound waves to create heat, which may help reduce pain in the soft tissues (such as the tendons). Hydrotherapy involves immersing the wrist in hot water for 3 minutes, then cold water for 3 minutes. Also known as contrast hydrotherapy, this increases circulation to the wrist. Complementary and alternative treatments are used, such as acupuncture, yoga, chiropractic manipulation, and taking vitamin B6 supplements, which may help with the symptoms or tingling, numbness, weakness, or pain felt in the fingers or hand.

Kinesio Taping® Method assists by reducing the edema and pain associated with Carpal Tunnel Syndrome, while allowing functional and bio-mechanical assistance.

Surgery is seen as a last resort when the pain or numbness of CTS persists. This involves cutting the ligament pressing on the nerve.

PRODUCTS/TECHNOLOGY

From wrist braces and splints to ergonomic products, quite a variety of options for both prevention and treatment of CTS are available. Wrist braces are worn for activities that require wrist range of motion, such as cutting food and preparing meals, typing, or keyboarding. Wrist splints are designed for nighttime use as they support and immobilize the wrist in a moderately extended position. They are not intended for daytime use where wrist motion is required; however, they can be worn during the day where more rigid support of the wrist is desired.

In addition to proper bracing, ergonomics, postural correction, and exercise are important components of treating CTS and help prevent repetitive stress injuries. There are stretch-out nylon straps with built-in loops, different types of cushions for neck support, shoulder and back cushions, stress balls, and wrist cushions for keyboards and mice.

A product called the Carpal Tunnel Stretch stretches the tight soft-tissue structures associated with CTS. Patients place their hand in the pad-like device and press down for 3 to 5 seconds. Another apparatus—the WristWand—is used to stretch key muscle groups of the hands, wrists, forearms, and upper arms. There is also the Armaid—a self-administered massage device that opens up tight muscles, tendons, and ligaments. Patients strap it to the thigh. It is equipped with snap-in therapy rollers and supportive padding. Carpal Ligament Traction (CTRAC) is another stretching device designed to open the carpal tunnel and provide more space for the median nerve using a three-point pressure system. The patient's hand is placed on the CTRAC, and a premeasured amount of stretching force is applied by inflating a cuff (bladder). Low-level cold lasers have been used for treatment, too.

RECOVERY/PROGNOSIS

If left untreated, CTS can lead to permanent nerve and muscle damage. Nonsurgical and surgical treatment relieves symptoms in approximately 90% of cases. Symptoms often improve with treatment, but research suggests that more than 50% of cases eventually require surgery. Surgery is often successful, but full healing can take months. Recurrence of CTS following treatment is considered rare, and the majority of patients recover completely.

Nina Silberstein is a contributing writer to Physical Therapy Products. For more information, contact .