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Carpal tunnel syndrome

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Carpal tunnel syndrome

Classification and external resources

Transverse section at the wrist. The median nerve is colored yellow. The carpal tunnel consists of the bones and flexor retinaculum. ICD-10 ICD-9 OMIM G56.0 354.0 115430

DiseasesDB 2156 MedlinePlus 000433 eMedicine MeSH orthoped/455 pmr/21 emerg/83 radio/135 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) is idiopathic median neuropathy at the carpal tunnel. The pathophysiology is not completely understood but can be considered compression of the median nerve traveling through the carpal tunnel.[1] The risk factors for CTS are primarily genetic rather than environmental.[2] The main symptom of CTS is intermittent numbness of the thumb, index, long and radial half of the ring finger.[3] The numbness usually occurs at night because we tend to sleep with our wrists flexed and is relieved by wearing a wrist splint that prevents flexion.[4] Long-standing CTS leads to permanent nerve damage with constant numbness, atrophy of some of the muscles of the thenar eminence, and weakness of palmar abduction.[5] There is a myth (in the sense of an unproved or false collective belief that is used to justify a social institution) that CTS manifests as pain with typing or other types of hand use.[6] Pain in carpal tunnel syndrome is primarily

numbness that is so intense that it wakes one from sleep. Pain in electrophysiologically verified CTS is associated with misinterpretation of nociception and depression.[7] Palliative treatments for CTS include use of night splints and corticosteroid injection. The only scientifically established disease modifying treatment is surgery to cut the transverse carpal ligament.[8] Carpal Tunnel Syndrome is considered by some to be a form of repetitive stress injury, and as such, is caused by repetitive motions, most famously from long hours of computer keyboard use. However, while studies have found associations between some work activities and Carpal Tunnel Syndrome, causality has not been demonstrated.[9]

Contents
[hide]

1 History 2 Anatomy 3 Symptoms 4 Causes

o o

4.1 Work related 4.2 Carpal tunnel syndrome associated with other diseases

5 Diagnosis 6 Prevalence 7 Prevention 8 Possible misdiagnosis 9 Treatment

o o o o

9.1 Immobilizing braces 9.2 Localized corticosteroid injections 9.3 Other medication 9.4 Carpal tunnel release surgery

9.4.1 Procedure 9.4.2 Efficacy

o o

9.5 Ultrasound treatment 9.6 Physiotherapy and occupational therapy

10 Role of Occupational Therapy

o o

10.1 Assessment 10.2 Intervention

10.2.1 Education

10.2.2 Physical Symptom Management Techniques

10.2.2.1 Splinting 10.2.2.2 Other

10.2.3 Modifications for Prevention/Reduction of Symptoms

10.2.3.1 Modification of Occupation (Task) 10.2.3.2 Modification of Equipment and Tools 10.2.3.3 Modification of Environment 10.2.3.4 Summary

o o o o o

10.3 Long term recovery 10.4 Notable cases 10.5 See also 10.6 References 10.7 External links

[edit] History
The condition known as Carpal Tunnel Syndrome has had major appearances throughout the years but it was most commonly heard of in the years following World War II.[10] Individuals who had suffered from this condition have been depicted in surgical literature for the mid-19th century.[10] In 1854, Sir James Paget was the first to report median nerve compression at the wrist in a distal radius fracture.[11] Following the early 20th century there were various cases of median nerve compression underneath the transverse carpal ligament.[11] Carpal Tunnel Syndrome was most commonly noted in medical literature in the early 20th century but the first use of the term was noted 1939. Physician Dr. George S. Phalen of the Cleveland Clinic identified the pathology after working with a group of patients in the 1950s and 1960s.[12]

[edit] Anatomy
Main article: Carpal tunnel

The carpal tunnel is an anatomical compartment located at the base of the wrist. Nine flexor tendons and the median nerve pass through the carpal tunnel that is surrounded on three sides by the carpal bones that form an arch. The nerve and the tendons provide function, feeling, and movement to some of the fingers. The finger and wrist flexor muscles including their tendons originate in the forearm at the medial epicondyle of the elbow joint and attach to the Metaphalangeal (MP), Proximal Interphalangeal (PIP), and Distal Interphalangeal bones of the fingers and thumb (BSI). The carpal tunnel is approximately as wide as the thumb and its boundary lies at the distal wrist skin crease and extends distally into the palm for approximately 2 cm.[citation needed] 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.[13] Simply flexing the wrist to 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 atrophy 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. There is a superficial sensory branch of the median nerve, which branches proximal to the TCL and travels superficial to it. This branch is therefore spared, and it innervates the palm towards the thumb.[14]

[edit] Symptoms

Untreated Carpal Tunnel Syndrome

Patients with CTS experience numbness, tingling, or burning sensations in the thumb and fingers, particularly the index, middle fingers, and radial half of the ring fingers which are innervated by the median nerve. Less specific symptoms may include pain in the hands or wrists and loss grip strength[15] (both of which are more characteristic of painful conditions such as arthritis). Patients may also report pain in the arm and shoulder.[16] Numbness and paresthesias in the median nerve distribution are the hallmark neuropathic symptoms (NS) of carpal tunnel entrapment syndrome. Weakness and atrophy of the thenar muscles may occur if the condition remains untreated.[17]

[edit] Causes
Most cases of CTS are of unknown causes, or idiopathic.[18] Carpal Tunnel Syndrome can be associated with any condition that causes pressure on the median nerve at the wrist. Some common conditions that can lead to CTS include obesity, hypothyroidism, arthritis, diabetes, and trauma.[19] Other causes of this condition include intrinsic factors that exert pressure within the tunnel, and extrinsic factors (pressure exerted from outside the tunnel), which include benign tumors such as lipomas, ganglion, and vascular malformation.[20]

[edit] 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.
[citation needed]

The relationship between work and CTS is controversial; in many locations, workers diagnosed with carpal tunnel syndrome are entitled to time off and compensation.[21] In the USA Carpal tunnel syndrome results in an average of $30,000 in lifetime costs (medical bills and lost time from work).[22]

Some speculate that carpal tunnel syndrome is provoked by repetitive movement 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,[9] but it is unclear if this refers to pain (which may not be due to carpal tunnel syndrome) or the more typical numbness symptoms.[23] 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,[24] The speculation or rationale that CTS is work related is based on debatable points such as: 1. CTS is found mostly in the working adult population. This may depend on how CTS is defined and diagnosed, but this seems untrue. For instance, in one recent representative series of a consecutive experience, most patients were older and not working.[25] Based on the claimed increased incidence in the workplace, arm use is implicated, but the weight of evidence suggests that this is an inherent, genetic, slowly, but inevitably progressive idiopathic peripheral mononeuropathy.[26]

[edit] Carpal tunnel syndrome associated with other diseases

A variety of patient factors can lead to CTS including heredity, size of the carpal tunnel, associated local and systematic diseases and certain habits contribute to its etiology.[1] 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.[27] Examples include:

Rheumatoid arthritis and other diseases that cause inflammation of the flexor tendons. With pregnancy and hypothyroidism, fluid is retained in tissues, which swells the tenosynovium. During pregnancy women experience CTS due to hormonal changes and water retention which is common during pregnancy. Previous injuries including fractures of the wrist. Medical disorders that lead to fluid retention or are associated with inflammation such as: inflammatory arthritis, Colles' fracture, amyloidosis, hypothyroidism, diabetes mellitus, acromegaly, and use of corticosteroids and estrogens. Carpal tunnel syndrome is also associated with repetitive activities of the hand and wrist, particularly with a combination of forceful and repetitive activities [19] Acromegaly, casues excessive growth hormones. This causes the soft tissues and bones around the carpel tunnel to grow causes compression of the median nerve. [28] 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. [29] Double crush syndrome is a debated hypothesis that compression or irritation of nerve branches contributing to the median nerve in the neck, or anywhere above the wrist, increases

sensitivity of the nerve to compression in the wrist. There is little evidence, however, that this syndrome really exists.[30]

Heterozygous mutations in a gene, SH3TC2, associated with Charcot-Marie-Tooth, confer susceptibility to neuropathy, including the carpal tunnel syndrome. [31] Parvovirus b19 has been associated with carpel tunnel syndrome
[32]

[edit] 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 along with positive Phalen's, Durkan's and eletrophysiological tests have at worst, a very mild case of carpal tunnel syndrome. A predominance of pain rather than numbness is unlikely to be caused by carpal tunnel syndrome no matter what 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. [33] 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. Phalen's sign is defined as pain and/or paresthesias in the median-innervated fingers with one minute of wrist flexion. Only this test has been shown to correlate with CTS severity when studied prospectively. [1] Tinel's sign, a classic, though less sensitive test, is a way to detect irritated nerves. Tinel's is performed by lightly tapping the skin over the flexor retinaculum to elicit a sensation of tingling or "pins and needles" in the nerve distribution. Tinel's sign (pain and/or paresthesias of the median-innervated fingers with percussion over the median nerve) is less sensitive, but slightly more specific than Phalens sign.[1] Durkan test, carpal compression test, or applying firm pressure to the palm over the nerve for up to 30 seconds to elicit symptoms has also been proposed. [34][35]

Other conditions may also be misdiagnosed as carpal tunnel syndrome. Thus, if history and physical examination suggest CTS, patients will sometimes 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).[36] Nerve conduction studies (NCS) are a sensitive measure of detecting compression of the median nerve. Electrodiagnosis rests upon demonstrating impaired median nerve conduction across the carpal tunnel in context of normal conduction elsewhere. Compression results in damage to the myelin sheath and manifests as delayed latencies and slowed conduction velocities [1] The role of MRI or ultrasound imaging in the diagnosis of carpal tunnel syndrome is unclear.[37][38][39]

[edit] Prevalence
Carpal tunnel syndrome can affect anyone. In the U.S., roughly 1 out of 20 people will suffer from the effects of carpal tunnel syndrome. Caucasians have the highest risk of CTS compared with other races such as non-white South

Africans.[40] Women suffer more from CTS than men with a ratio of 3:1 between the ages of 4560 years. Only 10% of reported cases of CTS are younger than 30 years.[40]

[edit] Prevention
A 2007 study, conducted by Lozano-Calderon et al. in the Department of Orthopaedic Surgery at Massachusetts General Hospital, states that carpal tunnel syndrome is primarily determined by genetics and structure.[41] Therefore, carpal tunnel syndrome is probably not preventable.[original research?] However, others[who?] think it can be prevented by developing healthy habits like avoiding repetitive stress, practicing healthy work habits like using ergonomic equipment (wrist rest, mouse pad), taking proper breaks, using keyboard alternatives (digital pen, voice recognition and dictation) and early passive treatment like taking turmeric (antiinflammatory), omega-3 fatty acids, and B vitamins. The persistence of such theories in spite of evidence to the contrary is remarkable. For instance, scientists have long abandoned the potential role of B-vitamins in carpal tunnel syndrome.[42][43] 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.[41] and they stigmatize arm use in ways that risks increasing illness.[44][45]

[edit] Possible misdiagnosis

There are some, such as Dr. Janet G. Travell, MD and Dr. David G. Simons, MD who believe that carpal tunnel syndrome is simply a universal label applied to anyone suffering from pain, numbness, swelling, and/or burning in the radial side of the hands and/or wrists. When pain is the primary symptom, carpal tunnel syndrome is unlikely to be the source of the symptoms.[23] As a whole, the medical community is not currently embracing or accepting trigger point theories due to lack of scientific evidence supporting their effectiveness.[46]

[edit] 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, physiotherapy (preferable), regular massage therapy treatments, chiropractic, medications, and surgical release of the transverse carpal ligament. According to the 2007 guidelines by the American Academy of Orthopaedic Surgeons,[47] early surgery with carpal tunnel release is indicated where there is clinical evidence of median nerve denervation or the patient elects to proceed directly to surgical treatment. Otherwise, the main recommended treatments are local corticosteroid injection, splinting (immobilizing braces), oral corticosteroids and ultrasound treatment. The treatment should be switched when the current treatment fails to resolve the symptoms within 2 to 7 weeks. However, these recommendations have sufficient evidence for carpal tunnel syndrome when found in association with the following conditions: diabetes mellitus, coexistent cervical radiculopathy, hypothyroidism, polyneuropathy, pregnancy, rheumatoid arthritis, and carpal tunnel syndrome in the workplace.[47]

[edit] Immobilizing braces

A rigid splint can keep the wrist straight.

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.[48] 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.[49][50][51] 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.[52][53]

[edit] Localized corticosteroid injections

Corticosteroid 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.[54] In certain patients, an injection may also be of diagnostic value. This treatment is not appropriate for extended periods, however. In general, medical professionals prescribe local steroid injections only until other treatment options can be identified. For most patients, surgery is the only option that will provide permanent relief.[55]

[edit] Other medication

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. [56]

[edit] Carpal tunnel release surgery

Scars from carpal tunnel release surgery. Two different techniques were used. The left scar is 6 weeks old, the right scar is 2 weeks old. Also note the muscular atrophy of the thenar eminence in the left hand, a common sign of advanced CTS

Carpal Tunnel Syndrome Operation

Release of the transverse carpal ligament is known as "carpal tunnel release" surgery. It is recommended when there is static (constant, not just intermittent) numbness, muscle weakness, or atrophy, and when night-splinting no longer controls intermittent symptoms.[57] 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.[58] [edit] 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 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 nerve inside, relieving the pressure.[59] 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.[citation needed] 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, since the 1990s, a growing number of surgeons now offer endoscopic carpal tunnel release.[citation needed] Open surgery involves an incision 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.[citation
needed]

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 visualize the underside of the transverse carpal ligament.[60] The endoscopic methods do not divide the subcutaneous tissues or the palmar fascia to the same degree as the open method does.[citation needed] Many studies have been done to determine whether perceived benefits of a limited endoscopic or arthroscopic release are significant. Brown et al. conducted a prospective, randomized, multi-center study and found no significant differences between the two groups with regard to secondary quantitative outcome measurements.[61] However, the open technique resulted in more tenderness of the scar than the endoscopic method. A prospective randomized study done in 2002 by Trumble revealed that good clinical outcomes and patient satisfaction are achieved more quickly with the endoscopic method. 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 caused greater scar tenderness during the first three months after surgery, and a longer time before the patients could return to work.[62] Many surgeons have embraced limited incision methods. 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 using a variety of devices or incisions. 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.[63] Despite these views, 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. At the 2007 meeting of the American Society for Surgery of the Hand, a former advocate of endoscopic carpal tunnel release, Thomas J. Fischer, MD, 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. Balloon Carpal Tunnelplasty is a technique that uses a minimally invasive balloon catheter director to access the carpal tunnel. The director protects the median nerve and contents of the carpal tunnel. Like a traditional tissue elevator/expander with Balloon Carpal Tunnelplasty the carpal ligament is elevated increasing the space in the carpal tunnel. The Balloon Carpal Tunnelplasty technique is performed through a one centimeter incision at the distal wrist crease, it is monitored and expansion confirmed by direct or endoscopic visualization. The purpose of Balloon Carpal Tunnelplasty is to avoid an incision in the palm of the hand, avoid cutting the transverse carpal ligament and maintain the biomechanics of the hand. ref:Berger, L. Balloon Carpal Tunnelplasty, First Comparative Clinical Study; The University of Pittsburgh Journal Vol 17, pg 80; 2006 [edit] 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.[64][65][66] In general, endoscopic techniques are as effective as traditional open carpal surgeries, [67][68] though the faster recovery time typically noted in endoscopic procedures is felt by some to possibly be offset by higher complication rates.[69][70] 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.[citation needed] Complications can occur, but serious ones are infrequent to rare.[citation needed] Carpal tunnel surgery is usually performed by a hand surgeon, orthopaedic or plastic surgeon. Some neurosurgeons and general surgeons also perform the procedure.[citation needed]

[edit] Ultrasound treatment

Some claim that Ultrasound to the wrist gives significant improvement of symptoms in people with CTS.[71] A treatment process may consist of 20 sessions of 15 minutes of ultrasound applied to the area over the carpal tunnel at a frequency of 1 MHz, and a power of 1.0 W/cm2.[71] However, many studies have shown no effect.[72][73] Given these inconsistencies, the role of ultrasound in the treatment of CTS is debatable and it should be considered an experimental treatment.

[edit] Physiotherapy and occupational therapy

Typical physiotherapy exercise for carpal tunnel syndrome.

One review of the evidence for possible symptom reduction found good evidence (level B recommendations) for splinting, ultrasound, nerve gliding exercises, carpal bone mobilization, magnetic therapy, and yoga for people with carpal tunnel syndrome.[74] However, a recent evidence based guideline produced by the American Academy of Orthopedic Surgeons assigned lower grades to most of these treatments.[75] Again, some claim that pro-active ways to reduce stress on the wrists, which alleviates wrist pain and strain, involve adopting a more ergonomic work and life environment. For example, some have claimed that 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.[76][77]

[edit] Role of Occupational Therapy

[edit] Assessment
Tinels sign and Phalens tests can be used to assess for CTS. They may be administered by an occupational therapist (OT). Tinels sign involves tapping at the volar wrist while Phalens test involves maintaining wrist flexion for 60 seconds. In both tests, a positive sign is indicated by numbness, tingling or pain in the thumb, index and half of the middle finger. Following positive signs, the OT may perform manual muscle testing for grip and pinch strength and assess range of motion.[78] The OT may perform a detailed step-by-step breakdown of what's involved in the activity to look at the specific tasks that could be affected by or be contributing to CTS symptoms. For example, the OT may analyze the activity of cooking. The OT may find, for example, that repetitive lifting of heavy skillets is a contributing factor to the individuals CTS symptoms. The OT may also observe the environment in which the activity is being performed and identify risk factors and compensatory strategies.[78]

[edit] Intervention
OTs provide protective and corrective non-surgical measures for CTS and focus intervention on the person's physical abilities, environment, and the activities they engage in. OT intervention has an emphasis on enabling function in

self-care activities, leisure and paid or unpaid work. At the level of person, occupational therapists can provide education and/or direct intervention for physical symptom treatment and management. At the levels of environment and occupation, OTs provide education and modifications related to the method of task completion, including equipment and tools used, and the setting in which it is being performed. OTs who provide intervention for individuals with CTS may also be hand therapists. Bash & Farber state that to become a hand therapist, an individual must be a physical or occupational therapist with at least 5 years experience, including 2000 hours of therapy pertaining directly to hands, and a certification exam is required.[79] [edit] Education OTs play a large role as educators. Education may be provided to an individual client or a group of people. Individuals with CTS or at risk for CTS may benefit from education in the areas outlined below:

signs & symptoms of CTS options for treatment: surgical and/or non surgical interventions how to reduce risks & decrease symptoms of CTS splint wearing regimen body mechanics & exercises task adaptation adaptive tools workplace adaptations

[edit] Physical Symptom Management Techniques

[edit] Splinting

OTs often use wrist splinting as a form of treatment. Splints may be pre-fabricated or customt-fit. Prefabricated splints are sold in health care supply stores and are an inexpensive option for clients. Prefabricated splints may be used but the fit may not be precise enough for all individuals. In this case, a custom fit splint is required.[80] A OT will fabricate a custom-fit splint by molding thermoplastic material unique to the client's hand, wrist and forearm. Splints can be based on the front (palmar), back (dorsal) or outer side (pinky) of the arm. According to Muller et als systematic review on interventions for CTS, volar cock-up splints and ulnar gutter splints are similar in their improvement of symptoms and function.[81] Dorsal splints are also recommended for CTS as they reduce pressure placed on the volar wrist.[82] Splints aim to immobilize the wrist to decrease pressure in the carpal tunnel.[83] Restricting wrist motion eliminates the repetitive movement and tension overload in the carpal tunnel.[84] This gives the tendon sheaths a chance to heal, reducing swelling, which then may decrease the pressure on the median nerve.[84] Splints also aim to keep the wrist at a certain angle to decrease pressure within the carpal tunnel.[82] Although there has been debate about the best angle for wrist immobilization, [85] the authors of a systematic review on non surgical carpal tunnel treatments conclude that there is limited evidence that the use of a wrist splint in neutral position is more effective than an extended wrist position of 20 degrees in patients with CTS in the short term.([86], p983)

In another systematic review on interventions for CTS, Muller et al found that wearing a nocturnal splint as well as wearing a splint during aggravating activities alleviate symptoms of CTS (numbness, pain and tingling) better than no treatment.[81] It follows that decreasing symptoms of CTS improves overall occupational function in activity.[87]
[edit] Other

An occupational or physiotherapist working as a hand therapist may be involved in other areas of treatment for the symptoms of CTS depending on their scope of practice.[81] These treatments may include but are not limited to ultrasound, electromagnetic field therapy, magnetic therapy, low level-laser therapy, or nerve gliding exercises.([81], [86] ) [edit] Modifications for Prevention/Reduction of Symptoms
[edit] Modification of Occupation (Task)

Modification of a task is about adjusting behaviors and actions that may contribute to the development or exacerbation of CTS. As part of the assessment, the OT will conduct an activity analysis to identify areas where change may be needed. Once a task is analyzed, alternative methods can be negotiated or discussed with the client. As Doheny et al suggest, tasks can be redesigned to include diversity and thus limit repetitive movements that can aggravate CTS.[88] For example, Keir et al suggest breaking up the repetitive action of using a computer mouse with other tasks because mouse use was shown to increase carpal tunnel pressure. This study also suggests minimizing wrist extension through appropriate body posture at the workstation which may help to reduce carpal tunnel pressure.
[89]

A review of the literature has found evidence supporting the use of exercise and/or rest breaks in reducing musculoskeletal discomfort during computer work.[90] Faucett et al found that people with CTS were more likely to continue with their current jobs if modifications were made to the tasks. Two of these modifications included limiting repetitive tasks and decreasing work time.[91] OT's can provide recommendations on job modifications to reduce risk factors by modifying client's work tasks.
[edit] Modification of Equipment and Tools

A major role of OTs is to introduce modified equipment and adaptive aids to enable occupational performance despite physical limitations. Modifying equipment and tools can correct positioning of the hand (e.g. keep it in a more neutral position) and reduce the hand force required to complete an action. For example, Dolby Laboratories introduced hand tools that reduced the hand force required, distributed the force over a larger surface area of the hand, and corrected the positioning of the hand through specially shaped handles that did not impinge on the median nerve area of the palm. These tools were designed to reduce risk factors associated with cumulative trauma disorders such as CTS.[92] For example, specialized spring-loaded pliers reduced the force required to cut wire for electronic assembly purposes. Adaptive aids can be useful in enabling individuals with CTS to participate in their chosen activities. One such adaptation is increasing the diameter of handles so that less grip strength is needed to grasp an object.[93] Any handle can be built up in this way. For example, someone who has CTS may have difficulty holding their toothbrush or utensils while eating. OTs can easily adapt these tools or purchase already adapted tools for a client. Specific risk factors that can contribute to CTS such as vibration can be reduced by introducing new tools with lower vibration levels as well as anti-vibration gloves.[94]
[edit] Modification of Environment

Another important avenue of occupational therapy is adapting the environment to facilitate occupational performance of a particular task. When modifying an environment, often the equipment and tool adaptations are part of that environmental change.

In the management of CTS, workstation modification (i.e. adapting the work environment) is a large part of OT intervention. By adjusting the workstation equipment, such as desks, chairs, monitors, and keyboards, the ideal position of the wrist and forearm can be achieved. This can help alleviate symptoms of CTS as well as prevent further damage and strain.[88] For example, there is moderate evidence that a modified ergonomic keyboard is more effective than a regular keyboard at relieving symptoms of CTS.[86] The addition of forearm supports can help to facilitate appropriate posture of the wrist by preventing extension while using a mouse.[89] Attention should also be given to psychosocial aspects of a work environment, such as job demands and job control, as they may help or hinder return to work and level of functioning within the workplace for those individuals with CTS.[95] Similar to the work environment, OTs can help adapt the home environment through the introduction of adaptive aids and adjustment of furniture or equipment. The interventions for CTS mentioned above can be used together as illustrated in a study by Bash and Farber. These authors found that many hand therapists with symptoms of CTS not only wore splints, but also engaged in modifying their tasks, tools and environments as part of their own intervention plan.[79] Hand therapists are an example of a population that has been found to have high instances of CTS due to repetitive, stressful movements on the job. The hand therapists in this study used the following intervention strategies and reported symptom relief:

made ergonomic changes to the work station (modify environment) used adaptive scissors and shears (modify tools/equipment) reheated splint material to trim edges (modify task) changed hand position (modify task) used assistive equipment for scar massage (modify tools/equipment) [79]

[edit] Summary

In summary, OTs are involved in the assessment and intervention process with clients with CTS. Within the area of intervention, OTs provide education; symptom management techniques such as splinting; and modification of specific tasks, equipment and the environment.

[edit] Long term recovery

Most people who find relief of their carpal tunnel symptoms with conservative or surgical management find minimal residual or "nerve damage".[96] Long-term chronic carpal tunnel syndrome (typically seen in the elderly) can result in permanent "nerve damage", i.e. irreversible 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.[97] Recurrence of carpal tunnel syndrome after successful surgery is rare.[98] If a person has hand pain after surgery, it is most likely not caused by carpal tunnel syndrome. It may be the case that the illness of a person who has hand pain after carpal tunnel release was diagnosed incorrectly, such that the carpal tunnel release has had no positive effect upon the patient's symptoms.

http://www.ninds.nih.gov/disorders/carpal_tunnel/detail_carpal_tunnel.htm

You're working at your desk, trying to ignore the tingling or numbness you've had for months in your hand and wrist. Suddenly, a sharp, piercing pain shoots through the wrist and up your arm. Just a passing cramp? More likely you have carpal tunnel syndrome, a painful progressive condition caused by compression of a key nerve in the wrist.
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What is carpal tunnel syndrome?

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. Sometimes, thickening from irritated tendons or other swelling narrows the tunnel and causes the median nerve to be compressed. 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.
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What are the symptoms of carpal tunnel syndrome?

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. Some carpal tunnel sufferers say their fingers feel useless and swollen, even though little or no swelling is apparent. The symptoms often first appear in one or both hands during the night, since many people sleep with flexed wrists. A person with carpal tunnel syndrome may wake up feeling the need to "shake out" the hand or wrist. 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 waste away. Some people are unable to tell between hot and cold by touch.

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What are the causes of carpal tunnel syndrome?

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; 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.

There is little clinical data to prove whether repetitive and forceful movements of the hand and wrist during work or leisure activities can cause carpal tunnel syndrome. Repeated motions performed in the course of normal work or other daily activities can result in repetitive motion disorders such as bursitis and tendonitis. Writer's cramp - a condition in which a lack of fine motor skill coordination and ache and pressure in the fingers, wrist, or forearm is brought on by repetitive activity - is not a symptom of carpal tunnel syndrome.
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Who is at risk of developing carpal tunnel syndrome?

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. 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. 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. 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. During 1998, an estimated three of every 10,000 workers lost time from work because of carpal tunnel syndrome. Half of these workers missed more than 10 days of work. The average lifetime cost of carpal tunnel syndrome, including medical bills and lost time from work, is estimated to be about $30,000 for each injured worker.
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How is carpal tunnel syndrome diagnosed?

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. 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. 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.
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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-surgical treatments Drugs - In special circumstances, various drugs can ease the pain and swelling associated with carpal tunnel syndrome. Nonsteroidal anti-inflammatory drugs, such as aspirin, ibuprofen, and other nonprescription pain relievers, may ease symptoms that have been present for a short time or have been caused by strenuous activity. Orally administered diuretics ("water pills") can decrease swelling. Corticosteroids (such as prednisone) or the drug lidocaine can be injected directly into the wrist or taken by mouth (in the case of prednisone) to relieve pressure on the median nerve and provide immediate, temporary relief to persons with mild or intermittent symptoms. (Caution: persons with diabetes and those who may be predisposed to diabetes should note that prolonged use of corticosteroids can make it difficult to regulate insulin levels. Corticosterioids should not be taken without a doctor's prescription.) Additionally, some studies show that vitamin B6 (pyridoxine) supplements may ease the symptoms of carpal tunnel syndrome. Exercise - Stretching and strengthening exercises can be helpful in people whose symptoms have abated. These exercises may be supervised by a physical therapist, who is trained to use exercises to treat physical impairments, or an occupational therapist, who is trained in evaluating people with physical impairments and helping them build skills to improve their health and well-being. Alternative therapies - Acupuncture and chiropractic care have benefited some patients but their effectiveness remains unproved. An exception is yoga, which has been shown to reduce pain and improve grip strength among patients with carpal tunnel syndrome. 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. The 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. The surgeon makes two incisions (about " 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 twoportal endoscopic surgery, generally performed under local anesthesia, is effective and minimizes scarring and scar tenderness, if any. Single portal endoscopic surgery for carpal tunnel syndrome is also available and can result in less post-operative pain and a minimal scar. It generally allows individuals to resume some normal activities in a short period of time. 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.
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How can carpal tunnel syndrome be prevented?

At the workplace, workers can do on-the-job conditioning, perform stretching exercises, take frequent rest breaks, wear splints to keep wrists straight, and use correct posture and wrist position. Wearing fingerless gloves can help keep hands warm and flexible. Workstations, tools and tool handles, and tasks can be redesigned to enable the worker's wrist to maintain a natural position during work. Jobs can be rotated among workers. Employers can develop programs in ergonomics, the process of adapting workplace conditions and job demands to the capabilities of workers. However, research has not conclusively shown that these workplace changes prevent the occurrence of carpal tunnel syndrome.
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What research is being done?

The National Institute of Neurological Disorders and Stroke (NINDS), a part of the National Institutes of Health, is the federal government's leading supporter of biomedical research on neuropathy, including carpal tunnel syndrome. Scientists are studying the chronology of events that occur with carpal tunnel syndrome in order to better understand, treat, and prevent this ailment. By determining distinct biomechanical factors related to pain, such as specific joint angles, motions, force, and progression over time, researchers are finding new ways to limit or prevent carpal tunnel syndrome in the workplace and decrease other costly and disabling occupational illnesses. Randomized clinical trials are being designed to evaluate the effectiveness of educational interventions in reducing the incidence of carpal tunnel syndrome and upper extremity cumulative trauma disorders. Data to be collected from a National Institute for Occupational Safety and Health-sponsored study of carpal tunnel syndrome among construction workers will provide a better understanding of the specific work factors associated with the disorder, furnish pilot data for planning future projects to study its natural history, and assist in developing strategies to prevent its occurrence among construction and other workers. Other research will discern differences between the relatively new carpal compression test (in which the examiner applies moderate pressure with both thumbs directly

on the carpal tunnel and underlying median nerve, at the transverse carpal ligament) and the pressure provocative test (in which a cuff placed at the anterior of the carpal tunnel is inflated, followed by direct pressure on the median nerve) in predicting carpal tunnel syndrome. Scientists are also investigating the use of alternative therapies, such as acupuncture, to prevent and treat this disorder.
http://www.womenshealth.gov/faq/carpal-tunnel-syndrome.pdf

Carpal TunnelSyndrome
Q: What is carpal tunnel syndrome (CTS)? A: Carpal tunnel syndrome (CTS) is the name for a group of problems that includes swelling, pain, tingling, and loss of strength in your wrist and hand. Your wrist is made of small bones that form a narrow groove or carpal tunnel. Tendons and a nerve called the median nerve must pass through this tunnel from your forearm into your hand. The median nerve controls the feelings and sensations in the palm side of your thumb and fingers. Sometimes swelling and irritation of the tendons can put pressure on the wrist nerve causing the symptoms of CTS. A persons dominant hand is the one that is usually affected. However, nearly half of CTS sufferers have symptoms in both hands. CTS has become more common in the U.S. and is quite costly in terms of time lost from work and expensive medical treatment. The U.S. Department of Labor reported that in 2003 the average number of missed days of work due to CTS was 23 days, costing over $2 billion a year. It is thought that about 3.7 percent of the general public in this country suffer from CTS. Q: What are the symptoms of CTS? A: Typically, CTS begins slowly with feelings of burning, tingling, and numbness in the wrist and hand. The areas most affected are the thumb, index and middle fingers. At first, symptoms may happen more often at night. Many CTS sufferers do not make the connection between a daytime activity that might be causing the CTS and the delayed symptoms. Also, many people sleep with their wrist bent, which may cause more pain and symptoms at night. As CTS gets worse, the tingling may be felt during the daytime too, along with pain moving from the wrist to your arm or down to your fingers. Pain is usually felt more on the palm side of the hand.Another symptom of CTS is weakness of the hands that gets worse over time. Some people with CTS find it difficult to grasp an object, make a fist, or hold onto something small. The fingers may even feel like they are swollen even though they are not. Over time, this feeling will usually happen more often.If left untreated, those with CTS can have a loss of feeling in some fingers and permanent weakness of the thumb. Thumb muscles can actually waste away over time. Eventually, CTS sufferers may have trouble telling the difference between hot and cold temperatures by touch. Q: What causes CTS and who is more likely to develop it? A: Women are three times more likely to have CTS than men. Although there is limited research on why this is the case, scientists have several ideas. It may be that the wrist bones are naturally smaller in most women, creating a tighter space through which the nerves and tendons must pass. Other researchers are looking at genetic links that make it more likely for women to have muscu-loskeletal injuries such as CTS. Women also deal with strong hormonal changes
during pregnancy and menopause that make them more likely to suffer from CTS. Generally, women are at higher risk of CTS between the ages of 45 and 54. Then, the risk increases for both men and women as they age. There are other factors that can cause CTS, including certain health problems and, in some cases, the cause is unknown. These are some of the things that might raise your chances of developing CTS: Genetic predisposition. The carpal tunnel is smaller in some people than others. Repetitive Movements. People who do the same movements with their wrists and hands over and over may be more likely to develop CTS. People with certain types of jobs are more likely

to have CTS, including manufacturing and assembly line workers, grocery store checkers, violinists, and carpenters. Some hobbies and sports that use repetitive hand movements can also cause CTS, such as golfing, knitting, and gardening. Whether or not long-term typing or computer use causes CTS is still being debated. Limited research points to a weak link, but more research is needed. Injury or Trauma. A sprain or a fracture of the wrist can cause swelling and pressure on the nerve, increasing the risk of CTS. Forceful and stressful movements of the hand and wrist can also cause trauma, such as strong vibrations caused by heavy machinery or power tools. Pregnancy. Hormonal changes during pregnancy and build up of fluid can put pregnant women at greater risk of getting CTS, especially during the last few months. Most doctors treat CTS in pregnant women with wrist splits or rest, rather than surgery, as CTS almost always goes away following childbirth. Menopause. Hormonal changes during menopause can put women at greater risk of getting CTS. Also, in some postmenopausal women, the wrist structures become enlarged and can press on the wrist nerve. Breast Cancer. Some women who have a mastectomy get lymphedema, the build-up of fluids that go beyond the lymph system's ability to drain it. In mastectomy patients, this causes pain and swelling of the arm. Although rare, some of these women will get CTS due to pressure on the nerve from this swelling. Medical Conditions. People who have diabetes, hypothyroidism, lupus, obesity, and rheumatoid arthritis are more likely to get CTS. In some of these patients, the normal structures in the wrist can become enlarged and lead to CTS. Also, smokers with CTS usually have worse symptoms and recover more slowly than nonsmokers.

Q: How is CTS treated? A: It is important to be treated by a doctor for CTS in order to avoid permanent damage to the wrist nerve and muscles of the hand and thumb. Underlying causes such as diabetes or a thyroid problem should be addressed first. Left untreated, CTS can cause nerve damage that leads to loss of feeling and less hand strength. Over time,

the muscles of the thumb can become weak and damaged. You can even lose the ability to feel hot and cold by touch. Permanent injury occurs in about 1 percent of those with CTS. CTS is much easier to treat early on. Most CTS patients get better after first-step treatments and the following tips for protecting the wrist. Treatments for CTS include the following: Wrist Splint. A splint can be worn to support and brace your wrist in a neutral position so that the nerves and tendons can recover. A splint can be worn 24 hours a day or only at night. Sometimes, wearing a splint at night helps to reduce the pain. Splinting can work the best when done within three months of having any symptoms of CTS. Rest. For people with mild CTS, stopping or doing less of a repetitive movement may be all that is needed. Your doctor will likely talk to you about steps that you should take to prevent CTS from coming back. Medication. The short-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) may be helpful to control CTS pain. NSAIDs include aspirin, ibuprofen, and other non-prescription pain relievers. In severe cases, an injection of cortisone may help to reduce swelling. Your doctor may also give you corticosteroids in a pill form. But, these treatments only relieve symptoms temporarily. If CTS is caused by another health problem, your doctor will probably treat that problem first. If you have diabetes, it is important to know that long-term corticosteroid use can make it hard to control insulin levels. Physical Therapy. A physical therapist can help you do special exercises to make your wrist and hand stronger. There are also many different kinds of treatments that can make CTS better and help relieve symptoms. Massage, yoga, ultrasound, chiropractic manipulation, and acupuncture are just a few such options that have been found to be helpful. You should talk with your doctor before trying these alternative treatments. Surgery. CTS surgery is one of the most common surgeries done in the U.S. Generally, surgery is only an option for severe cases of CTS and/or after other treatments have failed for a period of at least six months. Open release surgery is a common approach to CTS surgery and involves making a small incision in the wrist or palm and cutting the ligament to enlarge the carpal tunnel. This surgery is done under a local anesthetic to numb the wrist and hand area and is an outpatient procedure.

Q: What is the best way to prevent CTS? A: Current research is focused on figuring out what causes CTS and how to prevent it. The National Institute of Neurological Disorders and Stroke (NINDS) and the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) support research on work-related factors that may cause CTS. Scientists are also researching better ways to detect and treat CTS, including alternative treatments such as acupuncture.

For more information on research, contact: NINDS at http://www.ninds.nih.gov or call 1-800-352-9424 NIAMS at http://www.niams.nih.gov or call 1-301-496-8190 or 1-877-226-4267 The following steps can help to prevent CTS: Prevent workplace musculoskeletal injury. Make sure that your workspace and equipment are at the right height and distance for your hands and wrist to work with less strain. If you are working on a computer, the keyboard should be at a height that allows your wrist to rest comfortably without having to bend at an angle. Desk or table workspace should be about 27 to 29 inches above the floor for most people. It also helps to keep your elbows close to your sides as you type to reduce the strain on your forearm. Keeping good posture and wrist position can lower your risk of getting CTS. Take Breaks. Allowing your hand and wrist to rest and recover every so often will lower your risk of swelling. Experts believe that taking a 10 to 15 minute break every hour is a good way to prevent CTS. Vary Tasks. Avoid repetitive movements without changing up your routine. Try to do tasks that use different muscle movements during each hour. Break up tasks that require repetitive wrist and hand motion with those that do not. Relax Your Grip. Sometimes, people get into a habit of tensing muscles without needing to. Practice doing hand and wrist motion tasks more gently and less tightly. Stress and tension play a role in muscle strain and irritation. Do exercises. After doing repetitive movements for a while, you can sometimes cancel out the effects of those movements by flexing and bending your wrists and hands in the opposite direction. For example, after typing with your wrist and hand extended, it is helpful to make a tight fist and hold it for a second, then stretch out the fingers and hold for a few seconds. Try repeating this several times. Stay Warm. Muscles that are warm are less likely to get hurt and the risk of getting CTS is greater in a cold environment. It is important to keep your hands warm while you work, even if you must wear fingerless gloves.

http://www.upmc.com/HealthAtoZ/patienteducation/Documents/CarpalTunnel.pdf Carpal tunnel syndrome is a common condition that affects the wrist and hand. It occurs when too much pressure is put on the median nerve. The median nerve runs through the wrist to the hand and fingers. It goes through a passage in the wrist bones called the carpal tunnel (see diagram below). Any swelling in this tunnel causes the nerve to become pinched. This causes the pain, numbness, and tingling related to carpal tunnel syndrome. If the pressure is not relieved, the symptoms may get worse.

Carpal tunnel syndrome may occur after a wrist fracture or injury that causes swelling. It also can occur with certain conditions that cause fluid to build up, such as diabetes, kidney disease, or pregnancy.

What are the symptoms of carpal tunnel syndrome?

pain, which usually starts in the hand but may travel up the arm to the shoulder numbness, tingling, or the feeling of pins and needles in the hand or fingers burning feeling in the hand or fingers tenderness in the wrist area swelling in the wrist area weakness or loss of strength in the hand

How is carpal tunnel syndrome treated?

Treatment depends on how bad your symptoms are. Your doctor will check you and decide what treatments would be most helpful to you. Treatments for carpal tunnel include: Wrist splints. Your doctor or therapist may prescribe wrist splints. Moving your hand and wrist up or down narrows the space in the carpal tunnel. This puts more pressure on the median nerve. Wrist splints help to reduce pressure by keeping your wrist in a relaxed position. Some splints are worn only at night. Others protect the wrist during work or other activities. Hand and wrist exercises. These exercises are prescribed by your doctor or a physical or occupational therapist. Medicine to reduce swelling. Your doctor may prescribe medicine to help reduce swelling. As swelling in the carpal tunnel goes down, pressure is relieved from the median nerve. Medicine injected into the wrist area. Steroids are medicines that can be injected into the wrist area to help bring down the swelling in the carpal tunnel. When there is less swelling, there is less pressure on the median nerve. Surgery

Carpal tunnel release surgery

Carpal tunnel release is an operation done to relieve the pressure on the median nerve. Usually people having this operation come in

for surgery and go home that same day. The surgery usually is done using a local anesthetic, which affects only the area of your wrist. This means you wont go to sleep for this operation. During the operation, a small cut (incision) is made. This incision is usually on the palm side of your hand in the wrist area (see diagram below). A ligament called the carpal transverse ligament is divided. This opens up the carpal tunnel, relieving pressure on the median nerve. The operation usually takes about an hour.

After surgery
Medicine. Your doctor may prescribe pain medicine and an antibiotic after surgery. Be sure to take these as directed. Elevation. Its important to keep your hand raised above the level of your heart as much as possible for the first 48 hours following surgery. This helps to reduce swelling and pain. Dressing. Unless instructed otherwise, keep the dressing over your incision clean and dry until your follow-up appointment with your doctor. Your doctor will remove the stitches under the dressing. Activity. Do not lift anything with the hand you had surgery on until your doctor says its OK. Be sure to move your fingers regularly. This will keep them from getting stiff and help lessen the swelling.

When to call the doctor

Call your doctor if any of the following occur: an increase in pain not relieved by pain medicine an increase in swelling not relieved by elevating your hand a large increase in the amount of drainage on your dressing an increase in the feeling of coolness or color changes in your fingers or fingertips a foul smell from the dressing chills or fever of 101 F or above Follow-up appointment: http://www.nejm.org/doi/full/10.1056/NEJMcp013018

This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the authors' clinical recommendations.

A 64-year-old, right-handed, retired woman presents with intermittent numbness, tingling, and burning pain in the three radial digits of both hands. She has had these symptoms for three months, and they awaken her several times each night. She has no atrophy of the thenar muscles. Sensation to light touch is intact. How should she be evaluated and treated?

The Clinical Problem

Hand, finger, or wrist symptoms account for 2.7 million office visits to physicians for new problems per year in the United States.1 The differential diagnosis of discomfort of the hand and wrist includes entrapments of the nerves (such as carpal tunnel syndrome, entrapment of the ulnar nerve, and cervical radiculopathy), tendon disorders, overuse of muscles, nonspecific pain syndromes, and less common disorders. The prevalence of electrophysiologically confirmed, symptomatic carpal tunnel syndrome is about 3 percent among women and 2 percent among men, with peak prevalence in women older than 55 years of age.2 The carpal tunnel (Figure 1Figure 1 The Anatomy of the Carpal Tunnel.) is located at the

base of the palm, just distal to the distal wrist crease. It is bounded on three sides by the carpal bones, which create an arch, and on the palmar side by the fibrous flexor retinaculum, or transverse carpal ligament. Nine flexor tendons (two extending to each finger and one to the thumb) traverse the carpal tunnel, along with the median nerve. Carpal tunnel syndrome is caused by elevated pressure in the carpal tunnel3; this increased pressure produces ischemia of the median nerve, resulting in impaired nerve conduction and attendant paresthesia and pain. Early in the course, no morphologic changes are observable in the median nerve, neurologic findings are reversible, and symptoms are intermittent. Prolonged or frequent episodes of elevated pressure in the carpal tunnel may result in segmental demyelination and more constant and severe symptoms, occasionally with weakness. When there is prolonged ischemia, axonal injury ensues, and nerve dysfunction may be irreversible.3,4 A variety of conditions may be associated with carpal tunnel syndrome. These include pregnancy, inflammatory arthritis, Colles' fracture, amyloidosis, hypothyroidism, diabetes mellitus, acromegaly, and use of corticosteroids and estrogens.5,6 Up to one third of cases of carpal tunnel syndrome occur in association with such medical conditions7; about 6 percent of patients have diabetes.6 Carpal tunnel syndrome is also associated with repetitive activities of the hand and wrist, particularly with a combination of forceful and repetitive activities.8-10 Occupations associated with a high incidence of carpal tunnel syndrome include food processing, manufacturing, logging, and construction work.8,11 The natural history of carpal tunnel syndrome is variable. One 11-year study of workers with carpal tunnel syndrome showed that, although abnormalities of nerve conduction tend to worsen over time, the prevalence of carpal-tunnel symptoms diminishes.12

Strategies and Evidence

Diagnosis
A combination of electrodiagnostic studies (nerve-conduction studies and electromyography) and knowledge of the location and type of symptoms permits the most accurate diagnosis of carpal tunnel syndrome.13 Symptoms consistent with carpal tunnel syndrome occur in up to 15 percent of the population,2 and false negative14 and false positive15,16 results on electrodiagnostic testing have been well documented. Hence, both symptoms and electrodiagnostic studies must be interpreted carefully. Electrodiagnostic studies are most useful for confirming the diagnosis in suspected cases and ruling out neuropathy and other nerve entrapments.

History
Carpal tunnel syndrome generally produces pain, tingling, burning, numbness, or some combination of these symptoms on the palmar aspect of the thumb, index finger, middle finger, and radial half of the ring finger. Patients often report only on detailed questioning that no such symptoms affect the fifth finger. A diagram of symptoms in the hand can help patients to localize symptoms. A diagram of symptoms rated as classic or probable carpal tunnel syndrome according to a standard rating system had a sensitivity of 61 percent and a specificity of 71 percent for the diagnosis of carpal tunnel syndrome in a clinic-based sample.17 The sensitivity was lower and the specificity higher when the diagram was used to screen workers for carpal tunnel syndrome.18 A history of nocturnal symptoms has moderate sensitivity (51 to 77 percent) and specificity (27 to 68 percent).19 Often, patients report that they shake the symptomatic hand or hands when symptoms are at their worst. This response, the flick sign, had both a sensitivity and a specificity that exceeded 90 percent in one study,20 but it has not been evaluated further.

Physical Examination
Loss of two-point discrimination in the median-nerve distribution (inability to distinguish between one sharp point on the fingertip and two) as well as thenar atrophy occur late in the course of carpal tunnel syndrome. These signs have low sensitivity and high specificity.17,19 Tests of the patient's ability to perceive varying degrees of vibratory stimulation21 and direct pressure on the pulp of the finger22 in the median-nerve distribution are technically demanding and have moderate sensitivity and specificity. Several provocative tests may assist in the diagnosis. In Phalen's maneuver, the patient reports whether flexion of the wrist for 60 seconds elicits pain or paresthesia in the median-nerve distribution.23 Studies of Phalen's maneuver report a wide range of values for sensitivity and specificity, from 40 to 80 percent.17,19,21,22,24 Tinel's sign is judged to be present if tapping lightly over the volar surface of the wrist causes radiating paresthesia in the digits innervated by the median nerve.22,23 The sensitivity of Tinel's sign ranges from 25 to 60 percent, although its specificity is higher (67 to 87 percent).17,19,21,22,24 In the pressure provocation test,25 the examiner's thumb is pressed over the carpal tunnel for 30 seconds. In the tourniquet test, a bloodpressure cuff is inflated around the arm to above systolic pressure for 60 seconds. Both tests are deemed positive if they elicit radiating paresthesia in the median-nerve distribution. Estimates of sensitivity and specificity for both of these tests vary widely.20,26

Since findings on physical examination and the history have limited diagnostic value, they are most useful when there is a reasonable clinical suspicion of carpal tunnel syndrome (as when a patient presents with hand symptoms). The history and physical examination have poor predictive value when the likelihood of carpal tunnel syndrome is low (as it is among participants in population-based or workplace screening programs).17

Treatment Treating Associated Conditions

When carpal tunnel syndrome arises from rheumatoid arthritis or other types of inflammatory arthritis, treatment of the underlying condition generally relieves carpal-tunnel symptoms. Treatment of other associated conditions (such as hypothyroidism or diabetes mellitus) is also appropriate, although data are lacking on whether such treatment alleviates carpal tunnel syndrome. Similarly, it is not known whether stopping medications associated with carpal tunnel syndrome (such as corticosteroids or estrogen) leads to improvement, although taking such a step is also reasonable in the absence of contraindications.

Splinting
More than 80 percent of patients with carpal tunnel syndrome report that a wrist splint alleviates symptoms,27 generally within days. Splinting also reduces sensory latency,28 suggesting that the intervention may alter the underlying course of carpal tunnel syndrome. Splints are more effective if they maintain the wrist in neutral posture rather than in extension.27 Commercially available splints are acceptable, provided that they maintain such a neutral position.

Medications
Nonsteroidal antiinflammatory medications, diuretics, and pyridoxine (vitamin B6) have each been studied in small, randomized trials, with no evidence of efficacy. One four-week randomized trial involving 91 patients had four treatment groups; one group received placebo, one received nonsteroidal antiinflammatory medication, one received a diuretic, and one received 20 mg of prednisolone daily for two weeks followed by 10 mg daily for another two weeks. The prednisolone group had a substantial reduction in symptoms, whereas the outcomes in the other medication groups did not differ from those in the placebo group.29 In this small study, patients were not followed after the four-week course of treatment ended, nor did the study address the dose of corticosteroids needed to maintain a response. There were essentially no toxic effects of corticosteroids in this short-term trial, although risks including weight gain, hypertension, and hyperglycemia are recognized even with short-term treatment. Apart from this small, short-term study, there have been no other placebo-controlled trials of nonsteroidal antiinflammatory medications.

Local Corticosteroid Injection

Patients who remain symptomatic after modification of their activities and splinting are candidates for injection of corticosteroids into the carpal tunnel. A 25-gauge needle may be used

to inject 1 ml of 1 percent lidocaine just to the ulnar side of the palmaris longus tendon, proximal to the wrist crease. The needle is aimed toward the carpal tunnel at a 30-degree angle of entry. If there is no paresthesia on injection of a small amount of lidocaine, the rest of the lidocaine is injected followed by the depot corticosteroid. Injection of corticosteroids is superior to injection of placebo,30,31 improving symptoms in more than 75 percent of patients.30,32-34 Local injection of corticosteroids is also associated with improvement in median-nerve conduction.30,33,34 Symptoms generally recur within one year.30,32 Risk factors for recurrence include severe abnormalities on electrodiagnostic testing, constant numbness, impaired sensibility, and weakness or thenar muscular atrophy.30,32,34 The risks of infection and nerve damage resulting from corticosteroid injection are considered to be low but have not been formally studied. Many clinicians limit the number of injections into the carpal tunnel (as they would for other sites) to about three per year in order to minimize local complications (such as rupture of tendons and irritation of the nerves) and the possibility of systemic toxic effects (such as hyperglycemia or hypertension). The optimal number of injections per year has not been studied. Preliminary data suggest that iontophoresis with corticosteroid cream (a method that involves the use of an electrical current to deliver medication to deeper structures) may provide an alternative to corticosteroid injection.35 In general, conservative treatment is more successful in patients with mild nerve impairment. In one study,32 89 percent of patients with severe carpal tunnel syndrome (constant numbness with weakness, atrophy, or sensory loss) had recurrence of the syndrome within one year after a conservative program that included splinting and injection of corticosteroids into the carpal tunnel. Among patients with mild carpal tunnel syndrome (intermittent numbness and normal sensory and motor findings on physical examination), 60 percent had recurrence of symptoms after such conservative treatment.

Surgery
In general, the decision about whether to proceed with carpal-tunnelrelease surgery should be driven by the preference of the patient. However, if a patient has symptoms and signs that are suggestive of axonal loss constant numbness, symptoms for more than one year, loss of sensibility, and thenar muscular atrophy or weakness surgery should be seriously considered. There are several surgical approaches to carpal-tunnel release. In the traditional open procedure, the surgeon makes an incision 5 to 6 cm long, extending distally from the distal wrist crease, and releases the transverse carpal ligament under direct visualization. For endoscopic release, a device with either two portals36 or one portal37 is used to release the transverse carpal ligament. The endoscopic techniques carry a higher risk than open carpal-tunnel release of injury to the median nerve.37-39 Relief of symptoms is similar with the open and the endoscopic procedures,37,38 and many studies report that patients return to work earlier after the endoscopic surgery.37-39 In recent years, many surgeons have adopted a mini-open release that uses an incision of 2.0 to 2.5 cm to release the transverse carpal ligament under direct visualization. This approach is used in an attempt to achieve earlier recovery while avoiding the complications associated with the

endoscopic approach.40 The efficacies of the mini-open, endoscopic, and traditional open techniques have not been compared in an adequately powered randomized trial. More than 70 percent of patients report being completely satisfied or very satisfied with the results of carpal-tunnel surgery (irrespective of whether they have undergone open or endoscopic surgery).41 Similarly, 70 to 90 percent of subjects report being free of nocturnal pain after surgery.38,41 There have been no randomized controlled trials comparing carpal-tunnel release with conservative therapy. After surgery, pain relief occurs within days, but hand strength does not reach preoperative levels for several months.42 Tenderness of the surgical scar may also persist for up to a year after open release.41 Patients with better general functional status and mental health have more favorable outcomes after carpal-tunnel release.41,43 Among workers undergoing carpal-tunnel release, involvement of an attorney (generally to dispute a decision about a workers' compensation claim) is associated with a worse surgical outcome.43 Also, workers with less striking abnormalities on electrodiagnostic testing have worse outcomes.44 This somewhat paradoxical finding may reflect the inclusion of cases in which symptoms arise from other disorders of the arm or hand, underscoring the importance of careful selection of patients for surgery.

Alternative Therapies
Acupuncture for carpal tunnel syndrome has not been evaluated in controlled studies. In a randomized trial, an intervention involving yoga-based stretching, strengthening, and relaxation in patients with carpal tunnel syndrome resulted in greater improvement in grip strength and reduction of pain than did splinting.45 In one study, chiropractic therapy for carpal tunnel syndrome was as effective for pain as splints and medication,46 but data are limited.

Areas of Uncertainty
The benefit of modifying the patient's activities remains uncertain. It is reasonable to suggest that patients minimize forceful hand and wrist activities at home and work, since these activities increase carpal-tunnel pressure in patients with carpal tunnel syndrome,47 and that patients minimize any activities that exacerbate their symptoms. The effects of ergonomically designed equipment and frequent rest breaks on the incidence and course of carpal tunnel syndrome have not been studied rigorously. Rigorous studies are also needed to define the effectiveness of various medications, acupuncture, dietary supplements, chiropractic, and yoga, as well as the optimal timing of carpal-tunnel surgery and the results of carpal-tunnel release with a miniopen incision.

Guidelines
The Clinical Guideline on Wrist Pain from the American Academy of Orthopedic Surgeons recommends that patients with suspected carpal tunnel syndrome modify their activities for two to six weeks while they are treated with wrist splints and nonsteroidal antiinflammatory medication. If these therapies are ineffective, or if the patient has thenar-muscle atrophy or weakness, the guidelines recommend referral to a specialist for consideration of injection or

surgery.48 The practice guidelines of the American College of Occupational and Environmental Medicine49 suggest a similar approach and emphasize the importance of avoiding occupational activities that cause bothersome symptoms.

Conclusions and Recommendations

Patients with discomfort of the hand and wrist, such as the woman described in the vignette, should be evaluated with a detailed history of symptoms (which can be facilitated with a diagram of hand pain) and a physical examination that includes tests of sensory and motor-nerve function and provocative maneuvers. Findings on such examination have limited diagnostic value, however, and will not establish the diagnosis with certainty. If carpal tunnel syndrome seems likely, conservative management with splinting should be initiated. If splinting causes discomfort during the performance of some hand-intensive tasks, it is advisable either to avoid the activity or to perform it without the splint. We suggest that patients reduce activities at home and work that exacerbate symptoms. Although the effects of nonsteroidal antiinflammatory medications on carpal tunnel syndrome have not been well studied, we generally suggest a trial of these agents if there are no contraindications. We do not recommend use of vitamin B6 (because there is no evidence of efficacy) or oral corticosteroids (given the potential for toxic effects). We generally screen for and treat common underlying disorders specifically, diabetes and hypothyroidism. If the condition fails to improve, we recommend referral to a specialist with expertise in the diagnosis and management of carpal tunnel syndrome. If the diagnosis appears secure, the clinician should discuss the options of corticosteroid injection and surgical therapy with the patient. Injection is especially effective if there is no loss of sensibility or thenar-muscle atrophy and weakness and if symptoms are intermittent rather than constant. We perform electrodiagnostic studies if the diagnosis is uncertain, particularly if surgery is contemplated. For surgically treated patients, we favor the limited open incision for carpal-tunnel release. http://www.mayoclinic.com/health/carpal-tunnel-syndrome/DS00326 Definition By Mayo Clinic staff Carpal tunnel syndrome is a progressively painful hand and arm condition caused by a pinched nerve in your wrist. A number of factors can contribute to carpal tunnel syndrome, including the anatomy of your wrist, certain underlying health problems and possibly patterns of hand use. Bound by bones and ligaments, the carpal tunnel is a narrow passageway about as big around as your thumb located on the palm side of your wrist. This tunnel protects a main nerve to your hand and nine tendons that bend your fingers. Compression of the nerve produces the numbness, pain and, eventually, hand weakness that characterize carpal tunnel syndrome. Fortunately, for most people who develop carpal tunnel syndrome, proper treatment usually can relieve the pain and numbness and restore normal use of their wrists and hands.

Causes By Mayo Clinic staff Carpal tunnel syndrome occurs as a result of compression of the median nerve. The median nerve runs from your forearm through a passageway in your wrist (carpal tunnel) to your hand. It provides sensation to the palm side of your thumb and fingers, with the exception of your little finger. It also provides nerve signals to move the muscles around the base of your thumb (motor function). In general, anything that crowds, irritates or compresses the median nerve in the carpal tunnel space can lead to carpal tunnel syndrome. For example, a wrist fracture can narrow the carpal tunnel and irritate the nerve, as can the swelling and inflammation resulting from rheumatoid arthritis. In many cases, no single cause can be identified. It may be that a combination of risk factors contributes to the development of the condition. Risk factors By Mayo Clinic staff A number of factors have been associated with carpal tunnel syndrome. Although by themselves they don't cause carpal tunnel syndrome, they may increase your chances of developing or aggravating median nerve damage. These include:

Anatomic factors. A wrist fracture or dislocation that alters the space within the carpal tunnel can create extraneous pressure on the median nerve. Also, carpal tunnel syndrome is generally more common in women. This may be because the carpal tunnel area is relatively smaller than in men and there's less room for error. Women who have carpal tunnel syndrome may also have smaller carpal tunnels than women who don't have the condition. Nerve-damaging conditions. Some chronic illnesses, such as diabetes and alcoholism, increase your risk of nerve damage, including damage to your median nerve. Inflammatory conditions. Illnesses that are characterized by inflammation, such as rheumatoid arthritis or an infection, can affect the tendons in your wrist, exerting pressure on your median nerve. Alterations in the balance of body fluids. Certain conditions such as pregnancy, menopause, obesity, thyroid disorders and kidney failure, among others can affect the level of fluids in your body. Fluid retention common during pregnancy, for example may increase the pressure within your carpal tunnel, irritating the median nerve. Carpal tunnel syndrome associated with pregnancy generally resolves on its own after the pregnancy is over.

Workplace factors. It's possible that working with vibrating tools or on an assembly line that requires prolonged or repetitive flexing of the wrist may create harmful pressure on the median nerve, or worsen existing nerve damage. But the scientific evidence is conflicting and these factors haven't been established as direct causes of carpal tunnel syndrome. There is little evidence to support extensive computer use as a risk factor for carpal tunnel syndrome, although it may cause a different form of hand pain.

Tests and diagnosis

By Mayo Clinic staff

Your doctor may conduct one or more of the following tests to determine whether you have carpal tunnel syndrome:

History of symptoms. The pattern of your signs and symptoms may offer clues to their cause. For example, since the median nerve doesn't provide sensation to your little finger, symptoms in that finger may indicate a problem other than carpal tunnel syndrome. Another clue is the timing of the symptoms. Typical times when you might experience symptoms due to carpal tunnel syndrome include while holding a phone or a newspaper, gripping a steering wheel, or waking up during the night. Physical exam. Your doctor will want to test the feeling in your fingers and the strength of the muscles in your hand, because these can be affected by carpal tunnel syndrome. Pressure on the median nerve at the wrist, produced by bending the wrist, tapping on the nerve or simply pressing on the nerve, can bring on the symptoms in many people. X-ray. Some doctors may recommend an X-ray of the affected wrist to exclude other causes of wrist pain, such as arthritis or a fracture. Electromyogram. Electromyography measures the tiny electrical discharges produced in muscles. A thin-needle electrode is inserted into the muscles your doctor wants to study. An instrument records the electrical activity in your muscle at rest and as you contract the muscle. This test can help determine if muscle damage has occurred. Nerve conduction study. In a variation of electromyography, two electrodes are taped to your skin. A small shock is passed through the median nerve to see if electrical impulses are slowed in the carpal tunnel.

The electromyogram and nerve conduction study tests are also useful in checking for other conditions that might mimic carpal tunnel syndrome, such as a pinched nerve in your neck. Your doctor may recommend that you see a rheumatologist, neurologist, hand surgeon or neurosurgeon if your signs or symptoms indicate other medical disorders or a need for specialized treatment. Treatments and drugs

By Mayo Clinic staff CLICK TO ENLARGE Carpal tunnel release

Some people with mild symptoms of carpal tunnel syndrome can ease their discomfort by taking more-frequent breaks to rest their hands and applying cold packs to reduce occasional swelling. If these techniques don't offer relief within a few weeks, additional treatment options include wrist splinting, medications and surgery. Splinting and other conservative treatments are more likely to help you if you've had only mild to moderate symptoms for less than 10 months. Nonsurgical therapy If the condition is diagnosed early, nonsurgical methods may help improve carpal tunnel syndrome. Methods may include:

Wrist splinting. A splint that holds your wrist still while you sleep can help relieve nighttime symptoms of tingling and numbness. Nocturnal splinting may be a good option if you are pregnant and have carpal tunnel syndrome. Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs may help relieve pain from carpal tunnel syndrome in the short term. There's no evidence, though, that these drugs can actually improve the carpal tunnel syndrome itself. Corticosteroids. Your doctor may inject your carpal tunnel with a corticosteroid, such as cortisone, to relieve your pain. Corticosteroids decrease inflammation and swelling, which relieves pressure on the median nerve. Oral corticosteroids aren't considered as effective as corticosteroid injections for treating carpal tunnel syndrome.

If carpal tunnel syndrome results from an inflammatory arthritis, such as rheumatoid arthritis, then treating the underlying condition may reduce symptoms of carpal tunnel syndrome, but this hasn't been proved. Surgery If your symptoms are severe or persist after trying nonsurgical therapy, surgery may be the best option. The goal of carpal tunnel surgery is to relieve pressure on your median nerve by cutting the ligament pressing on the nerve. During the healing process after the surgery, the ligament tissues gradually grow back together while allowing more room for the nerve than existed before. The surgery may be done a couple of different ways. Either technique has risks and benefits that are important to discuss with your surgeon before surgery.

Endoscopic surgery. Carpal tunnel surgery can be done using an endoscope, a telescopelike device with a tiny camera attached to it that allows your doctor to see inside your carpal tunnel and perform the surgery through small incisions in your hand or wrist. Open surgery. In other cases, surgery involves making a larger incision in the palm of your hand over the carpal tunnel and cutting through the ligament to free the nerve.

In general, your doctor will encourage you to use your hand after surgery, gradually working back to normal use of your hand while avoiding forceful hand motions or extreme positions of your wrist. Soreness or weakness may take from several weeks to as long as a few months to resolve after surgery. If your symptoms were very severe before surgery, symptoms may not go away completely after surgery. Lifestyle and home remedies By Mayo Clinic staff These steps may help you gain at least temporary relief from your symptoms:

Take quick breaks from repetitive activities involving the use of your hands. Rotate your wrists and stretch your palms and fingers. Take a pain reliever, such as aspirin, ibuprofen (Advil, Motrin, others) or naproxen (Aleve, others). Try wearing a wrist splint at night. Wrist splints are generally available over-the-counter at most drugstores or pharmacies. The splint should be snug but not tight. Avoid sleeping on your hands to help ease the pain or numbness in your wrists and hands.

If pain, numbness or weakness recurs and persists, see your doctor. Alternative medicine By Mayo Clinic staff Alternative forms of therapy can be integrated into your regular health plan to help you deal with the signs and symptoms of carpal tunnel syndrome. You may have to experiment to find a treatment that works for you. Still, always check with your doctor before trying any complementary or alternative treatment.

Yoga. Yoga postures designed for strengthening, stretching and balancing each joint in the upper body, as well as the upper body itself, may help reduce the pain and improve the grip strength of people with carpal tunnel syndrome.

Hand therapy. Preliminary evidence suggests that certain physical and occupational hand therapy techniques may help improve symptoms of carpal tunnel syndrome. Ultrasound therapy. High-intensity ultrasound can be used to raise the temperature of a targeted area of body tissue to reduce pain and promote healing. A course of ultrasound therapy over several weeks may help improve the symptoms of carpal tunnel syndrome.

Prevention
By Mayo Clinic staff

There are no proven strategies to prevent carpal tunnel syndrome, but you can minimize stress on your hands and wrists by taking the following precautions:

Reduce your force and relax your grip. Most people use more force than needed to perform many tasks involving their 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. Give your hands and wrists a break by gently stretching and bending them periodically. 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.

http://www.post-polio.org/edu/pphnews/PPHsp07p3-5.pdf http://www.womenshealth.gov/faq/carpal-tunnel-syndrome.pdf http://www.upmc.com/HealthAtoZ/patienteducation/Documents/CarpalTunnel.pdf http://www.nejm.org/doi/full/10.1056/NEJMcp013018

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