CARPAL TUNNEL SYNDROME CTS
 
Carpal Tunnel Syndrome CTS
What is it?
Carpal Tunnel Syndrome or CTS is a condition in which the Median nerve is squashed in the wrist producing symptoms such as pins and needles, numbness, and aching pain in the fingers and thumb. The thumb, index, middle and part of the ring finger are affected. It does not affect the little finger. In some cases it affects both hands at the same time but usually this is because of another underlying condition. 

The tunnel is sandwiched between the small wrist carpal bones on one side and a very strong transverse ligament on the other. The median nerve shares the space inside the tunnel with other structures, such as finger and thumb tendons, so they are competing with each other for limited space.

The symptoms usually start off mild but over time increase in severity making it difficult to hold a phone, carry bags, reach to a high shelf, read a book, drive a car, and use a keyboard.  

Carpal Tunnel Syndrome is more common in women than men and this may be because the tunnel is smaller in women. Women are prone to developing CTS during pregnancy making caring for a baby very difficult afterwards. (see De-Quervain's tendonitis for thumb pain)

Most people feel relief from shaking out the hand(s) and notice they wake at night or morning with numb and/or painful symptoms eased by shaking and changing position of the wrists.
Carpal Tunnel Syndrome CTS
Causes
There is no main cause and in most cases it is as a result of multiple factors. In some cases the problem is not in the wrist at all but due to compression on the nerve at some other location closer to the neck.

The most common risk factors are:

Anatomic factors. A wrist fracture or dislocation, or arthritis that deforms the small bones in the wrist, can alter the space within the carpal tunnel and put pressure on the median nerve.

People with smaller carpal tunnels may be more likely to have carpal tunnel syndrome.

Nerve-damaging conditions. Some chronic illnesses, such as diabetes, increase your risk of nerve damage, including damage to your median nerve.

Inflammatory conditions. Illnesses that are characterised by inflammation, such as rheumatoid arthritis, can affect the lining around the tendons in your wrist and put pressure on your median nerve.

Obesity. Being obese is a significant risk factor for carpal tunnel syndrome.

Fluid retention. Fluid retention may increase the pressure within your carpal tunnel, irritating the median nerve. This is common during pregnancy and menopause. 

Workplace factors. There are three main positions increasing risk: 
  1. Working in an assembly line that requires prolonged or repetitive flexing of the wrist
  2. Office workers who have prolonged or repetitive wrist extension on a keyboard or mouse
  3. Using vibrating tools
These create harmful pressure on the median nerve or worsen existing nerve damage.
Carpal Tunnel Syndrome CTS
How is it diagnosed?
Symptoms of pins and needles , numbness and pain on the palm side of the thumb, index, middle and part of the ring finger means there is compression on the median nerve. Night waking, poor grip strength, electric shocks in the fingers, pain moving up through the arm, and in severe cases, loss of muscles that move the thumb, are all symptoms of CTS. 

An assessment which traces the nerve will help to find the source of the compression (where the nerve is squashed or pinched).

This may involve a simple tapping on the nerve to see where it is easily triggered (Tinel's sign), and/or by bending the wrist fully (Phalen's test) and/or elevating the arm in a certain position to place tension on the nerve. 

These tests can help to raise a suspicion about the diagnosis but if unclear or if there is any doubt about the cause of the symptoms or if disc problems or arthritis of the neck are suspected, a Nerve Conduction Study can be performed in a hospital.

Carpal Tunnel Syndrome CTS
Complications
Symptoms are usually mild to begin with and are associated with certain activities. Over time the symptoms last longer and become more severe lasting all night and all day. 

Left untreated compression on the median nerve can have serious consequences for thumb pinching muscles which lose signals from the weakened nerve and start to waste away (called atrophy).

In other situations the nerve may be compressed at more that one location and this is called double crush syndrome. Pain that is shooting up or down the arm from the neck may be a sign of compression closer to the cervical spine as well as in the carpal tunnel. 

CTS can lead to changes in a persons temperament as coping with pain and sleep disturbance can increase stress and frustration and cause missed days off work. It is important to discuss these feelings with a support person and make enquiries about CTS treatment options available to you. Fibromyalgia also has symptoms of sleep disturbance and pain in the arm and hand. People with fibromyalgia show a higher risk of developing CTS and double crush syndrome.
Carpal Tunnel Syndrome CTS
Treatment
It is important to treat carpal tunnel syndrome as early as possible after symptoms start.

Begin by taking more frequent breaks to rest your hands. Avoiding activities that worsen symptoms such as those that require repetitive wrist movements in flexion or extension. Apply cold packs to reduce any swelling on the palm side of the wrist if you notice swelling there.

The most effective treatment depends on your individual symptoms and how long your symptoms have been present. Early recognition of CTS and treatment with non-surgical methods is very effective within the first 10-12 months. This is known as conservative treatment

Conservative treatment involves:

Wrist splints worn at night while sleeping for 6-8 weeks and for selected (provoking) activities during the day can immediately reduce pins and needles ( Night time splinting may be a good option if you're pregnant and can't take medication). Changing how activities are performed by modifying certain aspects of them will ensure the condition does not recur.

Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs, such as ibuprofen, may help relieve pain from carpal tunnel syndrome in the short term.

Injection therapy - Corticosteroids. Your doctor may inject your carpal tunnel with a corticosteroid such as cortisone to relieve pain. This is best performed when the doctor can see into the carpal tunnel using ultrasound to guide the needle. Wearing a wrist splint immediately afterwards can help the steroid to soak into the wrist for a better result.

Injection therapy is not for everyone and in some cases it is contraindicated (the risk of side affects too high). 
If your GP recommends injection therapy the waiting time for this is very long. Enquire about conservative treatment using wrist splints and activity modification and ask to see a Hand therapist. At the very least it will help prevent the condition worsening while you wait for injection therapy or surgery.

Surgery:

Surgery may be appropriate if your symptoms are severe or don't respond to other treatments.

The goal of carpal tunnel surgery is to relieve pressure by cutting or stretching the transverse ligament pressing on the median nerve or making space inside the tunnel. 
Carpal Tunnel Syndrome CTS
What can Hand Kinetics do?
Please note:
If you have had arm or hand surgery please telephone to discuss this before attending. It is always helpful to bring any reports you may have if you recently attended hospital for your hand or arm condition.

Pressure can be removed from the median nerve using non surgical methods in most cases if treated early. This is called conservative management and is what we focus on at Hand Kinetics. We can assess your symptoms and devise a treatment plan with you which takes into consideration whether both sensory and motor parts of the nerve are affected.

Intervention usually requires making you a tailor made night resting splint worn for approximately 6-8 weeks while sleeping and also a wrist support for selected activities during the day. 

Your therapist can help you to identify any provoking activities you are doing so you know when to wear your wrist splint during the day. For some activities you may only need to make a small modification which will greatly improve the speed of healing and prevent recurrence when treatment has finished.

At Hand kinetics you will be shown how to safely exercise your wrists to keep your tendons and nerves gliding freely inside the tunnel so they don't get caught or stuck.

If you require additional support for your wrist or if your wrist is swollen we can teach you how to apply Kinesio tape to help with this.

If you have already had surgery and would like to know how to care for your new scar we can show you how.


Hand Kinetics Telephone: 0044 28 417 72301
www.handkinetics.com
contactus@handkinetics.com



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