Carpal Tunnel Syndrome


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Carpal Tunnel Syndrome

  1. 1. Hand Clin 18 (2002) 279–289 Nonoperative carpal tunnel syndrome treatment A. Lee Osterman, MDa,b, Marc Whitman, PTc,1, Linda Della Porta, OTR, CHTc,2,* a Philadelphia Hand Center, 834 Chestnut street, Philadelphia, PA, USA b Department of Orthopedic and Hand Surgery, Thomas Jefferson University Hospital, USA c Recipient of the Evelyn J Mackin Hand Therapy Fellowship, 834 Chestnut Street, Philadelphia, PA, USA Carpal tunnel syndrome (CTS) has been cited As CTS continues to manifest itself as a signifi- as the most common of the upper extremity com- cant economic and debilitating entity, it will be pression neuropathies [1–3]. A recent study exam- more important to research and develop treatment ined the prevalence osf CTS in a Swedish general approaches. We believe that nonoperative treat- population. The authors found, in a population ment is a viable option for the management of of 170,000, self-reported sensory changes and/or CTS. The following discussion will explore the pain in the median nerve (MN) distribution in various treatment options presented in the litera- 14.4%, clinical and electrophysiologically con- ture and the rationale behind their use. firmed CTS in 2.7% [4]. Among workers, the inci- Why choose nonsurgical treatments? There are dence of CTS, based on claim data, was reported several reasons: as 24.5 per 10,000 full-time employees in Washing- 1. Conservative management can cost less than ton State [5]. In addition, the Bureau of Labor surgical management. In California (1993), Statistics (BLS) reported 1,702,500 work-related the average cost of surgical intervention was injuries involving time away from work, and of $20,925, as compared with $5,246 for nonop- those 27,900 cases or 1.6% were CTS [6]. erative intervention [8]. In terms of cost and time away from work, CTS 2. Various nonsurgical treatments for CTS have has resulted in lost revenue for the employer and been shown to ameliorate symptoms in 13– employee. The BLS considers median days away 92% of patients [3,9–16]. These studies docu- from work a key indicator as to the severity of ment that conservative management is occupational injury. In 1999, CTS required the effective. highest time away at 27 days, followed by fracture 3. There is a population of CTS patients that is (20 days) and amputations (18 days) [7]. In Wash- appropriate for conservative treatment ington State, there were 27,148 claims filed for [17,18]. Patients with carpal tunnel symptoms CTS at an average cost of $12,627 per claim can generally be categorized based on chron- between 1992 and 1998 [5]. This resulted in more icity and severity of signs and symptoms. than $300,000,000 for the management of CTS [1,19,20]. Those patients with underlying sys- and may not include other costs such as litigation, temic disease or severe changes indicative of lost productivity, lost wages, or retraining. MN compromise need surgical decompres- sion or further medical management [18,21]. But as recommended by several authors * Corresponding author. [10,11,13,14,22], conservative treatment is E-mail address: (L. Della Porta). indicated for mild to moderate symptoms 1 Present address: P.O. Box 112192, Anchorage, AK with early intervention generally more predic- 99511-2192 tive of satisfactory outcomes. 2 Present address: 56 Parkton Road #1, Jamaica 4. It has been speculated [16] that many patients Plain, MA 02130 with the signs and symptoms of CTS are now 0749-0712/02/$ - see front matter Ó 2002, Elsevier Science (USA). All rights reserved. PII: S 0 7 4 9 - 0 7 1 2 ( 0 2 ) 0 0 0 2 3 - 9
  2. 2. 280 A.L. Osterman et al / Hand Clin 18 (2002) 279–289 seeking treatment earlier caused by the tunnel of the wrist. Currently, there is a debate improved access to information by various regarding whether ischemia or mechanical forces media sources. If this is the case, then nonsur- exerts the greatest impact on changes to the MN gical intervention will continue to be instru- [17,19,22–26]. Controversy also exists about the mental in treatment of this condition. role of inflammation. Although tissue studies do 5. Finally, as with any surgery, there are risks not support inflammation as a precursor to CTS associated with the procedure to release the [27,28], strategies to ‘‘reduce inflammation’’ have carpal tunnel. These include infection, stiff- been used with some success [29,30]. CTS is ness, reflex sympathetic dystrophy, and nerve regarded as a multifaceted syndrome, and causal- or tendon injury [19], which makes nonoper- ity is largely unknown. It has been associated, ative management a more appealing first line however, with various conditions that can pre- of treatment. dispose individuals to its development. These conditions are as follows: 1) acute trauma, We are not advocating that surgical interven- 2) endocrine disorders, 3) inflammatory arthritis, tion for CTS is unncessary or warranted, but, 4) chronic renal failure, 5) pregnancy, 6) mass potentially, surgery may be avoided and overall lesions within the carpal canal, 7) occupational/ cost and time away from work may be reduced recreational factors, 8) lifestyle, 9) traction injury, through the use of nonoperative treatment strat- and 10) double crush [1,31–33]. The development egies if applied consistently and early in the course of this neuropathy can also occur for seemingly of treatment (see Box 1). no reason at all and is thus labeled ‘‘idiopathic carpal tunnel syndrome.’’ Overview CTS generally is considered a compressive neu- Treatment ropathy of the MN as it courses through the carpal The first course of treatment for CTS generally consists of prescribed medication consisting of nonsteroidal anti-inflammatory drugs (NSAIDs) Box 1 Current nonoperative and/or steroids that can be delivered orally or by treatment injection. The action of these medications is to inhibit the chemical mediators of inflammation in Medicinal response to injury. By limiting the inflammatory • NSAIDs response, they also suppress pain by desensitizing • Steroids nociceptors to these same chemicals [34]. The effec- Injectible tiveness of NSAIDs versus steroids for treatment Oral of CTS was examined in a 1998 study. In a 4-week trial evaluating effect of medication as the sole • Pyridoxine (B6) treatment short-term, low-dose oral steroids were Modalities more effective than NSAIDs, diuretics, and pla- • Ultrasound cebo [35]. This was supported in another study, • Iontophoresis which also found low-dose, short-term oral ste- roids more effective than placebo only. This trial Splinting period was 8 weeks, however, and demonstrated Activity modification that the initial improvement provided by the ste- • Ergonomic intervention roid was temporary with a return in symptoms • Avocational assessment [36]. Oral steroids seem to show more promise in the short-term management of CTS than NSAIDs Exercise but are associated with negative side-effects if used • Tendon gliding for long periods. • Nerve gliding Local steroid injection into the carpal canal is • General conditioning an option to avoid the systemic actions of oral Yoga steroids. The injectable steroid of choice is water- Stretching soluble and can be combined with an anesthetic to reduce injection discomfort. A study examining
  3. 3. A.L. Osterman et al / Hand Clin 18 (2002) 279–289 281 injections [12] found long-term relief of symptoms at 20–30° of extension (Fig. 1). Ideally, a thermo- (‡1 year) in only 24% of subjects. An additional plastic splint should be custom-fit to ensure that 27% responded initially but then had a reoccur- the wrist is at a neutral angle (Fig. 2). It has been rence of symptoms within 1 year. Various other reported that individuals will experience a decrease studies have reported success rates from 13% to in symptoms after wearing a splint for 2 weeks [42]. 92% utilizing injections alone or combined with Optimal results with splints were obtained if splinting [10,14,16]. Success rates were defined as applied within the first 3 months of onset [43]. lasting improvement in symptoms 11–18 months But a 2-week trial is worthwhile regardless of in duration. Response to an injection can also cor- how long the individual has been experiencing relate and predict the response to surgical release symptoms [42]. The effect of lumbrical incursion [13]. This is particularly true when there are con- with finger position has been studied. It was deter- founding conditions, such as double crush syn- mined that increased finger flexion increases carpal drome [32], diabetes, and discrepancies on the canal pressures. Therefore, it was concluded that cervical spine exam. Complications and risks asso- finger motion as well as wrist position plays a role ciated with injection of the carpal canal include in carpal canal pressure [44]. A study of cadaveric tendon rupture, nerve injuries, pain, transient gly- dissections confirmed that the lumbrical muscles cemic elevation in diabetics, skin atrophy, and originate distal to the carpal canal with the fingers depigmentation. extended. With fingers flexed, lumbrical muscles Controversy still exists regarding the role of were found within the carpal canal. It was sug- pyridoxine (Vitamin B6) as a component in the gested that the lumbricals can contribute to com- treatment of CTS [37–40]. The current literature pression within the carpal tunnel [45]. Because does not clearly support or detract from the use increased finger flexion as well as wrist position of vitamin B6. Therefore, if utilized, it should be play a role in carpal canal pressures, a metacarpal in conjunction with other treatments (Box 1). block may be a consideration if symptoms do not subside with a standard wrist splint. Splinting Immobilization of the wrist through splinting is a component of nonoperative treatment. Individu- als are instructed to wear splints while sleeping because that is when symptoms tend to be most pronounced. In addition, it is more difficult to maintain the wrist in a neutral position at this time. During wakening hours, individuals can be instructed to monitor wrist position with activity and to maintain the wrist in a neutral alignment, avoiding ulnar deviation. Carpal tunnel pressures have been studied with flexion and extension to determine the position of the wrist that results in the lowest carpal canal pressures. It was reported that 2þ/ÿ9° of exten- sion and 2þ/ÿ6° of ulnar deviation is the position with the lowest carpal canal pressure. Immobiliza- tion of the wrist closest to neutral was recom- mended [41]. Symptom relief at neutral and at 20° of wrist extension have been compared. Results indicated that symptom relief was found to be greater at neutral than with 20 degrees of wrist extension [42]. With immobilization of the wrist, the angle of the splint should be carefully evaluated, as even small differences can affect carpal canal pressures and symptom relief. Fre- quently, prefabricated splints position the wrist Fig. 1. Commercially available splint.
  4. 4. 282 A.L. Osterman et al / Hand Clin 18 (2002) 279–289 other conservative measures. It would also be ben- eficial to study the effects of fewer ultrasound treatments as 20 treatments may be costly. Iontophoresis is an electrical modality used to deliver medication in an ion form with the objective of delivering a higher local concentra- tion, minimizing systemic concentration [49]. In a study by Banta, a standard treatment protocol was utilized using wrist splinting, NSAIDs, and ionto- phoresis with dexamethasone sodium phosphate [9]. The study revealed a success rate comparable with splinting plus injection of dexamethasone into the carpal tunnel space. It should be noted that the study had several shortcomings: a small sample size, lack of randomization and blinding, and no use of a sham iontophoresis group. In those individuals that are unable to tolerate steroid injections into the carpal canal, however, the use of iontophoresis may be an option. Ergonomic factors Pressure over the carpal canal [23], wrist posi- tioning [41–43], low temperatures [50], vibration [51,52], and high force with high repetition [30] have been cited as occupationally related risk fac- Fig. 2. Custom-made splint by hand therapist. tors in the development of CTS. Nonoccupational risk factors such as diabetes, rheumatoid arthritis, thyroid disease, and obesity have also been cited as Therapeutic modalities risks [50,53]. Weight and body mass have been cor- Therapeutic ultrasound is a modality that pro- related with slowing of sensory conduction of the duces acoustical high-frequency vibrations with median nerve [53]. It was suggested that individual both thermal and nonthermal effects [46]. It has characteristics, not job-related factors, were pri- been observed, ‘‘The literature suggest[s] that low mary determinants of CTS. The development of intensity pulsed ultrasound is the most appropriate carpal tunnel syndrome is multifactorial, therefore to promote healing of open wounds, to resolve controversy remains regarding the primary influ- acute and subacute inflammation, and to enhance encing and etiologic factors [54]. repair in tendon, nerve and bone’’ [47]. With CTS, Despite this controversy regarding primary flexor tendons may be inflamed. If ultrasound is influencing factors, it may be beneficial to address used, pulsed or nonthermal mode would be the individuals’ occupational and nonoccupational most appropriate as continuous or thermal mode risk factors in order to maximize the effectiveness may irritate inflamed tendons. of conservative treatment. Though ergonomic Recently, the effects of ultrasound for the treat- measures have not been shown to influence the ment of mild to moderate idiopathic CTS were development of CTS, they have been useful in studied. Twenty treatments of pulsed ultrasound the conservative management of those patients were applied to the area over the carpal tunnel. with established mild CTS. Results suggested satisfying short- to medium- Mechanical stress or direct pressure over the term effects. Individuals receiving ultrasound carpal canal has been shown to increase carpal treatments experienced reduced symptoms and canal pressures [23]. Wrist positioning with tool improved nerve conduction compared with results use can be modified when indicated. If a keyboard in a placebo control group [48]. This study utilized or tool is positioned incorrectly, direct pressure ultrasound as the sole treatment. Our opinion, may be placed over the carpal canal, causing an however, is that if ultrasound is used for carpal increase in carpal canal pressures. Rounding and tunnel treatment, it should be in conjunction with padding edges of workstations can be helpful.
  5. 5. A.L. Osterman et al / Hand Clin 18 (2002) 279–289 283 Positioning the wrist closest to a neutral align- of exposure to environmental factors through ment helps to achieve the lowest possible carpal job rotation or elimination of aggravating factor canal pressure [41–43]; therefore, this neutral wrist may be necessary. alignment should be maintained with work and avocational activities. With the increasing use of computers at home, it is insufficient to consider Exercises keyboard positioning for work needs only. Indi- An evaluation of upper extremity musculature viduals should be encouraged to apply ergonomic and cervical screen should be completed prior to principles with all other daily activities. Ulnar prescribing exercises or stretches for CTS. A prox- deviation in excess of 20° has been associated imal weakness may be contributing to overuse with increased carpal tunnel pressures [41]. Ergo- of distal musculature. An individual can also pre- nomic tools that are designed with bent handles or sent with muscle imbalances secondary to overuse adaptations can decrease ulnar deviation. An of flexors. In cases where extensor weaknesses ergonomic split keyboard maintains the wrist is noted, stretches of flexor musculature and as straight, decreasing wrist deviation. But because strengthening of extensors would be the most an item is labeled ergonomic does not mean that appropriate. Repetitive gripping exercises with it is the most appropriate. Items should be care- grip tools or balls can contribute to further inflam- fully evaluated and basic principles applied. An mation of flexor musculature and therefore should ergonomic keyboard will not be as effective if it be avoided. An assessment of daily activities or is placed at a level where the individual is unable components of work is helpful in determining the to maintain the wrist in neutral alignment. In a most appropriate stretches or exercises for an indi- recent study, it was found that in many partici- vidual. Stretch breaks from repetitive activities pants, carpal tunnel pressures measured during should be encouraged. In a recent study, signifi- mouse use were greater than pressures known to cant decreases in carpal tunnel pressures were alter nerve function and structure. Although not noted following 1 minute of hand and wrist exer- clinically demonstrated, authors’ recommenda- cises. Brief intermittent wrist and hand exercises tions include minimizing wrist extension, pro- were recommended to reduce intratunnel pressure longed mouse dragging, and performing other [57]. Based on these findings, specific exercises tasks with the mousing hand [55]. were developed for CTS [29,57]. It was reported by Silverstein that high force combined with high repetitiveness increases the risk more than 5· that of either factor alone [30]. Tendon gliding exercises and median nerve Strategies to decrease repetitiveness may include gliding exercises alternating repetitive with nonrepetitive work activity, stretch breaks, or job rotation. In order The effectiveness of nerve and tendon gliding to change force requirements, the tool itself may exercises for the conservative treatment of CTS need to be changed. Whenever possible, educate has been studied (Fig. 3 and Fig. 4). The study indi- the individual to avoid overuse of flexors or cated that 43% of those who performed the exercises exerting more muscle force than is required. Bio- did not undergo surgery, whereas 71.2% of those feedback can be helpful in increasing an indivi- who did not perform the exercises underwent sur- dual’s awareness of hand postures. In a study gery. The experimental and control groups both comparing the effects of biofeedback with CTS, received traditional conservative treatment with individuals reported that this feedback was help- splinting, nonsteroidal anti-inflammatory medica- ful in improving awareness. There was no direct tion, and steroid injections. The difference was that objective evidence, however, that biofeedback the experimental group also performed tendon and was helpful in reducing the symptoms of CTS nerve gliding exercises as developed by Totten and [59]. There is a correlation between carpal tunnel Hunter [15,58]. The authors of this study postulated syndrome and prolonged exposure to environ- that guiding the wrist and fingers through this pro- mental conditions such as vibration [51,56] and/ gram of nerve and tendon gliding exercises would or cold temperature exposure [50]. Work gloves help to maximize MN excursion in the carpal tunnel may be helpful but need to be carefully evaluated. and excursion of the flexor tendons relative to one An individual may grip more forcefully secondary another. They proposed that a ‘‘ milking’’ effect to a decrease in sensory feedback. When possible, would promote venous return and decrease the modify the tool to dampen vibration. Reduction pressure inside the perineurium [15,58]. Further
  6. 6. 284 A.L. Osterman et al / Hand Clin 18 (2002) 279–289 Fig. 3. (A–D) Tendon gliding exercises. (From Totten PA, Hunter JM. Therapeutic techniques to enhance nerve gliding in the thoracic outlet and carpal tunnel syndrome. Hand Clin 1991;7(3):505)
  7. 7. A.L. Osterman et al / Hand Clin 18 (2002) 279–289 285 Fig. 4. (A–E) Wrist level median nerve gliding exercises. (From Totten PA, Hunter JM. Therapeutic techniques to enhance nerve gliding in the thoracic outlet and carpal tunnel syndrome. Hand Clin 1991;7(3):505.)
  8. 8. 286 A.L. Osterman et al / Hand Clin 18 (2002) 279–289 to avoid aggravating symptoms. As symptoms decrease, the individual can progressively perform the remaining movements of the sequence [62]. Double crush syndrome, originally described by Upton and McComas [63], refers to the co- existence of dual lesions along the course of a nerve. They proposed that a more proximal lesion would lessen the ability of the nerve to withstand a more distal compressive force. The coexistence of CTS with cervical radiculopathy has been reported in the literature [32,64]. If the individual being treated for CTS presents with a more proximal lesion, performing wrist level median nerve gliding exercises only may be insufficient. Proximal shoulder or cervical issues should be evaluated. The effects of performing brachial plexus nerve glides have not been studied for the treatment of CTS. Further research on proximal as well as dis- tal stretches, nerve glides, or exercises would be beneficial to determine potential benefit in the treatment of CTS. Yoga Recently, a preliminary study compared effects of a yoga-based regimen in the treatment of CTS Fig. 4 (continued ) [65]. Subjects assigned to the yoga group per- formed 11 yoga postures along with relaxation research is needed to evaluate the most effective twice weekly for 1–1.5 hour sessions. Subjects in exercises and nerve gliding techniques for CTS. the yoga groups demonstrated improvements in grip strength, pain reduction, and improvements with Phalen’s sign. Significant differences were Brachial plexus gliding program not demonstrated with Tinel’s sign, sleep disturb- The median nerve has been shown to move ance, or in motor and sensory conduction time. within the carpal tunnel and the upper extremity This study demonstrated improvements with the with various positions. McLellan and Swash dem- use of yoga postures; however, several limitations onstrated movement of the MN longitudinally in exist. In addition to small sample size, medication the upper extremity, depending on joint position use, and splint angle for controls were not [60]. They also demonstrated longitudinal move- recorded. ment of the MN with proximal joint motion of It is important to realize that specific postures the shoulder and elbow. It was theorized that this were utilized; therefore, it is difficult to generalize longitudinal sliding is necessary to minimize local that all of yoga may be effective in improving car- stretching and to prevent entrapment along the pal tunnel symptoms. There are many different course of the nerve as the limb moves. schools of yoga, and varieties of teaching. Each In work by Butler, this longitudinal movement type of yoga emphasizes different postures, relaxa- of the peripheral nervous system is recognized. tion, and breathing techniques. Hatha yoga is the Butler describes selective tensioning of the upper branch of yoga involved with movement. There limb for treatment of neural entrapment. He has are forms of yoga that do not involve movement elaborated on Elveys brachial plexus tension test, and emphasize relaxation or attainment of spiri- with median ulnar and radial nerve bias [61,62]. tual goals. The yoga utilized in this study is based A brachial plexus gliding program has also been on movement or hatha yoga along with relaxation described to facilitate nerve gliding from proximal techniques. The exercises utilized emphasize upper to distal. With this program, the individual extremity movements and stretches, both proximal attempts to move to the point of tension, not pain, and distal. In our opinion, this study reinforces the
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