Carpal Tunnel Syndrome

What is Carpal Tunnel Syndrome?

Carpal tunnel syndrome (CTS) is a condition involving a nerve (the median nerve), which runs down the front of the forearm and through a tunnel in the wrist where it is being compressed.

CTS is the most common entrapment neuropathies, accounting for 90% of all neuropathies (9). The compression of the median nerve results in pain, tingling and/or numbness in the  thumb, index finger, middle finger, and the radial half (thumb side) of the ring finger. Pain also can radiate up the affected arm. With further progression, hand weakness, decreased fine motor coordination, clumsiness, and atrophy at the base of  thumb can occur.

In the early presentation of the disease, symptoms most often present at night when lying down and are relieved during the day. With further progression of the disease, symptoms will also be present during the day, especially with certain repetitive activities, such as when drawing, typing, or playing video games. Typical occupations of people with carpal tunnel syndrome include those who use computers for extended periods of time, those who use equipment that has vibration such as construction workers, and any other occupation requiring frequent, repetitive movement (9).  

CTS has a prevalence of 5.8% for men and 10% for women. There is a marked increase in prevalence with increasing age: 3.7% in those younger than 30 years of age compared to 11.9% in those over 50 years of age (3).

 

Risk factors (3)

• Obesity
• Age: the risk for CTS appears to increase linearly with age and more than doubles in those over the age of 50.
• Female sex: increases the risk between 1.5 and 4 times compared to male counterparts
• Diabetes
• Osteoarthritis
• Previous Musculoskeletal Disorders (e.g. chronic back pain, osteoarthritis, fibromyalgia, tendinopaties, rheumatoid arthritis, etc.)
• Cardiovascular Risk Factors: hypercholesterolemia (high cholesterol), hypertension, high triglycerides (fat in your blood)
• Hypothyroidism
• Family history of CTS
• Lack of physical activity

 

Classification of Carpal Tunnel Syndrome (2)

• Mild: intermittent symptoms
• Moderate: constant symptoms
• Severe: atrophy at the base of  thumb (Thenar muscle atrophy)

 

What can help my Carpal Tunnel Syndrome?

Primary interventions  (moderate evidence that it works) (3)

Night splinting

Corticosteroid injection (4)

 

Secondary interventions (weak evidence that it works)

Assistive techology: keyboards with reduced strike force for patients with CTS who report pain with keyboard use. Develop alternate strategies, including the use of arrow keys, touch screens, or alternating the mouse hand.

Thermotherapy: use of heat for short-term symptom relief.

Electrotherapy: application of microwave or shortwave diathermy for short-term pain and symptom relief.

Phonophoresis (a procedure that delivers drugs through the skin through the use of ultrasound): use for patients with mild to moderate CTS.

Manual therapy: performed directed at the cervical spine and upper extremity, for individuals with mild to moderate CTS in the short term.

Stretching: a combined orthotic/stretching program in individuals with mild to moderate CTS.

Conservative treatment Vs Surgery?

• Conservative treatment should be preferred for mild and short-term CTS. Surgery (usually carpal tunnel decompression) is more effective than conservative in CTS, and should be considered in persisting symptoms . Surgical treatment leads to a greater improvement of symptoms at six months. At 3 months and 12 months, the results were not significant in favor of surgery or conservative treatment (1).

• In the long term surgery is superior to conservative treatment (5).

 

• Surgical treatment seems to be more effective than splinting or anti-inflammatory drugs plus hand therapy in the short-term, midterm, and/or long-term to treat CTS. However there is strong evidence that a local corticosteroid injection is more effective than surgery in the short-term, and moderate evidence that manual therapy is more effective than surgery in the short-term and midterm (6).

 

The Goal of the surgery  is to relieve pressure by cutting the ligament pressing on the median nerve.

 

Surgery complications

Carpal tunnel decompression appears to be a safe operation in most patients, with an overall serious complication rate (requiring admission to hospital or further surgery) of less than 0·1% (7).

 

Take home message

If a period of conservative treatment causes little to no improvement and/or you have a severe diagnosis of CTS, then surgery may be appropriate. Take into account that in some cases CTS may be resolved spontaneously.

Treat CTS as early as possible after symptoms start. In the early stages, simple things that you can do for yourself may make the problem go away. For example (8):

• Take more-frequent breaks to rest your hands.
• Avoid activities that make symptoms worse.
• Apply cold packs to reduce swelling.

 

 

References:

1. Effectiveness of surgical versus conservative treatment for carpal tunnel syndrome: A systematic review, meta-analysis and qualitative analysis, 2018;
2. Carpal Tunnel Syndrome: A Summary of Clinical Practice Guideline Recommendations, JOSPT 2019;
3. Hand Pain and Sensory Deficits: Carpal Tunnel Syndrome, JOSPT 2019;
4. The clinical and cost-effectiveness of corticosteroid injection versus night splints for carpal tunnel syndrome (INSTINCTS trial): an open-label, parallel group, randomised controlled trial, 2018;
5. Comparison of splinting, splinting plus local steroid injection and open carpal tunnel release outcomes in idiopathic carpal tunnel syndrome, 2006;
6. Effectiveness of Surgical and Postsurgical Interventions for Carpal Tunnel Syndrome: A Systematic Review, 2017;
7. Serious postoperative complications and reoperation after carpal tunnel decompression surgery in England: a nationwide cohort analysis, 2020;
8. http://www.mayoclinic.org/diseases-conditions/carpal-tunnel-syndrome/diagnosis-treatment/;
9. Carpal Tunnel Syndrome, Justin O. Sevy et al. 2020.