A Patient's Guide to Carpal Tunnel Syndrome
Introduction
Carpal tunnel syndrome (CTS) is a common problem affecting the hand and wrist. Symptoms begin when the median nerve gets squeezed inside the carpal tunnel of the wrist, a medical condition known as nerve entrapment. Any condition that decreases the size of the carpal tunnel or enlarges the tissues inside the tunnel can produce the symptoms of carpal tunnel syndrome.
This syndrome has received a lot of attention in recent years because of suggestions that it may be linked with occupations that require repeated use of the hands, such as typing on a computer keyboard or doing assembly work. Actually, many people develop this condition regardless of the type of work they do.
This guide will help you understand
- where the carpal tunnel is located
- how carpal tunnel syndrome develops
- what can be done for the condition
Chiropractic Treatment
In each hand, eight bones, called carpal bones, come together at the wrist. The carpal tunnel is approximately the width of your index finger. The median nerve runs through this carpal tunnel. However, when the carpal bones become misaligned, the tendons become compressed. This leads to entrapment and compression of the median nerve against the flexor retinaculum, and a reduction in the blood supply with the resulting pain, numbness and tingling. Carpal bones become misaligned through injury, such as a fall or through repetitive motion, such as … typing and hammering which shocks and overstretch the wrist.
Chiropractic manipulation can help restore the normal alignment and motion of the carpal bones, thus taking pressure off of the tendons and median nerve. This is sometimes called closed reduction manipulation. Chiropractic care focuses on not just relieving the symptoms, but correcting the underlying problem. Before any treatment can begin, you will begin a standard chiropractic examination of the head, neck and upper back and entire upper extremity to check for any nervous system interference to the group of nerves called the brachial plexus.
As you progress, we have you start strengthening your hand by squeezing and stretching special putty. There is a specific protocol which uses a series of "fist" positions to encourage the finger tendons to slide within the carpal tunnel. Additional exercises to help strengthen and stabilize the muscles and joints in the hand will also be incorporated. Other exercises are used to improve fine motor control and dexterity. Some of the exercises you'll do are designed to get your hand working in ways that are similar to your work tasks and sport activities. We will help you find ways to do your tasks that don't put too much stress on your hand and wrist. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.
Activities that are causing your symptoms need to be changed or stopped if at all possible. Avoid repetitive hand motions, heavy grasping, holding onto vibrating tools, and positioning or working with your wrist bent down and out. If you smoke, talk to your doctor about ways to help you quit. Lose weight if you are overweight. Reduce your caffeine intake.
A wrist brace will sometimes decrease the symptoms in the early stages of CTS. A brace keeps the wrist in a resting position--not bent back nor bent down too far. When the wrist is in this position, the carpal tunnel is as big as it can be, so the nerve has as much room as possible inside the carpal tunnel. A brace can be especially helpful for easing the numbness and pain felt at night because it can keep your hand from curling under as you sleep. The wrist brace can also be worn during the day to calm symptoms and rest the tissues in the carpal tunnel.
If chiropractic treatment is successful, you should see improvement in four to six weeks. You may need to continue with chiropractic treatments and with wearing your wrist splint at night to control symptoms and keep your wrist from curling under as you sleep. Try to do your activities using healthy body and wrist alignment. Limit activities that require repeated motions, heavy grasping, and vibration in the hand.
Anatomy
Where is the carpal tunnel, and what does it do?
The carpal tunnel is an opening through the wrist to the hand that is formed by the bones of the wrist on the bottom and the transverse carpal ligament on the top. (Ligaments connect bones together.) This opening forms the carpal tunnel.
The median nerve passes through the carpal tunnel into the hand. It gives sensation to the thumb, index finger, long finger, and half of the ring finger.
The median nerve also sends a nerve branch to control the thenar muscles of the thumb. The thenar muscles help move the thumb and let you touch the pad of the thumb to the tips each of each finger on the same hand, a motion called opposition.
The median nerve and flexor tendons pass through the carpal tunnel. The median nerve rests on top of the tendons, just below the transverse carpal ligament.
The flexor tendons are important because they allow movement of the fingers, thumb, and hand, such as when grasping. The tendons are covered by a material called tenosynovium. The tenosynovium is a slippery covering that allows the tendons to glide next to each other as they are worked.
Causes
What causes carpal tunnel syndrome?
Any condition that makes the area inside the carpal tunnel smaller or increases the size of the tissues within the tunnel can lead to symptoms of carpal tunnel syndrome (CTS). For example, a traumatic wrist injury may cause swelling and extra pressure within the carpal tunnel. The area inside the tunnel can also be reduced after a wrist fracture or dislocation if the bone pushes into the tunnel.
Any condition that causes abnormal pressure in the tunnel can produce symptoms of CTS. Various types of arthritis can cause swelling and pressure in the carpal tunnel. Fractured wrist bones may later cause CTS if the healed fragments result in abnormal irritation on the flexor tendons.
Other conditions in the body can produce symptoms of CTS. Pregnancy can cause fluid to be retained, leading to extra pressure in the carpal tunnel. Diabetics may report symptoms of CTS, which may be from a problem in the nerve (called a neuropathy) or from actual pressure on the median nerve. People with low thyroid function (called hypothyroidism) are more prone to problems of CTS.
The way people do their tasks can put them at more risk for problems of CTS. Some of these risks include
- force
- posture
- wrist alignment
- repetition
- temperature
- vibration
One of these risks alone may not cause a problem. But doing a task that involves several factors may pose a greater risk. And the longer a person is exposed to one or more risks, the greater the possibility of having a problem with CTS. However, scientists believe that other factors such as smoking, obesity, and caffeine intake may actually be more important in determining whether a person is more likely to develop CTS.
In other instances, CTS can start when the tenosynovium thickens from irritation or inflammation. This thickening causes pressure to build inside the carpal tunnel. But the tunnel can't stretch any larger in response to the added swelling, so the median nerve starts to squeeze against the transverse carpal ligament. If the pressure continues to build up, the nerve is eventually unable to function normally.
When pressure builds on the median nerve, the blood supply to the outer covering of the nerve slows down and may even be cut off. The medical term for this is ischemia. At first, only the outside covering of the nerve is affected. But if the pressure keeps building up, the inside of the nerve will start to become thickened. New cells (called fibroblasts) form within the nerve and create scar tissue. This is thought to produce the feelings of pain and numbness in the hand. If pressure is taken off right away, the symptoms will go away quickly. Pressure that isn't eased right away can slow or even stop the chances for recovery.
Symptoms
What does CTS feel like?
One of the first symptoms of CTS is gradual numbness in the areas supplied by the median nerve. This is quickly followed by pain where the nerve gives sensation in the hand. The hand may begin to feel like it's "asleep," especially in the early morning hours after a night's rest.
Pain may spread up the arm to the shoulder and even to the side of the neck. If the condition progresses, the thenar muscles of the thumb can weaken, causing the hand to be clumsy when picking up a glass or cup. If the pressure keeps building in the carpal tunnel, the thenar muscles may begin to shrink (atrophy).
Touching the pad of the thumb to the tips of the other fingers becomes difficult, making it hard to grasp items such as a steering wheel, newspaper, or telephone.
Diagnosis
How do doctors identify the condition?
Your doctor begins the evaluation by obtaining a history of the problem, followed by a thorough physical examination. Your description of the symptoms and the physical examination are the most important parts in the diagnosis of CTS. Commonly, patients will complain first of waking in the middle of the night with pain and a feeling that the whole hand is asleep.
Careful investigation usually shows that the little finger is unaffected. This can be a key piece of information to make the diagnosis. If you awaken with your hand asleep, pinch your little finger to see if it is numb also, and be sure to tell your doctor if it is or isn't. Other complaints include numbness while using the hand for gripping activities, such as sweeping, hammering, or driving.
If your symptoms started after a traumatic wrist injury, X-rays may be needed to check for a fractured bone.
If more information is needed to make the diagnosis, electrical studies of the nerves in the wrist may be requested by your doctor. Several tests are available to see how well the median nerve is functioning, including the nerve conduction velocity (NCV) test. This test measures how fast nerve impulses move through the nerve.
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All materials from eORTHOPOD® are the sole property of Medical Multimedia Group, L.L.C.. and are used herein by permission. eORTHOPOD® is a registered trademark of Medical Multimedia Group, L.L.C..
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