How to tell...

Carpal Tunnel Syndrome is characterized by:
-- An ache in the wrist that may move into the hand or forearm;
-- Swelling in the wrist and hand;
-- Numbness, burning or tingling in the hand and fingers;
-- Increased pain when moving the hand or wrist;
-- Weakness in the thumb and first three fingers;
-- Loss of strength and difficulty gripping objects;
-- Pain in the wrist, palm or forearm;
-- Pronounced pain and/or numbing during sleep;
-- Muscle atrophy.

You are at risk if:

If you're performing jobs or participating in activities that require repetitive hand movements, you might be at risk for developing carpal tunnel syndrome. The condition, caused by inflammation and irritation in the narrow groove formed by eight small bones and tissue in the wrist, affects an estimated 3.7 percent of the U.S. population, or some 8.1 million individuals. Those most susceptible to the potentially debilitating ailment include mechanics, cashiers, carpenters, grocery store checkers, manufacturing or assembly-line workers, violinists, gardeners, golfers and knitters. Heavy computer use and typing also are suspected of bringing on CTS.

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 ½" 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 two-portal endoscopic surgery, generally performed under local anesthesia, is effective and minimizes scarring and scar tenderness, if any. One-portal endoscopic surgery for carpal tunnel syndrome is also available.
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.

What are the causes?

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.

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.

Diagnosis of Carpal Tunnel

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.

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.

Overview

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 ¾ 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.

Prevention

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.

Biomakers can warn of CTS

U.S. researchers say they've spotted biomarkers that herald carpal tunnel syndrome and other repetitive stress injuries.
This is the first time that such biomarkers (different kinds of chemicals) have been identified in humans, and the finding could someday lead to early detection and prevention of carpel tunnel, tendonitis and other related conditions, says a team from Temple University in Philadelphia.
"While not a diagnostic test, because the biomarkers could also indicate another type of injury, they do provide a red flag where before there was none," Ann Barr, an associate professor of physical therapy at Temple's College of Health Professions, said in a prepared statement.
Her team analyzed blood samples from 22 people and found the body's immune system pumps out these biomarkers as the body begins to suffer damage due to repetitive stress.
Currently, health providers have to rely on physical examinations and symptoms reported by the patient in order to diagnose repetitive motion injuries. But most people with these types of injuries don't suffer symptoms of pain until the damage has already started, the Temple researchers noted. Finding a way to detect the problem in the early stages could help prevent long-term damage and disability.
The study is published in the March issue of Clinical Science.

A groundbreaking study

Ergonomics researchers from the University of California at San Francisco and McMaster University in Ontario have conducted a groundbreaking study that establishes limits on how much a wrist can be flexed before nerve damage sets in.
Researchers anticipate that their findings can be used to create simple guidelines to help workers avoid wrist postures that are likely to cause nerve trauma, which can lead to carpal tunnel syndrome.
After analyzing the pressure placed on the nerve in the carpal tunnel of 37 healthy men and women between the ages of 22 and 50, researchers concluded that when sustained pressure on the carpal tunnel reaches 30 mmHG, injury is likely to occur.
The researchers recommend keeping the pressure below 30 mmHG. In order to do that:
Sustained wrist extension (bending the hand back) should not exceed 32.7 degrees.
Wrist flexion (bending the wrist toward the palm) should not exceed 48.6 degrees.
Ulnar deviation (sideways toward the small finger) should not exceed 14.5 degrees.
Radial deviation (sideways toward the thumb) should not exceed 21.8 degrees.
According to the researchers, a set of guidelines could be developed from their data – guidelines that could, if applied by engineers and designers during the design of work and tools, protect workers. Such guidelines also could be used to identify tasks that may put workers at risk for developing or aggravating CTS.
The findings of this study appear in the February issue of Human Factors: The Journal of the Human Factors and Ergonomics Society. The article can be downloaded at http://www.hfes.org.

Great tips for the office!

You know your chair is the perfect height if you can sit at your computer with your knees bent at right angles and your feet flat on the floor.

Rest your wrists when you are not typing.

Take frequent short breaks. Several brief respites do your wrists a lot more good than a single long one.

Stretch your wrists before you start to work and during breaks, and strengthen your wrists with exercise.

Exercise regularly. Overall body conditioning seems to help guard against repetitive motion injuries.

If you type standing up, as clerks at car-rental agencies do, you are at special risk because counters are usually not high enough to allow for a proper wrist position. You must be sure to do enough stretching and strengthening exercises to counteract this problem or ask your employer to adjust your work station.

Tips for the office

The following tips can help you avoid CTS:
Make sure you are positioned properly at your computer. The computer screen should be about two feet away from you and the top of your document should be equal to or just below your line of sight.
Set up your keyboard so it is flat rather than slanted down. You can use a three-quarter inch support under the keyboard to accomplish this.
Keep your wrists straight, your forearms parallel to the floor and your elbows bent at right angles while typing.
Movable forearm rests that attach to the chair or a wrist rest to put in front of the keyboard can help keep your wrists straight and in place. However, you should never place your wrists on the pad while you work. Always let them hover about a half-inch above it.

The wrist twist

Wrist Twist: Stand or sit with your elbows close to your waist, your forearms extended in front of you and parallel to the floor, and your palms down. Grasp a one-pound dumbbell in each hand and slowly turn your wrists and forearms until your palms are facing up, then turn them down again. Do 10 repetitions.

Useful and quick wrist exercises

Wrist Curl:
Stand or sit with your elbows close to your waist, your forearms extended in front of you and parallel to the floor, and your palms facing down. Grasp a one-pound dumbbell in each hand and slowly bend your wrists down, holding for five seconds. Do 10 repetitions.

Sideways Wrist Bend:
Stand or sit with your elbows close to your waist, your forearms extended in front of you and parallel to the floor, and your palms facing down. Grasp a one-pound dumbbell in each hand. Keeping your forearms still, slowly bend your wrists from side to side, moving the weights toward, then away from one another in a windshield wiper-like motion. Do 10 repetitions.

2 Exercises

Limbering up:
Massage the inside and outside of hand with thumb and fingers.
Grasp fingers and gently bend back wrist. Hold for five seconds.
Gently pull thumb down and back until you feel the stretch. Hold for five seconds.
Clench fist tightly, then release, fanning out fingers. Repeat five times.

Wrist Rotation:
Stand or sit with your elbows close to your waist, your forearms extended in front of you and parallel to the floor, and your palms facing down. Make fists with both hands and make circles with your fists in one direction. Do 10 repetitions, then reverse the direction. Next, open your hands, extend your fingers and repeat the entire sequence.

What Can My Doctor Do?

There are a number of treatments your doctor may use to alleviate CTS. During the day and/or night it may help to use a wrist splint, which keeps the wrist straight or slightly extended (no more than 15 degrees). Try to combine a splint with a real effort to change the positioning of your hand during the activity that causes you pain so that the problem doesn't recur once you no longer use the splint.
If a splint and anti-inflammatory medications, which reduce swelling around the nerve, don't ease the condition, your doctor may recommend a steroid injection. This may be warranted if you continue to have considerable pain or persistent numbness. Such shots should be given by a rheumatologist, hand specialist or other physician who is experienced in the procedure.
Ask your doctor about ultrasound treatment, which physical therapists often use to reduce tissue inflammation. In the late 90s, a study done at the University of Vienna in Austria, found that ultrasound therapy diminished the symptoms of CTS.
If these treatments are ineffective, or if you develop weakness in your thumb at any time, you may need carpal tunnel release surgery to relieve pressure on the nerve. In this procedure, the surgeon cuts the carpal tunnel ligament that covers the median nerve, to relieve the pressure on that nerve. This is usually a simple operation that can be done on an outpatient basis. Results from surgery are generally quite good if severe weakness has not developed.

What Can I Do to Treat CTS?

What Can I Do to Treat CTS?
Don't ignore wrist pain. Stop the activity that is triggering the problem and try some home treatments. If the symptoms decrease, resume the activity gradually, while making an effort to keep the wrist straight. If you cannot stop the activity, try to change the way you do it so that your wrist is not stressed. Try to alternate tasks so that you don't spend more than one to two hours at a time doing one that involves your hands.
Gently warm up your hands before starting work. Do some wrist circles and stretch your fingers and wrists. Repeat every hour.
Use a wrist support pad with your computer keyboard to help maintain the straight alignment of your wrist.
Apply ice or a cold pack to the palm side of the wrist for five to ten minutes as needed.
Use an over-the-counter anti-inflammatory pain reliever such as aspirin or ibuprofen.
See your doctor if the pain or numbness is severe and is not alleviated by rest and a normal dose of pain reliever; your hand grip becomes weak; minor symptoms do not improve after a month of home treatment; any numbness remains after one month of self-treatment (long-term numbness can lead to permanent loss of hand function).

What Can I Do To Prevent CTS?

What Can I Do To Prevent CTS?
Anything that compresses the median nerve, such as a cyst or rheumatoid arthritis, can cause CTS. Most often, however, CTS is caused by repeated motion that eventually causes the tendons in the fingers and hand to swell and press on the nerve. Occupational health experts agree that to prevent serious overuse injuries you should pay prompt attention to the first sparks of pain or discomfort. Ignoring symptoms can lead to permanent damage. In order to avoid CTS, take the following preventive measures.
Avoid doing repetitive hand motions with a bent wrist. Keep the wrist straight and relaxed when you write, type, draw, drive, use power tools, pliers, or scissors, play musical instruments, or do needlework.
Take frequent breaks (five minutes each hour) from repetitive hand motions to stretch your fingers and thumb, do wrist curls and circles, change your grip.
Avoid sleeping on your hands

What are the signs?

First of all, don't panic and assume that discomfort in your hands, wrists or arms is CTS. The pain may simply be overuse strain caused by doing too much too soon (just like an athlete, you need to train your limbs to go beyond a previously adequate level of conditioning). But don't try to diagnose your own problem; let a doctor do that. Accurately diagnosing and dealing with pain early on will avert more severe problems from developing.
Many people don't associate common early warning signs of CTS, such as awakening at night with numbness in the hand, to job-related stress. The following symptoms may be intermittent at first, but can become persistent if the condition is not treated.
Decreased mobility of the fingers, hand, elbow or shoulder
Decreased hand strength
Dull aching discomfort or pain that occurs most commonly at night or in the early morning
Severe pain that awakens you during the night
Wrist pain that radiates to the forearm, shoulders, neck and chest
Dry skin, swelling or color changes in the hand
Weakness of the thumb
Tingling in all but the little finger
Numbness in the hand, resulting in weakness or clumsiness

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 one side and the transverse carpal ligament on the other. (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. It 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.