Carpal Tunnel Syndrome

Overview: Carpal Tunnel Syndrome

• Carpal tunnel syndrome (CTS) is a compressive neuropa thy of the median nerve that affects women three times as often as men and usually develops after the age 30 of years.

• Symptoms typically include pain, numbness, tingling, weak ness of the thumb and first finger, and involvement of the palm and other fingers except the fifth.

• Wasting of the thenar eminence may be visible. Activities that may precipitate CTS include repetitive stress activities involving the wrist such as mechanical work, gardening, house painting, meat wrapping, and typing Trauma, both recent and remote, should be explored, and one of the "keystone" bones of the carpal floor, the lun lunate, has been implicated in ventral compression of the median nerve against the flexor retinaculum when it is subluxed or displaced.

• CTS is also commonly seen in per sons involved in the occupations listed.

Important points to consider

• The exact location of nerve entrapment can be diagnosed with electrodiagnostic studies, however results of nerve conduction studies may be normal in clinically symptomatic patients.

• Patients using dietary supplements should be advised to choose brands that have been certified for for content and purity. Testing for content and purity is not a mandatory requirement for dietary supplements. Trusted organizations that voluntarily test product punity are the United States Pharmacopeia (USP), (USF the Association of Analytical Communities (AOAC), and Consumer Labs (consumerlabs.com).

• Amics belongs to the Asteraceae/Compositae family. Patients allergic to other members of this family will also be allergic to arnica. Additional members of the Asteraceae/Compositae family include ragweed, chrysanthemums, marigolds, daisies, and many other herbs.

• The U.S. Recommended Dietary Allowance (RDA) values for vitamin B, are as follows:

  Men: 19 to 50 years old, 1.3mg; 51 years old and older, 1.7 mg Women: 19 to to 50 years old, 1.3mg: 51 years old and older, 1.5mg. Some researchers think that the RDA for women 19 to 50 years old should be increased to 1.5 to 1.7 mg Pregnant women: 1.9mg: lactating women: 2 mg

Prevention Prescription

• Avoid repetitive hand motions, especially those with forceful thrusting

• Avoid prolonged gripping.

• Avoid prolonged positioning of the wrist in extremes of flexion or extension.

• Avoid gripping vibrating workplace tools for a prolonged time.

• Avoid isolated finger motions, such as typing, for a prolonged time.

• Schedule rest and stretching breaks every 1 to 2 hours.

Integrative therapeutics review

• If a patient presents with mild to moderate symptoms of carpal tunnel syndrome (CTS), has no thenar flattening, and has had symptoms for less than 1 year. a stepwise approach is appropriate. Most therapies can be combined with nighttime splinting. If a patient has unrelenting numbness or pain or a history of symptoms lasting longer than I year, a thorough examination should be conducted to ensure a correct diagnosis, and then referral to a surgeon specializing in CTS release may be the most appropriate therapy.

• If a patient presents with thenar atrophy, this indicates long-standing neurologic compromise, so more aggressive diagnostic and therapeutic options should be given priority.

Lifestyle Changes

• Have the patient

• Reduce activities that bring on symptoms.

• Take frequent breaks to rest hands.

• Perform stretching or strengthening exercises for the hands (see Fig. 66-2).

Splint Therapy

• The patient should wear a splint as often as possible, even during the day if tolerated.

• Start with a rigid over-the-counter appliance first. ensuring proper fit and prevention of wrist flexion.

• Better results may be achieved with the wrist held in neutral position rather than extended. Reconsider therapy if no benefit is seen after 3 weeks.

Yoga

• A patient who is willing to try yoga, despite the cost of an individualized program, may see some benefit from it.

Ginger

• The dose of Eurovita Extract 33 is 170mg three times/day or 255 mg twice/day

• Ginger may be of benefit in patients with both osteoarthritis and CTS, as well as in pregnant patients with CTS and nausea or vomiting.

• Ginger should be used with caution in patients taking anticoagulants.

Osteopathic Manipulative Treatment

• Osteopathic manipulative treatment (OMT) can be done in combination with other therapies.

• In addition to OMT in the office (see Fig. 66-1), patients can do self-stretching exercises at home (see Fig. 66-2) 5 to 10 times/day until symptom resolution or for 2 to 3 weeks, at which point reassessment is warranted if no improvement has occurred.

Oral Steroids

• Prednisolone is taken at 20 mg/day for 2 weeks.

• The use of steroids in pregnancy is controversial.

Steroid Injection

• Injection of methylprednisolone acetate, 20 mg mixed with 1 ml. of 1% lidocaine, into the carpal canal by a physician trained in this procedure may offer some relief of symptoms. It may also delay the need for surgery.

• Use of more than three doses in I year suggests a need for surgical intervention.

Ultrasound

• Although costly and time consuming, ultrasound may be beneficial in patients with mild to moderate CTS. It can be combined with splint therapy, OMT, or medications.

Traditional Acupuncture

• Acupuncture can be used as a possible alternative to surgery for mild CTS.

• It may be costly and is usually not covered by medical insurance.

Surgery

• Surgery is likely most useful for patients with unrelenting pain or numbness, thenar atrophy, or treatment failure with other modalities.

• The clinician must be certain of the diagnosis and must choose a surgeon who has performed many CTS procedures.

• Referral to a CTS specialist for evaluation is recommended before surgery is suggested to the patient.

• Surgery is not advised for pregnant patients with CTS, which will probably resolve with delivery.

• Indications for surgery are unrelenting pain, thenar eminence atrophy, loss of motor function with diminished finger strength, and failure of other treatments.

Key Web Sources

• http://www.ninds.nih.gov/disorders/carpal_tunnel/detail_carpal_tunnel.htm

• http://www.medicinenet.com/carpal_tunne_syndrome/article.htm

• http://www.assh.org/Public/HandConditions/Pages/Carpal_Tunnel_Syndrome.aspx