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Fact Sheets

Carpal Tunnel Syndrome is a set of symptoms caused by compression of the median nerve as it passes through a "tunnel' in the wrist. This condition occurs when tendons or ligaments in the wrist become enlarged, often from inflammation. The inflammation is often caused by repeated actions that over time, irritate the tissues. The first symptoms usually appear at night. Symptoms range from a burning, tingling numbness in the fingers, especially the thumb and the index and middle fingers, to difficulty gripping or making a fist, to dropping things.

Common Symptoms/Course of disease

• Painful tingling in one or both hands during the night, frequently painful enough to disturb sleep.
• A feeling of uselessness in the fingers, which are sometimes described as feeling swollen, even though little or no swelling is apparent.
• As symptoms increase, tingling may develop during the day, commonly in the thumb, index, and ring fingers.
• A decreased ability and power to squeeze things may follow.
• In advanced cases, the thenar muscle at the base of the thumb atrophies, and strength is lost.
• Many persons with CTS are unable to differentiate hot from cold by touch, and experience an apparent loss of strength in their fingers.
• Persons with CTS may have trouble performing simple tasks such as tying their shoes or picking up small objects.
• The presence of referred pain in the forearm, possibly pain as high as the shoulder in the involved extremity.
• An increase of symptoms upon the performance of a sustained activity such as driving a car, performing computer activities, using tools, performing repetitive tasks.

Age of Onset: Adult years - symptoms may be exacerbated by pregnancy, diabetes, thyroid disease, or after a wrist fracture or arthritis flair-up.

Sex Bias: CTS is more common in women then men.

Other Biases: Carpal tunnel syndrome is particularly associated with certain tasks including:

• Repetitive hand motions
• Awkward hand positions
• Strong gripping
• Mechanical stress on the palm
• Vibration

Cashiers, hairdressers, or knitters or sewers are examples of people whose work-related tasks involve the repetitive wrist movements associated with carpal tunnel syndrome. Bakers who flex or extend the wrist while kneading dough, and people who flex the fingers and wrist in tasks such as milking cows, using a spray paint gun, and hand-weeding are other examples. Excessive use of vibrating hand tools may also cause carpal tunnel syndrome.

Current Medical Treatment: When symptoms of carpal tunnel syndrome are mild or likely to be temporary, treatment includes rest, anti-inflammatory drugs, and a metal splint. Even if a patient wears a splint that has been prescribed, he or she should avoid the activities that caused or aggravate the injury. Where this is not possible, patients should wear the splint after work and particularly during sleeping hours.

Therapy may be prescribed before surgical interventions are considered. The goal of any pre-surgery therapy is to decrease symptoms as means of eliminating the need for surgery.

Surgery may be necessary if the symptoms are severe and if the other measures do not provide any relief. Surgery should not be the first choice for treatment. If surgery is performed, the goals of post-surgery are to decrease formation of adhesions (scar tissue), to promote motion, circulation and function, and to improve strength and extremity. Even after surgery, a number of patients may still have some problems. Weakness of grip in the operated hand persists in about 30 percent of cases.

One post-surgery symptom that may occur after Carpal Tunnel Release surgery is "Pillar" pain. This is variously described as: pain in the thenar (thumb muscles on the palm) eminence and/or hypothenar (small finger muscle on the palm) eminence; discomfort in the area of the surgical incision; and/or radial (thumb side of the hand) or ulnar (small finger side of the hand) tenderness (Falkenstein & Weiss-Lessard, 1999). Therapy for the Pillar pain may include soft-tissue mobilization, vibration, the use of modalities, desensitization, or splinting. Please note that it is not uncommon for Pillar to persist for as long as 6 months- it is important to provide client reassurance attesting to the fact that this pain will subside! (Falkenstein & Weiss-Lessard, 1999).

Occupational Therapy Involvement

Occupational therapy is prescribed to address therapy goals, both pre and post- surgery. Occupational Therapists may also fabricate custom splints or recommend the use of pre-fabricated, commercially available splints.

Wrist splinting is widely used as a form of conservative treatment for CTS. For some individuals off-the-shelf pre-fabricated splints will be adequate to manage the condition. These splints are inexpensive and available at many health care supply stores. The occupational therapist is also able to custom fit splints. Custom splints are molded to the individual and provide a more secure fit and better stabilization of the wrist neutral in a position. This position alleviates pressure on the carpal tunnel to promote a decrease in inflammation.

Additionally, Occupational Therapist can asses the patient's current daily work, home and leisure activities, and make recommendations for activity modification. Common aspects of tasks that should be considered for adaptation are:

• The body posture used during the task.
• Modifications may be introduced differences in the way a task is done, like using a more ergonomically efficient keyboard layout like the DVORAK keyboard or using specialized equipment to change the move used to perform the task.
• Breaks from repetitive tasks.
• Education on simple exercises.

References

• American Society for Surgery of the Hand, (1983). The hand: Examination and diagnosis, 2nd ed. Churchill-Livingstone, New York
• Falkenstein, N. & Weiss-Lessard, (1999). Hand Rehabilitation: A Quick Reference Guide and Review. Mosby, St. Louis

How OT Makes a Difference: Evidence-Based Practice

Akalin, E., El, O., Peker, O., Senocak, O., Tamci, S., Gulbahar, S., et al. (2002) Treatment of carpal tunnel syndrome with nerve and tendon gliding exercises. American Journal of Physical Medicine & Rehabilitation, 81; Issue 2; Pages 108-113.

Andrew E. et al. Interventions for the Primary Prevention of Work-related CTS. American Journal of Preventive Medicine 18(4) 37-50, May, 2000.

Feuerstein, M. et al. Clinical management of carpal tunnel syndrome: a 12 year review of outcomes. American Journal of Industrial Medicine 35(3), 232-245, 1999.

Gerritsen, A. A. M., de Vet, H. C. W., Scholten, R. J. P. M., Bertelsmann, F. W., de Krom, M. C. T. F. M., & Bouter, L. M. (2002), Splinting vs surgery in the treatment of carpal tunnel syndrome: a randomized controlled trial. JAMA: Journal of the American Medical Association, , 288; Issue 10; Pages 1245-1251.

Lincoln, A., Vernick, J., Ogaitis, S., Smith, G., Mitchell, C., & Agnew, M. (2000). Interventions for the primary prevention of work-related carpal tunnel syndrome. American Journal of Preventive Medicine, 8; Issue 4 (supplement); Pages 37-50.

Provinciali, L., Giattini, A., Splendiani, G., & Logullo, F. (2000) Usefulness of hand rehabilitation after carpal tunnel surgery. Muscle & Nerve, Volume 23; Issue 2 (Feb); Pages 211-216.

Walker WC et al. Neutral wrist splinting in carpal tunnel syndrome: a comparison of night-only versus full-time wear instructions. Archives of Physical Medicine & Rehabilitation. 81(4):424-9, April, 2000.

Anecdotal Reports

The patient interviewed was a women who received OT in early 2000 at an outpatient rehabilitation clinic. She received treatment for about 2 months at 2-3x/week. The primary provider was an Occupational Therapist. The main focus of therapy was strengthening and reducing inflammation. The OT wanted to keep symptoms under control. She tried to keep the patients considerations in mind when conducting treatment session.

She did mostly strengthening and stretching exercises along with ultra sound and icing. The major benefits were that she taught the patient to strengthen and help prevent future inflammations. The patient was able to have the Occupational Therapist complete a work site evaluation. She found it very beneficial to have an ergonomic specialist come and set up her work station properly to help prevent and further damage.

Client Handout

• Carpal Tunnel Syndrome (PDF File)

Web Links

• http://www.certifiedpst.com/arms
  Association for Repetitive Motion Syndromes
• http://orthoinfo.aaos.org/category.cfm?topcategory=Hand
  Orthopedic Information
• http://www.ninds.nih.gov/health_and_medical/disorders/carpal_doc.htm
  National Institute of Health