Carpal tunnel syndrome

• According to the American Physical Therapy Association, carpal tunnel syndrome affects more than five million Americans, especially those individuals performing repetitive movements for long periods of time. The carpal tunnel is a small passageway approximately the size of the thumb located on the palm side of the wrist. This tunnel protects a main nerve to the hand and nine tendons that bend the fingers. Carpal tunnel syndrome is caused by compression of the median nerve (nerve connected to the hand that controls some muscles that move the thumb). When pressure is placed on the median nerve, numbness and pain occur that eventually may lead to hand weakness. A combination of factors may contribute to carpal tunnel syndrome including trauma or injury to the wrist as well as various health conditions. However, with appropriate treatment, individuals may regain normal use of their hands.

• Women are three times more likely than men to develop carpal tunnel syndrome. Additionally, the risk increases after menopause due to hormonal changes. Men are more likely to develop carpal tunnel syndrome mid-life.
• Carpal tunnel syndrome may be inherited from family members.
• Patients with certain health conditions, such as thyroid disorders, diabetes, obesity, and rheumatoid arthritis, may have an increased risk of developing carpal tunnel syndrome. Individuals experiencing fluid retention due to pregnancy may develop carpal tunnel syndrome, which usually improves after childbirth.
• Individuals who smoke cigarettes have a slower recovery rate from carpal tunnel syndrome than nonsmokers.

• Occupations:
  The following occupations are associated with a high incidence of carpal tunnel syndrome since they involve repetitive hand activities: food processing, manufacturing, logging (cutting down trees), construction work, violinists, and carpenters. Additionally, long-term typing or computer use may cause carpal tunnel syndrome. Also, various activities such as golfing, knitting, and gardening may lead to carpal tunnel syndrome. Additionally, some activities of hair dressers, farm and factory workers, and mechanics are also contributors to carpal tunnel syndrome.
• Repetitive use or injury:
  Repetitive flexing and extending the hands and wrists for long periods of time may increase pressure in the carpal tunnel. Additionally, wrist injury can cause swelling leading to excess pressure on the median nerve.

• Numbness: Individuals will usually first experience a loss of sensation in their fingers as they become numb. This symptom usually occurs while driving a car or holding something such as a phone or newspaper. These symptoms may impair an individual's daily activities.
• Pain:
  Individuals may experience pain traveling from the wrist up to the arm and extending into the palm or fingers. This sensation may feel similar to an electric-like shock.
• Weakness:
  As symptoms of carpal tunnel syndrome progress, patients may experience clumsiness or weakness in their hands making it difficult to hold or grasp small objects. Everyday activities such as buttoning a shirt may become difficult. Muscles in the palm of the hand may become visibly wasted (visible loss of muscle size and shape changes).

• Durkan carpal tunnel compression test: A doctor will press down on the median nerve in the wrist to determine whether the pressure causes the patient to experience any numbness or tingling in the wrists.
• Electrophysiological tests: Nerve function is tested with electrical stimulation when symptoms persist. Additionally, this test can help to confirm the diagnosis and determine the best treatment option.
• Phalen maneuver:
  This test is also known as wrist-flexion and requires patients to hold their forearms upright by pointing the fingers down and pressing the backs of the hands together. Carpal tunnel syndrome may be present if one or more symptoms (i.e. tingling or increasing numbness) occur(s) within one minute.
• Thumb abduction strength test:
  The doctor may straighten the thumb while it is being held to reveal signs of weakness in the median nerve.
• Tinel Sign:
  The doctor may tap on the patient's wrist with a reflex hammer. A positive test means that the patient experiences a tingling in the fingers or a shock-like sensation.

• Patients may develop permanent nerve damage resulting in recurring weakness, numbness, and tingling if carpal tunnel syndrome is not treated.

• Exercise:
  Stretching and strengthening exercises, under the direct supervision of a physical therapist, may help relieve symptoms.
• Medications:
  Over-the-counter medications such as acetaminophen (Tylenol®) and nonsteroidal anti-inflammatory drugs (i.e. ibuprofen, aspirin) may help decrease pain. Additionally, corticosteroids (i.e. prednisone) may be injected into the wrist to reduce inflammation, relieve pressure, and provide temporary relief. Injectable corticosteroids are available only with a prescription. However, corticosteroids may not be beneficial for long-term treatment since symptoms may return. Additionally, corticosteroids may lower an individual's resistance to infections and increase blood sugar levels.
• Splinting:
  At least 80% of patients with carpal tunnel syndrome report that wrist splints (hand braces) improve symptoms. Splints help to decrease pressure by keeping the wrist straight. Splints are available in most drug stores. Splints may be worn 24 hours a day or only at night. Wearing a splint at night may help reduce the pain. Additionally, splints may provide the most benefit if worn within three months of developing carpal tunnel symptoms.
• Support groups:
  Support groups may help patients with carpal tunnel syndrome cope with their feelings about the condition.
• Surgery:
  Surgery is usually recommended when symptoms last for six months. It involves cutting the band of tissue around the wrist to reduce pressure. Patients receive local anesthesia and may leave the hospital the same day of the surgery. Full recovery may take months. However, symptoms may be alleviated immediately following surgery. Surgery increases the risk of infection and may result in nerve damage, stiffness, and pain at the scar. It is important for patients to receive physical therapy after surgery to regain wrist strength.
• Treating underlying diseases:
  Treating diseases that may be causing carpal tunnel syndrome, such as hypothyroidism (under active thyroid) or rheumatoid arthritis, may help alleviate symptoms.

B

Good scientific evidence

• Yoga
  : Yoga therapy has been studied for carpal tunnel syndrome, but it is not clear if there are beneficial effects. Further research is needed before a conclusion can be made.
• Yoga is generally considered to be safe in healthy individuals when practiced appropriately. Avoid some inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, risk for blood clots, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, or cervical spondylitis. Certain yoga breathing techniques should be avoided in people with heart or lung disease. Use cautiously with a history of psychotic disorders. Yoga techniques are believed to be safe during pregnancy and breastfeeding when practiced under the guidance of expert instruction (the popular Lamaze techniques are based on yogic breathing). However, poses that put pressure on the uterus, such as abdominal twists, should be avoided in pregnancy.

C

Unclear or conflicting scientific evidence

• Acupuncture
  : Currently there is insufficient evidence available to recommend for or against the use of acupuncture in carpal tunnel syndrome. Additional research is needed in this area.
• Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders or with drugs that increase the risk of bleeding (anticoagulants), medical conditions of unknown origin, or neurological disorders. Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers.
• Astaxanthin
  : There is insufficient evidence to recommend for or against the use of astaxanthin for carpal tunnel syndrome. Evidence suggests that astaxanthin may have antioxidant effects and may enhance the immune system. Additional study is needed in this area.
• Avoid if allergic/hypersensitive to astaxanthin or related carotenoids, including canthaxanthin, or if allergic/hypersensitive to an astaxanthin algal source, such as Haematococcus pluvialis. Use cautiously if taking 5-alpha-reductase inihibitors, hypertensive agents, asthma medications, such as etirizine dihydrochloride and azelastine, cytochrome P450 metabolized agents, menopausal agents or oral contraception, or Helicobacter pylori agents. Use cautiously with hypertension, parathyroid disorders, and osteoporosis. Avoid with hormone-sensitive conditions, immune disorders or if taking immunosuppressive therapies. Avoid with previous experience of visual changes while taking astaxanthin and with low eosinophil levels. Avoid if pregnant or breastfeeding.
• Chiropractic, spinal manipulative therapy
  : There is not enough reliable scientific evidence to conclude the effects of chiropractic techniques in the management of carpal tunnel syndrome. Early evidence and some experts suggest that chiropractic manipulation may be as effective as conservative treatments, such as anti-inflammatory drugs or splinting.
• Use extra caution during cervical adjustments. Use cautiously with acute arthritis, conditions that cause decreased bone mineralization, brittle bone disease, bone softening conditions, bleeding disorders or migraines. Use cautiously with a risk of tumors or cancers. Avoid with symptoms of vertebrobasilar vascular insufficiency, aneurysms, unstable spondylolisthesis or arthritis. Avoid with agents that increase the risk of bleeding. Avoid in areas of para-spinal tissue after surgery. Avoid if pregnant or breastfeeding due to a lack of scientific data.
• Physical therapy
  : Carpal bone mobilization (technique involving movement of the bones and joints in the wrist) and median nerve mobilization (a technique used to regain function in the wrist) have both been studied for the treatment of carpal tunnel syndrome. Based on one study, no significant differences were found between treatments or compared with control groups. More study is needed in this area.
• Not all physical therapy programs are suited for everyone, and patients should discuss their medical history with a qualified healthcare professional before beginning any treatments. Physical therapy may aggravate pre-existing conditions. Persistent pain and fractures of unknown origin have been reported. Physical therapy may increase the duration of pain or cause limitation of motion. Pain and anxiety may occur during the rehabilitation of patients with burns. Both morning stiffness and bone erosion have been reported in the literature although causality is unclear. Erectile dysfunction has also been reported. Physical therapy has been used in pregnancy and although reports of major adverse effects are lacking in the available literature, caution is advised nonetheless. All therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician/gynecologist before initiation.
• Therapeutic touch
  : Therapeutic touch may provide limited benefit in carpal tunnel syndrome. More studies are needed in this area.
• Therapeutic touch is believed to be safe for most people. Therapeutic touch should not be used for potentially serious conditions in place of more proven therapies. Avoid with fever or inflammation, and on body areas with cancer.
• Vitamin B6
  : Preliminary data suggests that large doses of vitamin B6 may be helpful for carpal tunnel syndrome. Evidence suggests that carpal tunnel syndrome may be caused by vitamin B6 deficiency. Well-designed clinical trials are needed before a firm conclusion can be drawn.
• Avoid if sensitive or allergic to any vitamin B6 product ingredients. Some individuals seem to be particularly sensitive to vitamin B6 and may have problems at lower doses. Avoid excessive dosing. Vitamin B6 is likely safe when used orally in doses not exceeding the recommended dietary allowance (RDA). Use cautiously if pregnant or breastfeeding.

D

Fair negative scientific evidence

• Magnet therapy
  : Preliminary evidence suggests that a magnet attached via a bracelet to the wrist for 45 minutes does not improve pain in people with carpal tunnel syndrome.
• Avoid with implantable medical devices like heart pacemakers, defibrillators, insulin pumps, or hepatic artery infusion pumps. Avoid with myasthenia gravis or bleeding disorders. Avoid if pregnant or breastfeeding. Magnet therapy is not advised as the sole treatment for potentially serious medical conditions, and should not delay the time to diagnosis or treatment with more proven methods. Patients are advised to discuss magnet therapy with a qualified healthcare provider before starting treatment.

• Individuals employed in professions that may aggravate their carpal tunnel syndrome can perform stretching exercises while at work to alleviate symptoms. Additionally, taking breaks every 15 to 20 minutes to stretch and bend the wrists may be helpful.
• Wearing fingerless gloves may keep the hands warm and flexible and prevent pain and stiffness.
• Individuals should avoid bending the wrist excessively, especially while typing on a keyboard.
• Using a relaxed grip on items such as pens may prevent hand stiffness.