Carpal tunnel syndrome

Carpal tunnel syndrome is a condition in which the median nerve is squeezed where it passes through the wrist. Carpal is a medical term to describe the wrist and syndrome is a combination of symptoms caused by the nerve being squeezed. The median nerve provides muscle strength to the thumb and sensation to the thumb, index, middle and half of the ring fingers. Women are more likely to develop this condition than men. It can affect people of all ages, but more common in over 40’s. 

There are various causes of carpal tunnel syndrome including:

• Pregnancy: hormonal changes during pregnancy can cause swelling within the wrist which puts extra pressure on the nerve. Symptoms usually settle following the birth
• Obesity
• Degenerative or injury related changes to the wrist joint. Any arthritis (rheumatoid or osteoarthritis) in the wrist if there is swelling of the joints can cause symptoms. A fracture to the wrist or other wrist injuries
• Other medical conditions such as diabetes and underactive thyroid
• Workplace factors including using computer and/or mouse or manual work involving sustained pressure on the wrist and palm

Carpal tunnel syndrome causes pain, aching, tingling or numbness in the hand. It tends to come on gradually, over a period of weeks. The symptoms are usually worse in the thumb, index and middle and half the ring fingers, but sometimes it can feel like the whole hand is affected. You may also experience an ache extending up the arm and swelling of the hands. Symptoms can affect one or both hands.

Symptoms are usually worse at night and may cause sleep loss. You may notice that you wake in the night or early morning needing to shake your hand or hang your arm over the side of the bed to relieve symptoms of tingling or numbness in the hand.

Initially you may not notice symptoms during the day. However some tasks such as writing, typing, DIY or housework can bring on your symptoms. In some cases if the median nerve is continuously compressed symptoms may be felt throughout the day. It is not uncommon to experience weakness in the hand and you might find that you frequently drop items or struggle to undertake activities that involve fine movements such as fastening buttons or writing.

Fortunately, in 30% of cases symptoms will resolve with no treatment. However, if symptoms do not settle they may progress and result in weakness of function or wasting of muscle strength around the thumb.

Carpal tunnel syndrome can often be reliably diagnosed by taking a history of your condition and by conducting a diagnostic wrist flexion test (Phalen’s test). The main feature of the test is to reproduce symptoms of pins and needles when holding the wrist in sustained flexion by moving the palm of the hand towards the wrist or when tapping or pressing over the median nerve in the carpal tunnel.

Non-surgical management
Self-help
Many patients wish to know what they can do themselves to prevent or treat CTS. Unfortunately ,the options are rather limited but it is possible to make a few suggestions.

• Relative rest and change in aggravating activities – if you find that a particular activity reliably aggravates symptoms then it is probably worth trying to either do less of that activity or find an alternative way of doing it.
• Ergonomic changes – Carpal tunnel is often aggravated by repetitive activities or sitting with the wrist in flexion, for example when driving or at a computer. Try to find ways of changing your set up and take regular breaks from activity
• Splints – these can be obtained from your local pharmacist or on line at reasonable cost. The advice is to wear at night and when doing aggravating activities. If there is no improvement within 6 weeks it is unlikely to resolve the symptoms. Avoid wearing them all the time as the wrist may stiffen and muscles become weak
• Weight loss – If you are significantly overweight weight loss may help ease the symptoms

Corticosteroid injection therapy
If you have weakness or muscle wasting or persistent numbness then surgery is recommended. However for individuals with carpal tunnel syndrome who continue to suffer sensory (tingling and numbness) symptoms in spite a course of non-surgical management (outlined above) a corticosteroid injection can be offered as the next line of treatment. You can read more about local corticosteroid injections here.

Evidence for the effectiveness of a steroid injection is good for short term relief with evidence for more prolonged relief not as strong. A figure of 50% relief at 1 yr is a reasonable guide.

Surgical management
Carpal tunnel decompression surgery is an effective option for individuals who:

• Have constant sensory symptoms (numbness & tingling or pins and needles)
• Weakness or wasting of the thumb muscles
• Have significant pain or sensory symptoms which disturb sleep or daytime activities and have trialled non-surgical intervention for at least 3 months.

Many patients wish to know what they can do themselves to prevent or treat CTS Carpal tunnel syndrome. In the early stages of the condition the following advice can be beneficial.

• Relative rest and change in aggravating activities – if you find that a particular activity reliably aggravates symptoms then it is probably worth trying to either do less of that activity or find an alternative way of doing it.
• Ergonomic changes – Carpal tunnel is often aggravated by repetitive activities or sitting with the wrist in flexion, for example when driving or at a computer. Try to find ways of changing your set up and take regular breaks from activity.
• Splints – these can be obtained from your therapist, local pharmacist or on line at reasonable cost or therapist. The advice is to wear at night to keep the wrist in a straight position and when doing aggravating activities. It is important to note when wearing the splint the metal bar should be flattened and do not fasten the splint too tightly around the wrist as this will restrict blood flow. If there is no improvement within 12 weeks it is unlikely to resolve the symptoms. Avoid wearing them all the time as the wrist may stiffen and muscles become weak.

Weight loss – If you are significantly overweight, weight loss may help ease the symptoms.

The splint is made of neoprene and some people will find that the splint will make the hand hot and sweaty. Therefore you will want to wash the splint.

• Hand wash the splint in mild soapy warm water, removing the metal strip or plastic support before wetting the splint. Dry thoroughly before placing on the hand.

After washing the splint it can be dried near a gentle heat source e.g. near a radiator. DO NOT TUMBLE DRY OR DRY OVER A NAKED FLAME. Once dry, replace the metal or plastic support strip into its pocket.

If you notice any of the following, please contact the hand therapy department as soon as possible.

• Skin redness that doesn’t fade after 15-20 minutes
• Sores or blisters on the skin
• Pain, irritation or rubbing
• Any damage to the splint

Following today’s telephone consultation we ask that you wear the splint at night for the next 12 weeks. After the 12 weeks we will arrange to follow up this appointment with another phone call. If the symptoms are fully resolved or managed to your satisfaction with wearing the splint, then you can start to reduce the use of the splint, until you are able to sleep undisturbed without the splint needing to be worn. If symptoms recur in the future, simply start to wear the splint once more.

However if symptoms are not eased with wearing the splint you have the option of seeing one of the clinician’s at the Circle Integrated Care service to discuss alternative treatments.

• Arthritis UK
• Carpal Tunnel.net
• NHS