Carpal Tunnel Syndrome Treatment & Management

  • Author: Nigel L Ashworth, MBChB, MSc, FRCPC; Chief Editor: Robert H Meier III, MD   more...
 
Updated: Nov 3, 2011
 

Rehabilitation Program

Physical Therapy

Given that carpal tunnel syndrome (CTS) is associated with low aerobic fitness (and increased BMI), it makes inherent sense to provide the patient with an aerobic fitness program. Stationary biking, cycling, or any other exercise that puts strain on the wrists probably should be avoided.

The use of modalities (eg, ultrasonography, phonophoresis, iontophoresis) may provide relief in some patients.[16, 17] Interestingly, it may be possible to enlarge the carpal tunnel by specific stretching techniques. Such an exercise program may provide a new noninvasive treatment for CTS in the future.

Occupational Therapy

Work-site ergonomic assessment may help to reduce potentially exacerbating factors (eg, poor posture, excessive force).[18] Manufacture of a wrist-hand orthosis with the wrist joint in neutral (to be worn at nighttime for a minimum of 3-4 weeks) is one of the best evidence-based conservative treatments for carpal tunnel syndrome (CTS). A specific stretching/strengthening program for the hand and wrist may be useful in improving strength and dexterity (particularly following surgical treatment), although it can exacerbate symptoms. Massage and/or nerve glide techniques offer no proven benefit.[17]

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Medical Issues/Complications

Most individuals with mild-to-moderate carpal tunnel syndrome (CTS; according to electrophysiologic data) respond to conservative management, usually consisting of splinting the wrist at nighttime for a minimum of 3 weeks. Many off-the-shelf wrist splints seem to work well, although theoretically, a custom-made splint in neutral is probably the best choice.[16, 19]

Steroid injection into the carpal tunnel has been shown to be of long-term benefit and can be tried if more conservative treatments have failed[20] . Injections may also be worthwhile prior to surgical management or in cases in which surgery is relatively contraindicated (eg, because of pregnancy).[20, 21] Ultrasound measurements of the median nerve can help predict response to steroid injection.[22] .

Nonsteroidal anti-inflammatory drugs (NSAIDs) and/or diuretics may be of benefit. Vitamin B-6 or B-12 supplements are of no proven benefit.

Lack of aerobic exercise (along with increased body mass index [BMI]) is a risk factor for the development of CTS and should be addressed.

Overuse of legal drugs (eg, caffeine, nicotine, alcohol) can contribute to CTS and should therefore be reduced.[17]

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Surgical Intervention

Patients whose condition does not improve following conservative treatment and patients who initially are in the severe carpal tunnel syndrome (CTS) category (as defined by electrophysiologic testing) should be considered for surgery. Surgical release of the transverse ligament provides high initial success rates (greater than 90%), with low rates of complication; however, it has been suggested that the long-term success rate may be much lower than previously thought (approximately 60% at 5 y). Success rates also are considerably lower for individuals with normal electrophysiologic studies.[23, 24, 25]

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Consultations

Refer patients with suggested carpal tunnel syndrome to a specialist trained in clinical neurophysiology (usually a neurologist, physiatrist, or physical medicine and rehabilitation specialist) for possible electrophysiologic studies. These test results are important for diagnosis, instigation of appropriate treatment, determination of prognosis, and long-term follow-up.

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Other Treatment

Techniques and devices to stretch or manipulate the carpal tunnel have shown some promise but still are not accepted widely. Laser therapy also has shown some early promise.

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Contributor Information and Disclosures
Author

Nigel L Ashworth, MBChB, MSc, FRCPC  Professor and Chief, Division of Physical Medicine and Rehabilitation, Glenrose Rehabilitation Hospital, University of Alberta

Nigel L Ashworth, MBChB, MSc, FRCPC is a member of the following medical societies: American Association of Neuromuscular and Electrodiagnostic Medicine, Australian & New Zealand Association of Neurologists, British Medical Association, Canadian Association of Physical Medicine and Rehabilitation, Canadian Medical Association, Canadian Society of Clinical Neurophysiologists, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Specialty Editor Board

Benjamin M Sucher, DO, FAAPMR, FAOCPMR  Medical Director, EMG Labs of AARA (Arizona Arthritis & Rheumatology Associates)

Benjamin M Sucher, DO, FAAPMR, FAOCPMR is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Osteopathic Association, and American Osteopathic College of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Patrick M Foye, MD  Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society

Disclosure: Nothing to disclose.

Kelly L Allen, MD  Medical Director, Medevals

Disclosure: Nothing to disclose.

Chief Editor

Robert H Meier III, MD  Director, Amputee Services of America; Active Medical Staff, Presbyterian/St Luke's Hospital, Spalding Rehabilitation Hospital, Select Specialty Hospital; Consulting Staff, Kindred Hospital

Robert H Meier III, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and Association of Academic Physiatrists

Disclosure: Nothing to disclose.

References

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The hands of an 80-year-old woman with a several-year history of numbness and weakness are shown in this photo. Note severe thenar muscle (abductor pollicis brevis, opponens pollicis) wasting of the right hand, with preservation of hypothenar eminence.
Sensory nerve conduction studies from the left hand of a patient with a several-year history of numbness and weakness (responses from the median nerve in the right hand were completely absent). Note marked slowing of the conduction velocity (CV) to 29.8 and 25.5 m/s for digits 3 and 1, respectively (normal >50 m/s). The amplitude for both also is reduced markedly (normal >10). These findings are consistent with carpal tunnel syndrome.
Motor nerve conduction studies from the left hand of a patient with a several-year history of numbness and weakness (responses from the median nerve in the right hand were completely absent). Note that the conduction velocity (CV) across the carpal tunnel segment slows severely to 18.3 m/s (normal >50 m/s) and that the distal motor latency is prolonged at 6.3 ms (normal < 4.2 ms). Amplitudes are low for the wrist and elbow stimulus sites at 4.7 mV (normal >5 mV), but amplitudes are 31% higher distal to the carpal tunnel (at the palm). This discrepancy may represent conduction block (neurapraxia) at the level of the carpal tunnel or coactivation of the ulnar branch to adductor pollicis. Needle electromyography is required to determine whether axonal loss is present.
 
 
 
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