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Carpal Tunnel Syndrome Treatment & Management

  • Author: Nigel L Ashworth, MBChB, MSc, FRCPC; Chief Editor: Robert H Meier, III, MD  more...
 
Updated: Jul 01, 2015
 

Rehabilitation Program

Physical Therapy

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

The use of modalities (in particular therapeutic ultrasound) may provide short-term relief in some patients.[19, 20, 21] A study by Incebiyik et al indicated that in patients with mild to moderate CTS, treatment with short-wave diathermy (SWD) can produce significant short-term benefits, including alleviation of clinical symptoms and pain and improvement of hand function. In the prospective, randomized, controlled, double-blind trial, 31 patients (58 wrists) with mild to moderate CTS were treated with a combination of a hot pack, nerve and tendon gliding exercises, and either SWD or placebo SWD, undergoing this therapy five times per week for three weeks. A variety of evaluation measures, including the Tinel sign test, Phalen sign test, carpel tunnel compression test, and Boston Carpal Tunnel Questionnaire (BCTQ) Symptom Severity and Functional Status scales, were used to assess patient outcomes. Significant improvements were found in the patients who underwent SWD but not in those who receivedthe placebo treatment.[22]

Additionally, yoga and carpal bone mobilization techniques have some weak evidence for reducing symptoms in the short term.[21, 23]

Occupational Therapy

Wrist splints with the wrist joint in neutral or slight extension (to be worn at nighttime for a minimum of 3-4 wk) have some evidence for efficacy. Certainly, they are low cost and have very low risk of adverse effects and therefore can be considered as an initial therapy.[24] No evidence suggests that a specific stretching/strengthening program for the hand and wrist is useful for treating carpal tunnel syndrome.[23] Massage and/or nerve-glide techniques offer no proven benefit.[21, 23] Work-site ergonomic assessment, equipment, and/or ergonomic positioning seem to not provide any benefit.[20, 25]

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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.[19, 26, 24]

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[27] . Injections may also be worthwhile prior to surgical management or in cases in which surgery is relatively contraindicated (eg, because of pregnancy).[27, 28] Ultrasound measurements of the median nerve can help predict response to steroid injection.[29] .

Nonsteroidal anti-inflammatory drugs (NSAIDs) and/or diuretics may be of benefit in certain populations (eg patients with fluid retention or with wrist flexor tendinitis). Vitamin B-6 or B-12 supplements are of no proven benefit.[21]

Lack of aerobic exercise (along with increased BMI) seems to be a risk factor for the development of CTS and should be addressed.

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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.[30, 31, 32]

A study by Rozanski et al indicated that in patients who have undergone isolated carpal tunnel release, the greatest risk factors for symptoms in the ambulatory surgery center or problems within 24 hours after discharge are as follows: male sex, age 45 years or above, and participation of an anesthesiologist in the procedure. However, all such symptoms or problems in the study, which were found in 10% of patients, were minor and transient, according to the investigators. The study involved the records of 400,000 adult patients with CTS, as contained in the National Survey of Ambulatory Surgery database, who underwent isolated carpal tunnel release.[33]

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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.[23]

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Contributor Information and Disclosures
Author

Nigel L Ashworth, MBChB, MSc, FRCPC Professor, Divisions of Physical Medicine and Rehabilitation and Neurology, University of Alberta Faculty of Medicine and Dentistry, Canada

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Patrick M Foye, MD Director of Coccyx Pain Center, Professor and Interim Chair of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School; Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, University Hospital

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

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, Association of Academic Physiatrists

Disclosure: Nothing to disclose.

Additional Contributors

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

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

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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