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. [10, 11, 12] 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. [32]
Additionally, yoga and carpal bone mobilization techniques have some weak evidence for reducing symptoms in the short term. [12, 33]
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. [14] No evidence suggests that a specific stretching/strengthening program for the hand and wrist is useful for treating carpal tunnel syndrome. [33] Massage and/or nerve-glide techniques offer no proven benefit. [12, 33] Work-site ergonomic assessment, equipment, and/or ergonomic positioning seem to not provide any benefit. [11, 34]
Medical Treatment
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. [10, 13, 14]
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. [15] Injections may also be worthwhile prior to surgical management or in cases in which surgery is relatively contraindicated (eg, because of pregnancy). [15, 35] Ultrasonographic measurements of the median nerve can help predict response to steroid injection. [36]
A double-blind, randomized, controlled study by Chen et al indicated that both direct and ultrasonographically guided corticosteroid injections in patients with idiopathic CTS lead to improvements in clinical signs and symptoms, physical function, and the majority of electrodiagnostic parameters. However, ultrasonographically guided injection in the study was associated with greater improvements in the Semmes-Weinstein monofilament test and digit 4 comparison study, as well as sensory nerve conduction velocity. [37]
A randomized clinical trial by Raeissadat et al indicated that in patients with mild to moderate CTS, a local progesterone injection produces improvement comparable to that from a corticosteroid injection, with functional outcome actually being superior to that from corticosteroid treatment. The study, which included 78 CTS patients, found no significant difference between the progesterone and corticosteroid groups with regard to factors such as pain and electrophysiologic findings, at 6-month follow-up, while functional status, as evaluated using the Boston/Levine symptom severity and functional status scale, was significantly better in the progesterone group. [38]
The anticonvulsants gabapentin and pregabalin, which have come to be administered for various types of neuropathic pain, can be used, off-label, for CTS. [39, 40]
Nonsteroidal anti-inflammatory drugs (NSAIDs) and/or diuretics may be of benefit against CTS in certain populations (eg patients with fluid retention or with wrist flexor tendinitis). The efficacy of gabapentin, diuretics, and NSAIDs is controversial, however, with guidelines from the American Academy of Orthopaedic Surgeons stating that oral agents are no better than placebo in the treatment of CTS. [41] Additionally, vitamin B-6 and B-12 supplements are of no proven benefit against the disorder. [12]
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. [16]
In a literature review of patients with severe CTS, Meyers et al reported that significant improvements occurred following carpal tunnel release. Across the range of evaluated studies, the investigators found that paresthesia completely resolved in 55-98% of hands; pain, in 64-100% of hands; and weakness, in 60-75% of hands. In addition, numbness resolved in 39-94% of hands, and improvements occurred in power grip, key, tripod, index-thumb pulp pinch, and thumb opposition. [42]
However, it has been suggested that the long-term success rate for surgical release of the transverse ligament may be much lower than previously thought (approximately 60% at 5 y). Success rates also are considerably lower for individuals with normal electrophysiologic studies. [17, 18, 19]
A study by Rivlin et al found that in patients evaluated at 2 weeks and 3 months postoperatively, the efficacy of carpal tunnel release—as measured using the Quick Disabilities of the Arm, Shoulder and Hand questionnaire; symptom severity scale; and functional status scale—did not differ according to preoperative electrodiagnostic grade of CTS. [43]
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. [44]
A retrospective study by Pace et al reported that among patients who underwent revision carpal tunnel surgery, self-reported symptom severity and functional scores were the same between patients who underwent repeat decompression alone (17 hands) and those who underwent a combination of decompression and hypothenar fat pad transposition (16 hands). [45]
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.
Other Treatment
Techniques and devices to stretch or manipulate the carpal tunnel have shown some promise but still are not accepted widely. [33]
-
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.
