How to treat Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) is a condition involving a nerve that runs down the front of the forearm and through a tunnel in the wrist where it is being compressed (3). The compression of this nerve results in pain, tingling and/or numbness in the fingers, palm and can extend into the forearm (3). CTS is more common in female’s and commonly related to the following factors (1,3):

1. Overloading the wrist and/or fingers
2. Previous wrist fracture or injury
3. Pregnancy
4. Diabetes
5. Arthritis

CTS is the most common compressive neuropathy involving the arms and is often associated with certain occupations (3). CTS has a prevalence of 3-4%, is most common between the ages of 40-60 and affects women 10 more often than men (1).

How do I know I have CTS?

When assessing a client for CTS it is important to include the following:

• History of the disease
• Clinical symptoms
• Changes in dimensions of the hand
• Imagery (for verification)
• BCTQ (Boston Carpal Tunnel Questionnaire)

When assessing for CTS, Electroneurography (ENG) is a nerve conduction study that is the most accurate way to diagnose CTS (1). It shows the size, character and determines the stage of the disease (1). It does this through assessing the median nerve and the muscle groups it innervates as CTS is often associated with significant reduction in muscle performance and strength (1). However, ultrasound imagery, despite having a lower sensitivity than ENG, is the cheapest and  fastest way of diagnosing CTS (1).

What if it isn’t CTS?

It is important also, to rule out other conditions that may present similarly – these include:

• Spinal cord or brachial plexus
• Thoracic outlet syndrome
• Median nerve compression in the upper arm
• Degenerative changes

Will I make a full recovery from CTS?

In general, those diagnosed with CTS respond well to the various treatment types on offer. Treatment can begin as soon as symptoms start with some simple and common sensical things you can try initially include:

1. Take more-frequent breaks to rest your hands.
2. Avoid activities that make symptoms worse.
3. Apply cold packs to reduce swelling.

Post-operatively, less than half of those who undergo surgery report their hand to return to “normal” or a pre-injury level of function. Residual weakness or altered sensation is common following an operation and many have to adjust their work set-up for several weeks following their operation.

What can help my CTS?

Manual therapy

Researches found the use of manual therapy on various parts of the hand and wrist can help improve the symptoms related to CTS. Some example techniques used within the studies in demonstrated below.

 

Neuromobilisation

Researchers that reviewed physiotherapy effectiveness on CTS clients – state that participants with CTS had reduced median nerve mobility. This lack of mobility stems from the flexor retinaculum (sheath across the wrist) that compresses the median nerve as well as their blood vessels (1). This compression over time can lead to the formation of oedema and scar tissue which reduces the mobility of neighbouring tissues further (1). Within these studies, statistically higher nerve mobility was found in those participants who had CTS and received neural mobilisation treatment. The images below demonstrate a neuromobilisation technique that may achieve these positive results.

Kinesiotape

A study within the review tested the application and effects of kinesiotaping for the treatment of CTS – this is shown in the image below. The study that the application of the kinesiotape – when combined with exercise therapy – could prove to be an effective method of CTS treatment (1).

Yoga-based intervention

Interestingly, an older study in 1998 investigated the use of a yoga-based exercise regime on a group of those diagnosed with CTS and compared the results to a group that didn’t receive any treatment. The regime was carried out for 8 weeks and consisted of stretching, strengthening and balancing of the upper limbs along with relaxation techniques (yoga).

The results concluded that those in the yoga group had statistically significant improvements in both pain scores and grip strength as well as showing less positive Phalen’s sign on nerve testing following the regime (yoga).

The authors’ suggested that stretching may help relieve pressure in the wrist, improved posture may reduce intermittent compression and improving the blood flow may have had ischemic effects on the injured nerve (yoga).

Corticosteroid injections (CSI) vs Night splinting

A 2018 study investigated the differences between CSI and night splinting for those with an 18+ month history of a CTS diagnosis with mild-moderate symptoms (4). One group received a single CSI while the other group used a night splint. This study proved that there were no statistical differences between the two groups at the 12 and 24 month follow ups (4). However, it was shown that there was a greater number of patients that had received the CSI being later referred for (28% vs 20%), and undergoing a surgical intervention (22% vs 16%) (4). This in combination with CSI being less cost-effective in comparison to night splinting can lead to the conclusion that night splinting is a more effective, long-lasting and affordable option when compared to a single CSI.

What exercises may help my CTS?

Below are some suggested exercises that may help reduce your CTS symptoms. It is recommended that a health professional is consulted before doing these exercises frequently or intensely. This will allow them to assess and prescribe exercises that are appropriate to your injury as well as adjust technique to help prevent potential worsening of symptoms.

 

 

 

         

 

  

 

 

 

 

 

 

 

Median Nerve Glider/Flosser

 What if mine is severe or not improving with treatment?

Surgery may be indicated for individuals with symptoms that persist following a course of conservative treatment, or for those with severe symptoms (3). Other indications for surgery include (7):

• Several weeks to months of failed conservative management
• Loss of thumb strength, sensation and/or coordination in fingers
• Tumors or growths that need to be removed
• Damage to the median nerve (on imagery or loss of strength) or at risk of damaging the median nerve

In the U.S 40% of those with CTS undergo surgery and in the U.K, 31%. Post-operative rehabilitation for carpal tunnel release surgeries focus on improving the recovery time from the operation, managing the symptoms related to the surgery as well as improving wrist function through strengthening and mobility exercises (3).

Risk and complication rates for carpal tunnel release procedures sits at less than 1% (7). These potential complications usually surround median nerve or other structures that may have been damaged during the operation (7). Possible infections and tenderness around the scar are other possibilities if a surgical procedure is undertaken for CTS (7).

Summary

CTS can affect up to 4% of the world’s population (1). Physiotherapists offer a range of treatment methods and exercises that can help to reduce symptoms or rehabilitate the injured structures. If a period of conservative treatment causes little to no improvement and/or you have a severe diagnosis CTS or CTS with complications then a surgical route may be pursued.

If you have symptoms similar to, or any questions regarding CTS then feel free to contact myself (details below) or your trusted healthcare professional.

 

 

Alec Lablache
POGO Physiotherapist
Featured in the Top 50 Physical Therapy Blog

Book an Appointment with Alec here

 

References:

1. Bobowik, P. Ż. (2019). Effectiveness of physiotherapy in carpal tunnel syndrome (CTS). Postępy Rehabilitacji, 2019(2), 47-58. doi:10.5114/areh.2019.85023

1. Duckworth, Andrew D., MBChB, MSc, Jenkins, P. J., MBBS, & McEachan, J. E., MBBS. (2014). Diagnosing carpal tunnel syndrome. Journal of Hand Surgery, 39(7), 1403-1407. doi:10.1016/j.jhsa.2014.03.039
2. Whitehead, L. (2018). Rehabilitation following carpal tunnel release: A cochrane review summary. International Journal of Nursing Studies, 79, 167-168. doi:10.1016/j.ijnurstu.2017.08.012
3. Chesterton, L. S., Blagojevic-Bucknall, M., Burton, C., Dziedzic, K. S., Davenport, G., Jowett, S. M., . . . Roddy, E. (2018). The clinical and cost-effectiveness of corticosteroid injection versus night splints for carpal tunnel syndrome (INSTINCTS trial): An open-label, parallel group, randomised controlled trial. The Lancet (British Edition), 392(10156), 1423-1433. doi:10.1016/s0140-6736(18)31572-1
4. Mayo Clinic. (2020). Carpal Tunnel Syndrome, diagnosis and treatment. Retireved from https://www.mayoclinic.org/diseases-conditions/carpal-tunnel-syndrome/diagnosis-treatment/drc-20355608
5. Gale OneFile. (2019). Carpal Tunnel Syndrome Exercises. Retrieved from: https://go-gale-com.elibrary.jcu.edu.au/ps/i.do?p=HRCA&u=james_cook&id=GALE%7CA587016782&v=2.1&it=r&sid=summon (pics)
6. Garfinkel, M. S., Singhal, A., Katz, W. A., Allan, D. A., Reshetar, R., & Schumacher, J., H. Ralph. (1998). Yoga-based intervention for carpal tunnel syndrome: A randomized trial. JAMA : The Journal of the American Medical Association, 280(18), 1601-1603. doi:10.1001/jama.280.18.1601