Carpal Tunnel Syndrome
Carpal Tunnel Syndrome (CTS) is the most frequent musculoskeletal problems in the working age people doing repetitive movements, working on things that had hand arm conveyed pulsation, vigorous manual labor and circuitous movement of the wrist (Roquelaure et al., 2017). Incidence rates in the overall population are approximately 61–120 per 100,000 women and 35–60 per 100,000 men annually. Older women aging between 65-74 years have the highest prevalence that is nearly four times higher in men which is 5.1% compared to 1.3% individually (Padua et al., 2016).
CTS is frequently heard and is extensively researched nerve entrapment condition. The median nerve that is passing through the tight spaced osteofibrous canal known as the carpal tunnel is being squeezed as repetitive and circuitous movement is done. The tight spaced carpal tunnel is where the wrist bones (distal tip of the ulna, radius and the carpometacarpal joint), oblique carpal ligament, median nerve, and digital flexor tendons are anatomically situated. Edema, tendon swelling, hormonal changes, and physical movement can influence the intensified nerve entrapment and at times becomes painful and hand paresthesias occur. In cases where there is in the median nerve weakness, the muscles affected by it cannot be normally innervated causing hand weakness in acute cases (Padua et al., 2016).
Physical Assessment and Examination
On assessment, CTS patients presents with hand pain specifically in the thenar area, weakness or ineptness in the hand or the proximal forearm. Pain at times is felt radiating to the shoulder of the affected hand. There are reports of numbness and tingling sensation in index, thumb, thenar area and arm. When there is severe compression of the median nerve area, patients usually report to waking up at night causing sleep disturbance and may be eased by shaking the hand. Inspection of the hand should paid attention to evidence of swelling, nodules, inflammation, tenderness, atrophy especially in the base of the thumb or the thenar eminence (Chesterton, et al., 2016). To further assess for CTS, palpation of the joints of hand and wrist, range of motion as well as the capillary refill should be checked. Phalen’s test where the patient is asked to flex the wrist and pressing the back of the hands for 1 minute, positive maneuver is when the patient reports to having paresthesias in one or both thumbs or the thumb and the index finger. Positive Tinel’s sign where there is a reproduction of tingling sensation or shock-like feeling that travels from the palm of the hand to the index finger and thumb after the palmar portion of the wrist is tapped with a reflex hammer. Another assessment and examination tool is the carpal compression test where the flexor retinaculum (a tendon that is positioned across the proximal portion of the wrist) is pressed for half a minute to one minute. Positive test is when there is numbness and tingling in the thumb, index finger and middle finger of the pressed hand (Zycowicz, South, Martin-Plank & Dunphy, 2015).
Evidence based Treatment Plan
So far the diagnosis of CTS in primary care does not recommend surgery right away and there is no known best treatment identified. Splinting the wrist especially at night, taking anti-inflammatory medications, steroid injection and referral to the neurosurgeon is what I have witnessed so far in the clinical rotation. Carpal tunnel release or decompression is often believed to be the ultimate solution to solve symptoms in severe cases. It is believed that surgery is better than splinting and corticosteroid injection has temporary benefits compared to surgery (Chesterton et al., 2016). Commonly recommended non-surgical interventions include use of splints, nerve and tendon gliding exercises through physical therapy and activity modification for work related CTS (Lewis, Ross, Coppieters, Vicenzino & Schmid, 2016). For patients with restrictive movements of their wrists and fingers, an x-ray of hands and wrist could be ordered to rule out arthritis. Patients who are pregnant should be informed that paresthesia should be resolved after pregnancy (Zycowicz et al., 2015).
Typing, performing repetitive tasks in endoscopy units, in the factory should be looked into. Work related CTS should have ergonomically altered work spaces. Lifting techniques and applying proper body mechanics in performing jobs, anti-vibrating gloves should be worn by employees who use vibrating tools all day. Patients who do not engage in the aforementioned job should be particular in the stress they put into doing everyday chores at home like gardening and knitting and cleaning. Emphasis on using the nighttime wrist splint and taking non-steroidal anti-inflammatory drugs (NSAIDS) is encouraged (Zycowicz et al., 2015).
Referral to neurosurgeon as to the severity of CTS needed to be timely to prevent damage to the nerve for patients coming in and had positive symptoms when Tinel’s, Phalen’s maneuver and compression tests were performed. Patients should follow up with the primary care provider in 2 weeks or a month when the symptoms are not relieved by taking NSAIDS or splinting during the night. Patient’s portal should be used in updating/ coordinating with the provider as this is open 24/7 and there should be a covering provider for consult when the primary provider is not on duty.
Chesterton, L. S., Dziedzic, K. S., van der Windt, D. A., Davenport, G., Myers, H. L.,Rathod, T., & … Hay, E. M. (2016). The clinical and cost effectiveness of steroid injection compared with night splints for carpal tunnel syndrome: the INSTINCTS randomised clinical trial study protocol. BMC Musculoskeletal Disorders, (1), doi:10.1186/s12891-016-1264-8
Lewis, K. J., Ross, L., Coppieters, M. W., Vicenzino, B., & Schmid, A. B. (2016). Education, night splinting and exercise versus usual care on recovery and conversion to surgery for people awaiting carpal tunnel surgery: a protocol for a randomised controlled trial. BMJ Open, 6(9), e012053. doi:10.1136/bmjopen-2016-012053
Padua, L., Coraci, D., Erra, C., Pazzaglia, C., Paolasso, I., Loreti, C., & … Hobson-Webb, L. D. (2016). Review: Carpal tunnel syndrome: clinical features, diagnosis, and management. The Lancet Neurology, 151273-1284. doi:10.1016/S1474-4422(16)30231-9
Roquelaure, Y., Chazelle, E., Gautier, L., Plaine, J., Descatha, A., Evanoff, B., & … Catherine, B. (2017). Time trends in incidence and prevalence of carpal tunnel syndrome over eight years according to multiple data sources: Pays de la Loire study. Scandinavian Journal Of Work, Environment & Health, 43(1), 75-85. doi:10.5271/sjweh.3594
Zycowicz, M., South, T., Martin-Plank, L. & Dunphy, L.M. (2015). Musculoskeletal problems. In L.M. Dunphy, B.O. Porter, D.J. Thomas & J.E. Winland-Brown (Eds.), Primary care: The art and science if advanced practice nursing. (4th ed., pp.755-839), Philadelphia, PA: F.A.Davis Company