How To Prevent Carpal Tunnel Injury? We all know someone who is struggling to cope with the agony of Carpal Tunnel Syndrome. The tingling, numbness, weakness & shooting pain..... so what is carpal tunnel syndrome? In the wrist, a major nerve, the median nerve and various tendons pass through a narrow space called the carpal tunnel. You may feel pain if this nerve becomes irritated or compressed by swelling in the carpal tunnel. Injury to your nerve may also cause carpal tunnel syndrome. Generally, symptoms occur in your thumb, index finger, middle finger and ring finger because the median nerve provides sensation to those areas. CTS can occur in one or both hands. But did you know that by observing a few simple, preventative measures we can help avoid suffering the agonizing pain of carpal tunnel? Orthopedic specialists recommend that the best preventative measure is wearing mildly-compressive far infrared therapy garments specially designed to align your hands and wrists when working at repetitive tasks by correctly supporting wrist movements. This compressive support is particularly important during those activities which require up-and down or side-to–side movements of your wrist. Further, when working at your computer your wrists should be approximately parallel with your elbows maintaining a 90 degree angle to your keyboard or work surface. Choose specially-designed supportive FIR therapy garments, such as thermal health gloves and wrist body bands to encourage your hands to maintain a natural, relaxed and open posture when using the mouse. It’s also important that you don’t grip the mouse between your thumb and little fingers. Generally, wrist rests should be avoided because of the awkward position they create for your lower arm and it’s best to keep the mouse close to your keyboard to help maintain a relaxed upper body posture. This also encourages you to use your entire arm to move your mouse rather than wrist-straining side-to-side movements. Orthopedic specialist and physiotherapists suggest you avoid resting your wrists on hard surfaces for extended periods, that you choose tools that are ergonomically designed for ease of use and to change hands regularly during repetitive tasks. Activities such as writing, typing, those that involve forceful or repetitive finger or wrist action and the use of vibrating power tools can also increase your risk of developing Carpal Tunnel Syndrome. In the workplace, regularly perform gentle hand stretching exercises, be sure to take frequent rest breaks, and most importantly, wear supportive therapy garments to maintain optimum wrist position and avoid tendon strain. Studies show that adapting your workplace conditions and job demands to your own capabilities will also help reduce your risk of developing carpal tunnel injury. Further, desk and chair height, workstations, the position of your computer keyboard and the tasks you perform should all be individually adjusted to encourage your wrists to maintain a healthy and natural position. It is also worthwhile knowing that some health conditions such as arthritis, diabetes, poor circulation, pregnancy, thyroid disease and being over- weight may make you more susceptible to developing carpal tunnel injury. Far infrared therapy garments are effective pain management tools for these serious health complaints, too. So, by simply paying attention to these very easy strategies you can prevent the strain and injury of this debilitating and painful injury. Far Infrared Medical Organization Copyright 2008 |
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Pathophysiology: Until the advent of electrophysiological testing in the 1940s, this syndrome commonly was thought to be the result
of compression of the brachial plexus by cervical ribs and other structures in the anterior neck region. Now, it is known that the
median nerve is damaged within the rigid confines of the carpal tunnel, initially undergoing demyelination followed by axonal
degeneration. Sensory fibers often are affected first, followed by motor fibers. Autonomic nerve fibers carried in the median nerve also
may be affected.
The risk of development of CTS appears to be associated, at least in part, with a number of different epidemiological factors,
including genetic, medical, social, vocational, avocational, and demographic. A complex interaction probably exists between some or
all these factors, eventually leading to the development of CTS. Definite causative factors, however, are far from clear.
Frequency:
In the US: Incidence is 1-3 cases per 1000 subjects per year; prevalence is approximately 50 cases per 1000 subjects in the general
population. Incidence may rise as high as 150 cases per 1000 subjects per year, with prevalence rates greater than 500 cases per
1000 subjects in certain high-risk groups.
Internationally: A paucity of population-based studies exists; however, the incidence and prevalence in developed countries seems
similar to the United States (eg, incidence in the Netherlands is approximately 2.5 cases per 1000 subjects per year; prevalence in
the United Kingdom is from 70-160 cases per 1000 subjects). CTS is almost unheard of in some developing countries (eg, among
nonwhite South Africans).
Mortality/Morbidity: The syndrome is not fatal, but it can lead to complete irreversible median nerve damage with consequent severe
loss of hand function if left untreated.
Race: Whites are probably at highest risk. The syndrome appears to be very rare in some racial groups (eg, nonwhite South Africans).
In North America, white US Navy personnel have CTS at a rate 2-3 times that of black personnel.
Sex: The female-to-male ratio is 3-10:1.
Age: The peak age of development of CTS is from 45-60 years. Only 10% of CTS patients are younger than 31 years.
Carpal tunnel syndrome (CTS) is a collection of characteristic symptoms and signs that occurs following entrapment of the median
nerve within the carpal tunnel. Usual symptoms include numbness, paresthesias, and pain in the median nerve distribution. These
symptoms may or may not be accompanied by objective changes in sensation and strength of median-innervated structures in the
hand.
Pathophysiology: Until the advent of electrophysiological testing in the 1940s, this syndrome commonly was thought to be the result
of compression of the brachial plexus by cervical ribs and other structures in the anterior neck region. Now, it is known that the
median nerve is damaged within the rigid confines of the carpal tunnel, initially undergoing demyelination followed by axonal
degeneration. Sensory fibers often are affected first, followed by motor fibers. Autonomic nerve fibers carried in the median nerve also
may be affected.
The cause of the damage is subject to some debate; however, it seems likely that abnormally high carpal tunnel pressures exist in
patients with CTS. This pressure causes obstruction to venous outflow, back pressure, edema formation, and, ultimately, ischemia in
the nerve.
The risk of development of CTS appears to be associated, at least in part, with a number of different epidemiological factors,
including genetic, medical, social, vocational, avocational, and demographic. A complex interaction probably exists between some or
all these factors, eventually leading to the development of CTS. Definite causative factors, however, are far from clear.
Frequency:
In the US: Incidence is 1-3 cases per 1000 subjects per year; prevalence is approximately 50 cases per 1000 subjects in the general
population. Incidence may rise as high as 150 cases per 1000 subjects per year, with prevalence rates greater than 500 cases per
1000 subjects in certain high-risk groups.
Internationally: A paucity of population-based studies exists; however, the incidence and prevalence in developed countries seems
similar to the United States (eg, incidence in the Netherlands is approximately 2.5 cases per 1000 subjects per year; prevalence in
the United Kingdom is from 70-160 cases per 1000 subjects). CTS is almost unheard of in some developing countries (eg, among
nonwhite South Africans).
Mortality/Morbidity: The syndrome is not fatal, but it can lead to complete irreversible median nerve damage with consequent severe
loss of hand function if left untreated.
Race: Whites are probably at highest risk. The syndrome appears to be very rare in some racial groups (eg, nonwhite South Africans).
In North America, white US Navy personnel have CTS at a rate 2-3 times that of black personnel.
Sex: The female-to-male ratio is 3-10:1.
Age: The peak age of development of CTS is from 45-60 years. Only 10% of CTS patients are younger than 31 years.
History: The patient's history often is more important than the physical examination in making the diagnosis of CTS.
Numbness and tingling
The most common complaints include that the hands fall asleep or things slip from the fingers without the person's noticing (loss of
grip, dropping things), as well as numbness and tingling.
Symptoms are usually intermittent and are associated with certain activities (eg, driving, reading the newspaper, crocheting, painting).
Nighttime symptoms that wake the individual are more specific of CTS, especially if the patient relieves symptoms by shaking the
hand/wrist. Bilateral CTS is common, although the dominant hand is usually affected first and more severely than the other hand.
Complaints should be localized to the palmar aspect of the first to the fourth fingers and the distal palm (ie, the sensory distribution of
the median nerve at the wrist). Numbness predominantly in the fifth finger or extending to the thenar eminence or dorsum of the hand
should suggest other diagnoses. A surprising number of CTS patients are unable to localize their symptoms further (eg, whole
hand/arm feeling dead). This generalized numbness may indicate autonomic fiber involvement and does not exclude CTS from the
diagnosis.
Pain
The sensory symptoms above commonly are accompanied by an aching sensation over the ventral aspect of the wrist. This pain can
radiate distally to the palm and fingers or, more commonly, extend proximally along the ventral forearm.
Pain in the epicondylar region of the elbow, upper arm, shoulder, or neck is more likely to be due to other musculoskeletal diagnoses
(eg, epicondylitis) with which CTS commonly is associated. This more proximal pain also should prompt a careful search for other
neurologic diagnoses (eg, cervical radiculopathy).
Autonomic symptoms
Not infrequently, patients report symptoms in the whole hand. Many patients with CTS also complain of a tight or swollen feeling in
the hands and/or temperature changes (eg, hands being cold/hot all the time).
Many patients also report sensitivity to changes in temperature (particularly cold) and a difference in skin color. In rare cases, there
are complaints of changes in sweating. In all likelihood, these symptoms are due to autonomic nerve fiber involvement (the median
nerve carries most autonomic fibers to the whole hand).
Weakness/clumsiness: Loss of power in the hand (particularly for precision grips involving the thumb) does occur; however, in
practice, loss of sensory feedback and pain is often a more important cause of weakness and clumsiness than loss of motor power
per se.
Physical: Clinical examination is important to rule out other neurologic and musculoskeletal diagnoses; however, the examination
often contributes little to the confirmation of the diagnosis of CTS.
Sensory examination
Abnormalities in sensory modalities may be present on the palmar aspect of the first 3 digits and radial one half of the fourth digit.
Semmes-Weinstein monofilament testing or 2-point discrimination may be more sensitive in picking this up; however, in the author's
experience, pinprick sensation is as good as any test.
Sensory examination is most useful in confirming that areas outside the distal median nerve territory are normal (eg, thenar
eminence, hypothenar eminence, dorsum of first web space).
Motor examination: Wasting and weakness of the median-innervated hand muscles (LOAF muscles) may be detectable.
L - First and second lumbricals
O - Opponens pollicis
A - Abductor pollicis brevis
F - Flexor pollicis brevis
Special tests: No good clinical test exists to support diagnosis of CTS.
Hoffmann-Tinel sign
Gentle tapping over the median nerve in the carpal tunnel region elicits tingling in the nerve's distribution.
This sign still is commonly looked for despite the low sensitivity and specificity.
Phalen sign
Tingling in the median nerve distribution is induced by full flexion (or full extension for reverse Phalen) of the wrists for up to 60
seconds
This test has 80% specificity but lower sensitivity.
The carpal compression test
This test involves applying firm pressure directly over the carpal tunnel, usually with the thumbs, for up to 30 seconds to reproduce
symptoms.
Reports indicate that this test has a sensitivity of up to 89% and a specificity of 96%.
Palpatory diagnosis
This test involves examining the soft tissues directly overlying the median nerve at the wrist for mechanical restriction.
This palpatory test has been noted to have a sensitivity over 90% and a specificity of 75% or greater.
The square wrist sign
The ratio of the wrist thickness to wrist width is greater than 0.7.
This test has a modest sensitivity/specificity of 70%.
Several other tests have been advocated but rarely provide additional information beyond what the Phalen and square wrist signs
provide.
Causes: Note that CTS is associated with many different factors. In particular, the more the hand and wrist are used, the greater the
symptoms. This observation does not necessarily mean that using the hand and wrist causes the syndrome or that more median
nerve damage ensues. Association should not be assumed to signify causation.
Demographics
Increasing age
Female sex
Increased body mass index (BMI), especially recent increases
Square-shaped wrist
Short stature
Dominant hand
Race (white)
Genetics
A strong family susceptibility exists, probably related to multiple inherited characteristics (eg, square wrist, thickened transverse
ligament, stature).
A number of inherited medical conditions also are associated with CTS (eg, diabetes, thyroid disease, hereditary neuropathy with
liability to pressure palsies).
Medical conditions
Wrist fracture (Colles)
Acute severe flexion/extension injury of wrist
Space-occupying lesions within the carpal tunnel (eg, flexor tenosynovitis, ganglions, hemorrhage, aneurysms, anomalous muscles,
various tumors, edema)
Diabetes
Thyroid disorders (usually myxoedema)
Rheumatoid arthritis and other inflammatory arthritides of the wrist
Recent menopause (including post-oophorectomy)
Renal dialysis
Acromegaly
Amyloidosis
Vocational/avocational: Activities involving (1) prolonged severe force through the wrist, (2) prolonged extreme posture of the wrist, (3)
high amounts of repetitive movements, and (4) exposure to vibration and/or cold may be associated with CTS (particularly in
combination).
Other factors
Lack of aerobic exercise
Pregnancy and breastfeeding
Use of wheelchairs and/or walking aids
There are several common causes of CTS, including:
Arthritis or wrist fracture
Pregnancy
Diabetes
Repetitive movements or overuse, such as typing or sport
Thyroid disease
of compression of the brachial plexus by cervical ribs and other structures in the anterior neck region. Now, it is known that the
median nerve is damaged within the rigid confines of the carpal tunnel, initially undergoing demyelination followed by axonal
degeneration. Sensory fibers often are affected first, followed by motor fibers. Autonomic nerve fibers carried in the median nerve also
may be affected.
The risk of development of CTS appears to be associated, at least in part, with a number of different epidemiological factors,
including genetic, medical, social, vocational, avocational, and demographic. A complex interaction probably exists between some or
all these factors, eventually leading to the development of CTS. Definite causative factors, however, are far from clear.
Frequency:
In the US: Incidence is 1-3 cases per 1000 subjects per year; prevalence is approximately 50 cases per 1000 subjects in the general
population. Incidence may rise as high as 150 cases per 1000 subjects per year, with prevalence rates greater than 500 cases per
1000 subjects in certain high-risk groups.
Internationally: A paucity of population-based studies exists; however, the incidence and prevalence in developed countries seems
similar to the United States (eg, incidence in the Netherlands is approximately 2.5 cases per 1000 subjects per year; prevalence in
the United Kingdom is from 70-160 cases per 1000 subjects). CTS is almost unheard of in some developing countries (eg, among
nonwhite South Africans).
Mortality/Morbidity: The syndrome is not fatal, but it can lead to complete irreversible median nerve damage with consequent severe
loss of hand function if left untreated.
Race: Whites are probably at highest risk. The syndrome appears to be very rare in some racial groups (eg, nonwhite South Africans).
In North America, white US Navy personnel have CTS at a rate 2-3 times that of black personnel.
Sex: The female-to-male ratio is 3-10:1.
Age: The peak age of development of CTS is from 45-60 years. Only 10% of CTS patients are younger than 31 years.
Carpal tunnel syndrome (CTS) is a collection of characteristic symptoms and signs that occurs following entrapment of the median
nerve within the carpal tunnel. Usual symptoms include numbness, paresthesias, and pain in the median nerve distribution. These
symptoms may or may not be accompanied by objective changes in sensation and strength of median-innervated structures in the
hand.
Pathophysiology: Until the advent of electrophysiological testing in the 1940s, this syndrome commonly was thought to be the result
of compression of the brachial plexus by cervical ribs and other structures in the anterior neck region. Now, it is known that the
median nerve is damaged within the rigid confines of the carpal tunnel, initially undergoing demyelination followed by axonal
degeneration. Sensory fibers often are affected first, followed by motor fibers. Autonomic nerve fibers carried in the median nerve also
may be affected.
The cause of the damage is subject to some debate; however, it seems likely that abnormally high carpal tunnel pressures exist in
patients with CTS. This pressure causes obstruction to venous outflow, back pressure, edema formation, and, ultimately, ischemia in
the nerve.
The risk of development of CTS appears to be associated, at least in part, with a number of different epidemiological factors,
including genetic, medical, social, vocational, avocational, and demographic. A complex interaction probably exists between some or
all these factors, eventually leading to the development of CTS. Definite causative factors, however, are far from clear.
Frequency:
In the US: Incidence is 1-3 cases per 1000 subjects per year; prevalence is approximately 50 cases per 1000 subjects in the general
population. Incidence may rise as high as 150 cases per 1000 subjects per year, with prevalence rates greater than 500 cases per
1000 subjects in certain high-risk groups.
Internationally: A paucity of population-based studies exists; however, the incidence and prevalence in developed countries seems
similar to the United States (eg, incidence in the Netherlands is approximately 2.5 cases per 1000 subjects per year; prevalence in
the United Kingdom is from 70-160 cases per 1000 subjects). CTS is almost unheard of in some developing countries (eg, among
nonwhite South Africans).
Mortality/Morbidity: The syndrome is not fatal, but it can lead to complete irreversible median nerve damage with consequent severe
loss of hand function if left untreated.
Race: Whites are probably at highest risk. The syndrome appears to be very rare in some racial groups (eg, nonwhite South Africans).
In North America, white US Navy personnel have CTS at a rate 2-3 times that of black personnel.
Sex: The female-to-male ratio is 3-10:1.
Age: The peak age of development of CTS is from 45-60 years. Only 10% of CTS patients are younger than 31 years.
History: The patient's history often is more important than the physical examination in making the diagnosis of CTS.
Numbness and tingling
The most common complaints include that the hands fall asleep or things slip from the fingers without the person's noticing (loss of
grip, dropping things), as well as numbness and tingling.
Symptoms are usually intermittent and are associated with certain activities (eg, driving, reading the newspaper, crocheting, painting).
Nighttime symptoms that wake the individual are more specific of CTS, especially if the patient relieves symptoms by shaking the
hand/wrist. Bilateral CTS is common, although the dominant hand is usually affected first and more severely than the other hand.
Complaints should be localized to the palmar aspect of the first to the fourth fingers and the distal palm (ie, the sensory distribution of
the median nerve at the wrist). Numbness predominantly in the fifth finger or extending to the thenar eminence or dorsum of the hand
should suggest other diagnoses. A surprising number of CTS patients are unable to localize their symptoms further (eg, whole
hand/arm feeling dead). This generalized numbness may indicate autonomic fiber involvement and does not exclude CTS from the
diagnosis.
Pain
The sensory symptoms above commonly are accompanied by an aching sensation over the ventral aspect of the wrist. This pain can
radiate distally to the palm and fingers or, more commonly, extend proximally along the ventral forearm.
Pain in the epicondylar region of the elbow, upper arm, shoulder, or neck is more likely to be due to other musculoskeletal diagnoses
(eg, epicondylitis) with which CTS commonly is associated. This more proximal pain also should prompt a careful search for other
neurologic diagnoses (eg, cervical radiculopathy).
Autonomic symptoms
Not infrequently, patients report symptoms in the whole hand. Many patients with CTS also complain of a tight or swollen feeling in
the hands and/or temperature changes (eg, hands being cold/hot all the time).
Many patients also report sensitivity to changes in temperature (particularly cold) and a difference in skin color. In rare cases, there
are complaints of changes in sweating. In all likelihood, these symptoms are due to autonomic nerve fiber involvement (the median
nerve carries most autonomic fibers to the whole hand).
Weakness/clumsiness: Loss of power in the hand (particularly for precision grips involving the thumb) does occur; however, in
practice, loss of sensory feedback and pain is often a more important cause of weakness and clumsiness than loss of motor power
per se.
Physical: Clinical examination is important to rule out other neurologic and musculoskeletal diagnoses; however, the examination
often contributes little to the confirmation of the diagnosis of CTS.
Sensory examination
Abnormalities in sensory modalities may be present on the palmar aspect of the first 3 digits and radial one half of the fourth digit.
Semmes-Weinstein monofilament testing or 2-point discrimination may be more sensitive in picking this up; however, in the author's
experience, pinprick sensation is as good as any test.
Sensory examination is most useful in confirming that areas outside the distal median nerve territory are normal (eg, thenar
eminence, hypothenar eminence, dorsum of first web space).
Motor examination: Wasting and weakness of the median-innervated hand muscles (LOAF muscles) may be detectable.
L - First and second lumbricals
O - Opponens pollicis
A - Abductor pollicis brevis
F - Flexor pollicis brevis
Special tests: No good clinical test exists to support diagnosis of CTS.
Hoffmann-Tinel sign
Gentle tapping over the median nerve in the carpal tunnel region elicits tingling in the nerve's distribution.
This sign still is commonly looked for despite the low sensitivity and specificity.
Phalen sign
Tingling in the median nerve distribution is induced by full flexion (or full extension for reverse Phalen) of the wrists for up to 60
seconds
This test has 80% specificity but lower sensitivity.
The carpal compression test
This test involves applying firm pressure directly over the carpal tunnel, usually with the thumbs, for up to 30 seconds to reproduce
symptoms.
Reports indicate that this test has a sensitivity of up to 89% and a specificity of 96%.
Palpatory diagnosis
This test involves examining the soft tissues directly overlying the median nerve at the wrist for mechanical restriction.
This palpatory test has been noted to have a sensitivity over 90% and a specificity of 75% or greater.
The square wrist sign
The ratio of the wrist thickness to wrist width is greater than 0.7.
This test has a modest sensitivity/specificity of 70%.
Several other tests have been advocated but rarely provide additional information beyond what the Phalen and square wrist signs
provide.
Causes: Note that CTS is associated with many different factors. In particular, the more the hand and wrist are used, the greater the
symptoms. This observation does not necessarily mean that using the hand and wrist causes the syndrome or that more median
nerve damage ensues. Association should not be assumed to signify causation.
Demographics
Increasing age
Female sex
Increased body mass index (BMI), especially recent increases
Square-shaped wrist
Short stature
Dominant hand
Race (white)
Genetics
A strong family susceptibility exists, probably related to multiple inherited characteristics (eg, square wrist, thickened transverse
ligament, stature).
A number of inherited medical conditions also are associated with CTS (eg, diabetes, thyroid disease, hereditary neuropathy with
liability to pressure palsies).
Medical conditions
Wrist fracture (Colles)
Acute severe flexion/extension injury of wrist
Space-occupying lesions within the carpal tunnel (eg, flexor tenosynovitis, ganglions, hemorrhage, aneurysms, anomalous muscles,
various tumors, edema)
Diabetes
Thyroid disorders (usually myxoedema)
Rheumatoid arthritis and other inflammatory arthritides of the wrist
Recent menopause (including post-oophorectomy)
Renal dialysis
Acromegaly
Amyloidosis
Vocational/avocational: Activities involving (1) prolonged severe force through the wrist, (2) prolonged extreme posture of the wrist, (3)
high amounts of repetitive movements, and (4) exposure to vibration and/or cold may be associated with CTS (particularly in
combination).
Other factors
Lack of aerobic exercise
Pregnancy and breastfeeding
Use of wheelchairs and/or walking aids
There are several common causes of CTS, including:
Arthritis or wrist fracture
Pregnancy
Diabetes
Repetitive movements or overuse, such as typing or sport
Thyroid disease
| Diabetes A report released this week shows that 1.4 million Australians now suffer Type 2 diabetes, showing a dramatic increase in the last 15 years. |