Physiatric Management of Carpal Tunnel Syndrome

Abstract

Carpal Tunnel Syndrome (CTS) is the most common entrapment neuropathy of the upper limb. Diagnosis of CTS was rare before middle of the nineteenth century but in recent years it continues to be made with increasing frequency by the virtue of wide spread public awareness and highly specific diagnostic tests. Individuals engaged in repetitive works which involves flexion and extension of the wrist, strong grip or exposure to vibration are particularly at risk of developing the disease. It is now accounted amongst the common work related claimed disabilities in our country.

Full text

KYAMC Journal       Vol. 10, No.4, January 2020
Review Article
Physiatric Management of Carpal
Tunnel Syndrome
Md. Israt Hasan1, Mohammed Emran2, Fatema Newaz3, Md. Atiquzzaman4, Tawfiq Morshed5,
Amitav Banik6, A B M Zafar Sadeque7, Shaila Sharmin8.
1. Medical Officer, Department of Physical Medicine and Rehabilitation, Kurmitola General hospital, Dhaka, Bangladesh.
2. Assistant Professor, Department of Physical Medicine and Rehabilitation, KwajaYunus Ali Medical College, Sirajganj, Bangladesh.
3. Assistant Professor, Department of Physical Medicine and Rehabilitation, Kumudini Womens Medical College, Tangail, Bangladesh.
4. Medical Officer, Department of Physical Medicine and Rehabilitation, Kurmitola General hospital, Dhaka, Bangladesh.
5. Registrar, Department of Orthopedics, Kurmitola General Hospital, Dhaka, Bangladesh.
6. Assistant Professor, Department of Physical Medicine and Rehabilitation Sir Salimullah Medical College, Dhaka, Bangladesh
7. Assistant Professor, Department of Physical Medicine and Rehabilitation, Shahid Sheikh Abu Nasser Specialized Hospital, Khulna, Bangladesh
8. Consultant, Nrayangonj Diabetic Hospital, Narayangonj, Bangladesh.
Correspondent: Md. Israt Hasan, Medical Officer, Department of Physical Medicine and Rehabilitation, Kurmitola General Hospital, Dhaka,
Bangladesh. Mobile:+8801711-222912, E-mail: isratpmr@gmail.com
Introduction
CTS, the most common focal peripheral neuropathy, results
from compression of the median nerve at the wrist.1 The most
common finding in CTS is an increased carpal tunnel
pressure.2 It used to be unclear whether this was due to a
reduction of the size of the carpal tunnel or an increase of its
content, but several authors have stated that the increase in
volume is caused by a non-inflammatory synovial fibrosis of
the connective tissue within the carpal tunnel.3 The syndrome
affects an estimated 3 percent of adult Americans and is
approximately three times more common in women than in
men.4 Patients complains of paresthesia in the hand along the
distribution of the median nerve and often pain radiates to the
arm. The syndrome intensified at night and the patient tries to
get relief by shaking the hand in the air.
Synonyms
CTS have some special synonyms. They are:
n Tardy median nerve palsy5
n Acroparesthesia6
n Median neuritis
n Median thenar neuritis
n Occupational median neuritis
n Thenar neural atrophy
Historical Background
Sir James Paget first described the symptoms of CTS in 1854
and in 1911 Ramsey Hunt described this neuropathy.7 Phalen
wrote several article on CTS since 1950.8
Abstract
Carpal Tunnel Syndrome (CTS) is the most common entrapment neuropathy of the upper limb. Diagnosis of
CTS was rare before middle of the nineteenth century but in recent years it continues to be made with
increasing frequency by the virtue of wide spread public awareness and highly specific diagnostic tests.
Individuals engaged in repetitive works which involves flexion and extension of the wrist, strong grip or
exposure to vibration are particularly at risk of developing the disease. It is now accounted amongst the
common work related claimed disabilities in our country.
Keywords: CTS, Physiatric Management.
Date of received: 13.06.2019.
Date of acceptance: 25.11.2019. KYAMC Journal. 2020;10(4): 206-210 .
DOI: https://doi.org/10.3329/kyamcj.v10i4.45721
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Incidence and Epidemiology
A recent study shows that the mean annual crude incidence
was 329 cases per 100,000 person-years, and the standardized
incidence was 276. The sex-specific incidences were 139 for
men and 506 for women. The mean annual incidence for men
increased moderately but significantly during the study period,
whereas that for women remained constant. The age-specific
incidence for women increased gradually with age, reaching a
peak between 50 and 59 years, after which it declined. In men,
there was a bimodal distribution with peaks between 50 and 59
years and between 70 and 79 years. Rural and industrial areas
had higher crude and age- and sex-specific incidences than did
urban areas.9
Anatomy and Etiology
The carpal tunnel consists of the flexor tendons and the
median nerve. These structures are surrounded by the sub-
synovial connective tissue (SSCT), which consists of multiple
layers of fibrous tissue that are interconnected by collagenous
fibers.10,11,12 Guimberteau reported that blood and lymphatic
vessels, which irrigate the tendons, are also present in the
SSCT.13 The SSCT is surrounded by a radial and ulnar
bursa.14,15,16,17,18,19 A non-inflammatory synovial fibrosis of the
connective tissue is the most common finding in carpal tunnel
syndrome.20,21,22,23 but the reason why this fibrosis develops
remains unclear.
Pathophysiology
CTS is the classic example of a chronic compression
neuropathy. The entrapment neuropathy combines phenomena
of compression and traction. Nerve compression and
traction may cause disorders of the intra neural
microcirculation, lesions in the myelin sheath and the axon,
as well as alterations in the supporting connective tissue.
The entrapment of a peripheral nerve occurs as a result
of its passage through an anatomical compartment that
has become too tight, resulting in altered function within the
nerve and dysfunction/damage of the nerve from the site
of compression and beyond.24 The pathophysiology of CTS
is complex and results from interactions of many mechanisms
like increased carpal tunnel pressure25, Median nerve
microcirculation injury26, Median nerve connective tissue
alteration27 ,28 synovial tissue hypertrophy29,30 has been
proposed.
Presentation
n Fullness of the wrist
n Poor dexterity of the fingers and droping of items
nParesthesia and numbness of the fingers and nocturnal
dysesthesia
n Pain worsening at night which is relived by shaking the hand
in the air.31
Clinical Findings
The median nerve is accessible in front of the wrist flexion
crease and behind the long palmar tendon or in the middle of
the wrist.
n Tinel sign: The sensitivity is between 26 and 79% and the
specificity is between 40 and 100%.32
n Phalen sign: The sensitivity is between 67 and 83% and the
specificity is between 47 and 100%.32,33
n Paley and Mc Murphy test: the sign is positive if manual
pressure close to the median nerve (between 1 and 2 cm
proximally to the wrist flexion crease) triggers pain or
paresthesia. The sensitivity is 89% and the specificity is
45%.32,34
n Compression test with wrist flexed: pressure is applied
using two fingers on the median region of the carpal tunnel,
with the wrist flexed at 60°, elbow extended and forearm
supinated. The test is positive if paresthesia appears in the area
of the median nerve. Tetro et al. found sensitivity of 82% and
specificity of 99%.31
Diagnosis
The diagnosis of CTS is based on the history and physical
examination. Nerve Conduction Study (NCS) is recognized as
the diagnostic standard for it.35 NCS considered positive when
the median nerve sensory latency exceeds the standard radial
and ulnar nerve sensory latency by more than 0.4 millisecond.
MRI of wrist proves both sensitive and specific in detecting
CTS.37
Management
Non surgical management with rehabilitation of the affected
condition in the department of Physical Medicine and
Rehabilitation is popularly known as Physiatric management.
A trial of physiatric or conservative management can be
pursued after diagnosis.38,39
A) Drug management
1) NSAIDs: NSAID have little effect in relieving the
symptoms and night pain but are recommended as primary
treatment by some authors.40,41
2) Diuretics: Chang et al found that Trichlorthiazide 2mg daily
for 4 weeks is less effective than NSAIDs and Prednisolone.42
3) Vitamin B6: Vitamin B6 is effective in selected cases of
CTS and help in relieving symptoms earlier.43
4) Oral Steroid: A significant improvement shown by using
prednisolone 25 mg/day with two and four weeks of
treatment.42,44,45
B) Interventional Physiatry
Corticosteroid injections are used frequently to treat CTS as it
is considered to be both safe and effective for short term
management.46 Pathology specimens from carpal tunnel
release have revealed chronic synovial inflammation, and it is
suggested that corticosteroid injections are effective by
decreasing the swelling of the flexor synovialis. A common
belief is that corticosteroid injections can relieve the early
symptoms of CTS.47 Intra lesional corticosteroid injection
improves VAS scores and Boston carpal tunnel
questionnaire (BCTQ) either the symptom severity or
functional capacity for mild to moderate CTS.48
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Ultrasound-guided hydrodissection has recently been proposed
to treat nerve entrapment. Hydrodissection leads to improved
nerve mobility, greater reduction in symptoms, or decreased
recurrence rate in comparison with regular ultrasound-guided
injections.49-51
C) Physical Modalities
Iontophoresis is a method of transdermal administration of
ionized drugs in which electrically charged molecules are
propelled through the skin by an external electrical field.52
Advantages of steroid iontophoresis include being painless,
noninvasive, sterile and providing local and little systemic
concentration of the drug.52
Therapeutic ultrasound is a modality that produces acoustical
high-frequency vibrations with both thermal and non thermal
effects.53 Deep, pulsed ultrasound over the carpal tunnel for 15
min for 20 treatments decreases pain and paresthesia
symptoms, reduces sensory loss, and improves median nerve
conduction and strength when compared with sham
ultrasound.54-56
D) Therapeutic Splinting
Splinting is a relatively inexpensive, non operative treatment
for CTS. As CTS has been associated with forceful, repetitive
hand and wrist activities, one purpose of splinting is to
minimize motion at the wrist and subsequently decrease
symptoms of pain and/or numbness.57,58 Splinting is helpful for
the common symptom of nocturnal paresthesias by limiting
prolonged periods of excessive wrist flexion or extension
during sleep. Positions of wrist flexion and extension causes
increased pressure within the carpal tunnel, similar to the
findings of increased pressure in the carpal tunnel with CTS,
and is associated with changes in nerve structure.59.60 Neutral
wrist position results in lower carpal tunnel pressures
compared with flexion or extension. 61,62
E) Exercise
Mobilization exercises (e.g., tendon gliding and nerve gliding)
are commonly employed for symptoms of CTS and are felt to
improve axonal transport and nerve conduction.63 Tendon and
nerve gliding exercises may maximize the relative excursion
of the median nerve in the carpal tunnel and the excursion of
the flexor tendons relative to one another.64
F) Acupuncture
Acupuncture may be useful as an adjunct treatment or an
acceptable alternative for managing CTS.65
G) Activities of daily living (ADL)
Changing the workstation and design of tools to eliminate the
stimuli for cumulative trauma can be both preventive and
curative.
H) Occupationat therapy
Job modification decreases the incidence of CTS.66
Conclusion
CTS is a frequent genesis of pain and impairment throughout
the population. Nonsurgical interventions are regularly used
for CTS and include medications, splinting, exercises,
modalities and alternative therapies. Although there is no
absolute satisfactory conservative management available at
present, trials suggest that physiatric management which
encompasses pharmacological, non-pharmacological and
rehabilitation aspects seems to offer clear advantages over
surgical options.
Acknowledgment
We would like to thank our esteemed institutions and our
collegues for their support.
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