Carpal Tunnel Syndrome - What, Why, Treatment
You're sitting at your desk, typing out some notes from the day and begin to feel tingling into your hands. You shake it out and start typing again, but it comes back. From there you might try and stretch your forearms, find some relief from it for the day and finish your notes. However, tomorrow you start typing again and it sets off faster. You might be thinking what the heck is going on. Hopefully this article sheds some light and explains the what, why, and treatment of Carpal Tunnel Syndrome (CTS) to you.
This is not medical advice, purely an informative piece to help bring education to the public. If you are experiencing Carpal Tunnel Syndrome symptoms, you should seek out an appropriate medical provider. We highly recommend http://www.clinicalathlete.com/
What is Carpal Tunnel Syndrome?
Carpal Tunnel Syndrome (commonly just called Carpal Tunnel) is when an individual begins to experience compression of their median nerve within the carpal tunnel and gets symptoms such as pain, numbness and tingling down the arm/hand, and can even lead to weakness.
Why does this occur?
The carpal tunnel is a region of the hand/wrist where the small bones of the wrist (carpal bones) form a “tunnel” to allow tendons of the forearm to pass into the hand. Along with those tendons, the median nerve travels into the hand through this region. This dense region can get compressed for a wide range of reasons - trauma, overuse, secondary to diabetes, hypothyroidism, pregnancy, and occupational factors.
The median nerve supplies motor innervation (muscle usage) to many of the muscles that help with opposition (bringing your thumb and pinky finger together) as well as your muscles that help flex your knuckle joints of your index and middle finger. It also provides sensory innervation to the palm, thumb, index, middle, and half of the ring finger. Due to this, people can experience symptoms of weakness in their with opposition and flexing their ring and middle finger, while also getting numbness and tingling into the hand.
What do I do about it?
Much like many injuries of the body, there is a period which healing requires. There has been a great deal of research showing spontaneous recovery of CTS. This does not mean it instantly heals, but that it got better without treatment. To reassure individuals, average time for recovery is 4-8 weeks with conservative treatment, but it can extend up to 6 months. This range depends upon many factors - particularly the general health of individual.
While we know that many people will recover from it if given enough time, below is what the literature says on possible interventions you could explore to help expedite the process.
Non-surgical treatment (conservative treatment)
If you think you have Carpal Tunnel Syndrome, it is recommended to begin doing “conservative” treatment - like physical therapy - before exploring other options. For most people conservative management can find a resolution to the symptoms.
The treatment options for CTS can vary greatly upon who you ask. So many people have an opinion about the benefits of X, Y, or Z intervention, but we are not here to give recommendations based purely on opinion. Instead, we dug into the best quality evidence we could. We are going to outline what the best quality research says about different treatment options often recommended.
Splinting has a great deal of good support in the literature. In particular, splinting is generally recommended for 2-6 weeks as a means of helping to reduce the overall stress to the wrist. When a splint is used, it is shown to be superior to be used in a neutral wrist position over extension. Finally, it is unclear if using a splint through the day is more beneficial than just at night, but utilizing one at night is very strongly beneficial. It is important to note that once exceeding the 2-6 week timeframe, if symptoms have not resolved, it is likely no longer beneficial to use the splint.
This is often touted as being a beneficial treatment for CTS. However, when it is compared to placebo in higher quality research, it shows no more benefit than placebo. This stands for all varieties of ultrasound. Ultrasound is likely not worth your money or time investment and you could just do other options instead.
From a purely biomechanical standpoint, these have an argument to be made. However, when researched and compared to a standard keyboard, they were no more beneficial for recovery from CTS. If you find relief from changing position of your wrist, then go with that, but don't think it is a requirement.
Nonsteroidal anti-inflammatories (NSAIDs)
CTS often gets described as merely inflammation in the carpal tunnel. However, it is a multifactorial condition that extends beyond just inflammation. In particular, as a chronic condition it is often not respondent to NSAIDs. In fact, when compared to placebo it did not improve symptoms. Ideally NSAIDs are restricted and only utilized in a highly irritated situation for a short time period.
The benefits of acupuncture get touted very highly, particularly by those who have firm beliefs in the Chinese medicine community. When acupuncture treatment gets reviewed and compared to placebo, in regards to CTS management, it showed no benefits over placebo. Much like ultrasound, this is likely not worth your time or money investment.
While there a host of benefits of exercise in general, when we are discussing specifically exercises targeted to CTS we see a myriad of benefits for the individual. Of all of the interventions we have discussed, the two with the most support are wrist splints and exercise. However, the exact kind of exercises that are beneficial is where things get unclear. It seems to be that different kinds of exercises offer different benefits - indicating we likely need to take a wider attack to manage CTS. For example, nerve and tendon glide exercises were shown to be of benefit for two-point discrimination improvements - a measure of sensation that is often lost with CTS - but were not beneficial for most other symptoms. Whereas yoga was shown to be beneficial other measures, such as reducing pain and the phalen’s sign (8 week treatment).
As we described in the article so far, and also in the video, there are a number of different options for exercise.
General exercise - being active can be beneficial, incorporating walking, cycling, and resistance training that is targeted towards the rest of your body can help with symptoms.
Deep breathing - beneficial to help with reducing anxiety and tone management if these are an issue. Including a few minutes of deep calm breathing can often help managing symptoms.
Stretching, range of motion, and self massage - for many of the individuals who deal with CTS, tension in the flexor forearm muscle group is a common complaint. Utilizing some low intensity stretches and self massage can help with the perception of this tension.
Nerve glides - incorporating these into a global approach to managing CTS can be an added benefit, particularly in the recovery of sensation issues. These are not the be all end all, but can be beneficial to include.
Strengthening - developing strength in the musculature of the forearm may offer benefit to some individuals. Strengthening the forearm flexors can be of benefit if your forearm flexors are not sufficiently able to handle whatever tasks you are currently giving them - causing them to be inflamed. Similarly, the forearm extensors may not be sufficiently strong for the activities - such as typing - and it is creating an imbalance of stresses leading to compression in the carpal tunnel. Anecdotally, I’ve seen individuals benefit from strengthening their forearm and hand extensors.
Cervical and thoracic range of motion - the cervical and thoracic spine influence the positioning of the shoulder and arm which can play a factor in the stress on the median nerve. While the research in this realm is lacking (currently one study found that reflected limited cervical spine range of motion in CTS patients), there is no research refuting it either. Having some component of this in the management of CTS should allow for reduction of tension placed on the nerve, reducing irritation. Thoracic extension drills to help reduce any possible nagging nerve related issues at the thoracic spine. As well, with cervical spine being shown in research playing a factor in many CTS cases, we can reduce the stress on the C-spine by getting into a bit more extension.
Possible exercises to include in management:
Side lying thoracic windmill
T-spine extension on roller
Cervical Range of motion
Median Nerve Glide
Wrist extension w/ finger flexion extension
Surgical intervention should be reserved for extreme cases for those who have constant symptoms, severe sensory disturbance, and/or hand motor weakness (via Cochrane). It is generally recommended that individuals attempt conservative intervention for at minimum 6 months, with symptoms lasting at least 9 months, before surgical intervention is used. (Hunter)
Hopefully this overview helps to cover the wide range of questions people have relating to it!
O’Connor D, Marshall S, Massy-Westropp N. Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome (review). The Cochrane Library. 2008;4:1-80.
Hunter J, Davlin LB. Major neuropathies of the upper extremity: The median nerve. In: Hunter J, Schnider L, Mackin E, eds. Rehabilitation of the Hand: Surgery and Therapy. Vol 4. 4th ed. St. Louis: Mosby; 1995:905.
De-La-Llave-Rincon A, Fernadez-De-Las-Penas C, Palacios-Cena D, Cleland JA. Increased forward head posture and restricted cervical range of motion in patients with carpal tunnel syndrome. JOSPT. 2009;39(9):658-666.