Carpal Tunnel Syndrome

Description

Alternative Names

Treatment

It is critical to begin treating early phases of carpal tunnel syndrome before the damage progresses. A conservative approach to CTS is the first step in treating this disorder, which may include corticosteroid injections and splinting. Nevertheless, relapse is common and studies suggest that surgery is a better option for severe CTS. In one study, 89% of patients who had conservative treatments suffered a recurrence of symptoms within a year. Conservative treatment works best in men under 40 and least well in young women. The conservative approach is also most successful in patients with mild carpal tunnel syndrome. According to one study, however, even among these patients, 60% can expect a relapse. Some researchers are reporting better results when specific exercises for carpal tunnel are added to the program.

Limiting Movement. If possible, the patient should avoid activities at work or home that may aggravate the syndrome. The affected hand and wrist should be rested for two to six weeks. This allows the swollen, inflamed tissues to shrink and relieves pressure on the median nerve. If the injury is work related, the worker should ask to see if other jobs are available that will not involve the same actions. Few studies have been conducted on ergonomically designed furniture or equipment or frequent rest breaks, but it is reasonable to ask for these if other work is not available.

Conservative Treatment Approach. In a major analysis, the following conservative approaches were shown to provide symptom relief:

• Wrist splints.
• Corticosteroids (steroids). Injected or short-term oral corticosteroids may be tried next if previous methods fail. (People with diabetes may find additional relief by including insulin injections with steroid injections.)
• Yoga. In one study, after eight weeks regular yoga practice reduced pain significantly better than splinting.
• Carpal bone mobilization. This is an approach that uses physical therapy to move the bones and tissues in the wrist.
• Ultrasound. It may be necessary to undergo at least seven weeks of treatment before significant improvement is evident.

A major analysis of other conservative approaches found no significant relief from nonsteroidal anti-inflammatory drugs (NSAIDs), which include common pain relievers such as aspirin and ibuprofen (Advil). The same report also found no benefits from diuretics, which eliminate fluid, or a number of alternative methods, including magnet therapy, laser acupuncture, vitamin B6, exercise or chiropractic care. Other approaches that merit some research include omega-3 fatty acid and cognitive-behavioral therapy.

Treating Any Underlying Condition. It is, of course, important treat any underlying medical condition that might be causing carpal tunnel syndrome. For example, reducing inflammation in rheumatoid arthritis or other forms of inflammatory disorders that directly cause CTS is very helpful.

Treatments for diseases only associated with carpal tunnel, such as hypothyroid or diabetes may not be as effective for relieving CTS symptoms. Some interesting research involves injections of insulin into the median nerves of patients with type 2 diabetes mellitus who had mild to moderate CTS. Insulin has a nerve regenerating effect. In one study, after an initial steroid injection, seven weekly insulin injections proved significantly beneficial compared to placebo. Further research is needed on this therapy.

Wrist Splints

Wrist splints are used to keep the wrist from bending. They are not as beneficial as surgery for patients with moderate to severe CTS, but they appear to be helpful in specific patients. In one study, the best success rates were in patients with mild to moderate nighttime symptoms of less than a year's duration. In selected patients, up to 80% report fewer symptoms, usually within days of wearing the sprint.

Although typically the splint is worn at night or during sports, one 2000 study reported that wearing it full time is most beneficial. (In the study, few patients actually complied with the regimen and wore them full time, but any regular use appeared to improve nerve function and symptoms.) The splint is used for several weeks or months depending on the severity of the problem, and may be combined with hand and finger exercises.

Corticosteroids

Corticosteroid Injections. Corticosteroids (also called steroids) reduce inflammation. If restriction of activities and the use of painkillers are unsuccessful, the doctor may inject a corticosteroid into the carpal tunnel. Some experts recommend them for patients with CTS whose symptoms are intermittent and there is no evidence of a permanent injury. In CTS, steroid injections (such as cortisone or prednisolone) shrink the swollen tissues and relieve pressure on the nerve. Evidence strongly suggests that they offer relief in more than 75% of CTS patients. It should be noted that the pain may increase for a day or two after the injection and skin color may change.

Unfortunately, in most cases, steroid injections provide only temporary relief. In a major analysis, after one month, these injections were not more effective than placebo (sham) injections. Most physicians limit steroid injections to about three per year, since they can cause complications such as rupture of tendons, nerve irritation, or more widespread side effects such as hypertension or elevated blood sugar levels.

Low-Dose Oral Corticosteroids. Short-term use (two to four weeks) of low-dose oral corticosteroids may provide long term relief. In one study, between a third and half of patients who took the corticosteroid prednisolone for two to four weeks were still pain-free after a year. It should be noted that oral steroids can have serious side effects, although they are likely to be minimal when taken in low doses for a brief period.

Yoga and Other Exercise Programs

Yoga. Some evidence suggests that yoga practice may be specifically very helpful for carpal tunnel, since yoga postures are designed to stretch, strengthen, and balance upper body joints. In one study, people who practiced yoga for eight weeks experienced significantly reduced symptoms compared to wrist splints or no treatment at all. Two other small studies also reported improvement in pain relief. Some people anecdotally report that positive effects take a few weeks of regular practice of at least two sessions a week.

General Exercise Program. Some experts have reported that people who are physically fit, including athletes, joggers, and swimmers, have a lower risk for cumulative trauma disorders. Although there is no evidence that exercise can directly improve CTS, a regular exercise regimen using a combination of aerobic and resistance training techniques strengthens the muscles in the shoulders, arms, and back, helps reduce weight, and improves overall health and well-being. In one 2001 study, CTS patients experienced symptom relief and signs of improved nerve conduction after 10 months of participation in an aerobic exercise program. (Such improvements appeared to be due to both weight loss and higher oxygen levels.) One study found that most people with CTS felt improvement after two months of physical therapy that included exercises to improve balance and posture. People with any chronic medical condition or with risk factors for heart disease should check with their physicians about an appropriate regimen.

Physical Therapy and Carpal Bone Mobilization

If symptoms subside, the patient may proceed with a supervised program of joint mobilization and hand and wrist strengthening and stretching, usually offered by physical or occupational therapists. Hand and wrist exercises may be most beneficial for patients with mild to moderate disease who are also treated with splints and other conservative measures.

Ultrasound

Ultrasound employs high-frequency sound waves directed toward the inflamed area. The sound waves are converted into heat in the deep tissues of the hand, which opens the blood vessels and allows oxygen to be delivered to the injured tissue. A major analysis suggested this approach may be effective when used for seven weeks or more.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Nonsteroidal anti-inflammatory drugs (NSAIDs), which include aspirin and ibuprofen (Advil) are the most common pain relievers used for CTS. They block prostaglandins, the substances that dilate blood vessels and cause inflammation and pain. Unfortunately, as with most other medications used for carpal tunnel syndrome, there are few well-conducted studies to determine their role in CTS. To date, there is no evidence that they offer any significant relief and regular use can have serious side effects.

NSAIDs Used. There are dozens of NSAIDs. The most common are the following:

• Over-the-counter NSAIDs include aspirin, ibuprofen (Advil, Nuprin, Motrin IB, Rufen), naproxen (Aleve), ketoprofen (Actron, Orudis KT).
• Prescription NSAIDs include ibuprofen (Motrin), naproxen (Naprosyn, Anaprox), flurbiprofen (Ansaid), diclofenac (Voltaren), tolmetin (Tolectin), ketoprofen (Orudis, Oruvail), dexibuprofen (Seractil), indomethacin (Indocin).

Regular use of even over-the-counter NSAIDs may be hazardous for anyone and has been associated with the following side effects:

• Ulcers and gastrointestinal bleeding. This is the major danger with long-term use of NSAIDs.
• Increased blood pressure. Most NSAIDs appear to pose this risk, with higher risks observed with piroxicam (Feldene), naproxen (Aleve), and indomethacin (Indocin). (Sulindac has the smallest effect and aspirin has no risk.) People with hypertension, severe vascular disease, kidney, or liver problems and those taking diuretics must be closely monitored if they need to take NSAIDs.
• May delay the emptying of the stomach, which could interfere with the actions of other drugs. The elderly are at special risk.
• Dizziness.
• Tinnitus (ringing in the ear)
• Headache.
• Skin rash.
• Depression has also been noted.
• Confusion or bizarre sensation (in some higher-potency NSAIDs, notably indomethacin).
• Possible higher risk for miscarriage (particularly if the NSAID is taken for more than a week or around the time of conception).
• Kidney abnormalities. These have been reported in people taking NSAIDs, which resolve when the drugs are withdrawn. Any sudden weight gain or swelling should be reported to a physician. Anyone with kidney disease should avoid these drugs.
• There is a slight risk for liver abnormalities.

COX-2 Inhibitors (Coxibs). Celecoxib (Celebrex), rofecoxib (Vioxx), and valdecoxib (Bextra) are known as COX-2 (cyclooxygenase-2) inhibitors, or coxibs. They inhibit an inflammation-promoting enzyme called COX-2. Others, such as etoricoxib, are under investigation. Meloxicam (Mobicox) is a related drug known as a preferential COX-2 inhibitor.

Evidence is increasing that the coxibs are significantly less harmful to the gastrointestinal (GI) tract than common NSAIDs. In an important 2003 study, Celebrex had a significantly better safety record in the GI tract than NSAIDs and had lower rates of ulcers even in patients who also needed to take aspirin to prevent heart attacks. Another 2003 study also suggested that rofecoxib was safer for the GI tract than NSAIDs. Some early evidence also suggests that, like NSAIDs, they may be partially protective against colon cancer and possibly even Alzheimer's disease.

In spite of their potential promise, some researchers theorize that inhibiting COX-2 may have some negative side effects over the long term. The effects of these drugs on the heart particularly require clarification.

Other Conservative Approaches

Ice and Warmth. Ice may provide benefit for acute pain. Some patients have reported that alternating warm and cold soaks have been beneficial. (If hot applications relieve pain, most likely the problem is not caused by CTS but by another condition producing similar symptoms.)

Anesthetic Injections. In some cases, injections of an anesthetic (such as lidocaine) may be helpful.

Pheresis. The word "pheresis" means to carry. In the case of carpal tunnel, pheresis is a technique being investigated to deliver (to carry) a corticosteroid cream deep within the wrist. One such technique called iontophoresis uses an electrical current and another called phonophoresis uses ultrasound.

Diuretics. Diuretics, such as trichlormethiazide, which reduce fluid in the body, are sometimes used. Studies are not reporting any significant benefits with these agents, however.

Low-Level Laser Therapy. Some investigators are working with low-level laser therapy (LLLT), which generates extremely pure light in a single wavelength. The procedure is painless, but studies are mixed on whether it is any more effective than sham treatment. One major analysis reported that laser therapy was more effective over time than steroid injections (although it does not appear to provide much immediate relief.) Further research is warranted.

Muscle Stimulation. Two investigative procedures called automated or electrical twitch obtaining intramuscular stimulation (ATOIMS or ETOIMS) are showing promise. ATOIMS uses an automated mechanical device that vibrates the muscle using a tiny pin. (The sensation is described as similar to a mosquito bite.) ETOIMS uses an extremely mild electrical current. They can also be used together. Both approaches cause the muscles to twitch and then relax until the process is completed. Discomfort is minimal. Small studies are reporting some help in relieving a number of conditions that cause chronic pain, including carpal tunnel syndrome.

Alternative Therapies

Many alternative therapies are offered to sufferers of carpal tunnel syndrome and other repetitive stress disorders. Few, however, have any proven benefit.

Vitamin B6 (Pyridoxine). Vitamin B6 (pyridoxine) is often used for carpal tunnel syndrome. Studies have not supported its benefits, however, either in oral or cream form. It should also be noted that excessively high doses of vitamin B6 can be toxic and cause nerve damage.

Acupuncture. Acupuncture may be beneficial. New techniques employing painless laser acupuncture may prove to be particularly effective. The National Institutes of Health issued a Consensus Statement on Acupuncture in 1997 which declared this ancient form of treatment useful as a supplement to standard treatment or even as part of a comprehensive management program for CTS.

Chiropractic Therapies. Chiropractics has been useful for some people whose condition is produced by pinched nerves. In one small study, the technique was as effective as medications or wrist splints for relief of pain, though further research is needed.

Magnets. Magnets are a popular but unproven therapy for pain relief. One small study of patients who wore magnets attached to their wrists showed no benefits over those who wore a nonmagnetic placebo device, although both groups did experience pain relief, perhaps due to a placebo response.

Herbal or Natural Remedies. There are a number of herbal and homeopathic remedies sold for pain relief. A small 2002 British study suggested that preparations containing arnica, a popular remedy for swelling and bruising, may ease discomfort following surgery for carpal tunnel, but a 2003 study reported no advantages compared to placebo (an inactive substance).

People should carefully educate themselves about how alternative therapies may interact with other medications or impact other medical conditions and should check with their physician before trying any of them.

Cognitive Behavioral Therapy and Stress Management

Research indicates that anxiety, depression, and even pain related to CTS can be ameliorated to some extent with cognitive behavioral therapy. The focus of this therapeutic approach is to change negative thinking about one's ability to manage pain. Cognitive behavioral therapy is particularly helpful in defining and setting limits. It may be expensive and not covered by insurance, although it is usually of short duration, typically six to 20 one-hour sessions, plus homework, which usually includes attempting a task that the patient has avoided because of negative thinking. Even if people cannot afford this type of therapy, support groups for carpal tunnel syndrome and other sufferers of repetitive stress injuries can be very helpful for exchanging information, specific advice, and solace. Stress management techniques can also be useful in dealing with the psychologic and emotional issues accompanying these injuries.