Carpal tunnel syndrome due to repetitive activities has referred to one of the repetitive stress injuries. In some rare diseases such as amyloidosis, leukemia, multiple myeloma, and sarcoidosis, deposition of abnormal substances in and around the carpal tunnel leads to nerve irritation. Prolonged flexion or extension of the wrists under the patients head or pillow during sleep is believed to contribute to the prevalence of nocturnal symptoms. Usually patient complaints pain, numbness and tingling sensation in the hand and fingers. Symptoms worsening at night typically awakening the patient or occurring on bunching up the hand for tasks such as writing.
Carpal tunnel syndrome is the most common cause of acroparaesthesiae often pain and paraesthesiae may be the only symptoms for many months or years. The syndrome is essentially a sensory one; the loss or impairment of superficial sensation affects the thumb, index and middle fingers and may be or may not split the ring finger. There may be wasting and weakness of the thenar muscles. Weakness and atrophy of the abductor pollicis brevis and other muscles supplied by median nerve occur in only the most advanced cases of compression.
Degrees of carpal tunnel syndrome are classified as dynamic, mild, moderate and severe. The pathophysiology of carpal tunnel syndrome is typically demyelination. Secondary axon loss may present in more severe cases. With 20 to 30 mm hg compression, the initial insult is a reduction in epineural blood flow. With wrist extension, intracarpal pressures routinely measure atleast 33 mm hg and often upto mm hg in patients with carpal tunnel syndrome.
Edema in the epineurium and endoneurium is caused by continued or increased pressure. Carpal tunnel syndrome diagnosed by detailed history collection, phalen maneuver, percussion test, two point discrimination test, vibrometry, monofilament test, distal sensory latency and conduction velocity, distal motor latency conduction, upper limb tension tests. X-ray is taken to check for arthritis and fracture. If there is a suspected medical condition that is associated with carpal tunnel syndrome, laboratory tests may be done.
This condition could be mistaken for a brachial neuritis due to cervical intervertebral disc prolapse at C5 — C7 level. Nerve conduction tests on the median nerve help to localize the lesion in the tunnel. Both conservative and surgical management options are available in order to reduce pressure over median nerve. Anyone of the measures alone or in combination can be effective in treating early carpal tunnel syndrome.
Tendon gliding exercises are performed to lubricate and increase gliding of the flexor pollicis longus, flexor digitorum superficialis and flexor digitorum profundus tendons. They are best performed with the hand elevated to concurrently control local edema.
Median nerve gliding exercises and the upper limb tension test with median nerve bias can be used as treatment techniques. Exercise intervention for carpal tunnel syndrome focuses on mobility and strengthening without producing an exacerbation. Stretches for the extrinsic and intrinsic muscles are prescribed for several times each day. If working, a patient should perform them before work. They should be performed slowly and gently; the patient feel only a gentle stretching sensation.
In workplace, modification of the job site or complete ergonomic redesign is typically the most helpful approach. In addition yoga, chiropractics, laser treatment have been advocated. In severe cases surgical division of the transverse carpal ligament relieves the condition. Surgical management includes open carpal tunnel release and endoscopic release. It aims to decompress nerve, to improve excursion and to prevent flexor damage. Splinting is the most popular method of conservative management of carpal tunnel syndrome.
Splints are recommended by the American Academy of Neurology for the Carpal tunnel syndrome with light and moderate pathology. Immobilization of the wrist joint in a neutral position with splint will increase the carpal tunnel volume and minimize the median nerve pressure.
Wrist Splinting in a neutral position will help reduce and may even completely relieve Carpal tunnel syndrome Slater RR et al Ultrasound therapy is more useful in the management of Carpal tunnel syndrome. It has the potential to accelerate normal resolution of inflammation. Ultrasound therapy elicit anti inflammatory and tissue stimulating effects. Ultrasound therapy accelerates the healing process in damaged tissues. Pulsed Ultrasound therapy with the intensity of 1. Nerve and tendon gliding exercises are used in conservative treatment of carpal tunnel syndrome to decrease adhesions and to regulate venous return in nerve bundles Rozmaryn et al.
Nerve and tendon gliding exercises may maximize the relative movement of the median nerve within the Carpal tunnel and the excursion of flexor tendon relative to one another Rempel D, Manojlovic R et al. Wrist splint along with nerve and tendon gliding exercises showed significant improvement in reducing symptoms in Carpal tunnel syndrome. Akalin et al. Ultra sound therapy, splints, nerve and tendon gliding exercises are significantly effective in reducing symptoms in the treatment of Carpal tunnel syndrome. Combination of various treatments is also useful in reducing symptoms in Carpal tunnel syndrome.
Ultrasound therapy helps to increase healing process in damaged tissue. This study aimed to find out the effect of Ultrasound therapy in reducing pain in patients with Carpal tunnel syndrome. There is no significant effect of Splint and Exercises in reducing pain in patients with Carpal Tunnel Syndrome. There is no significant difference between the effect of Ultrasound Therapy, Splint and Exercises and Splint and Exercises in reducing pain in patients with Carpal Tunnel Syndrome.
There is significant effect of Splint and Exercises in reducing pain in patients with Carpal Tunnel Syndrome. There is significant difference between the effect of Ultrasound Therapy, Splint and Exercises and Splint and Exercises in reducing pain in patients with Carpal Tunnel Syndrome. Stated that carpal tunnel syndrome is the most common entrapment neuropathy.
The syndrome is characterised by pain, paraesthesia, and weakness in the median nerve distribution of the hand. The etiology of carpal tunnel syndrome is multifactorial which is contributed by various degrees of local and systemic factors. Symptoms of carpal tunnel syndrome are due to ischemia and impaired axonal transport of the median nerve which results from median nerve compression at the wrist.
Lunborg G, Dahlin LB Elevated pressure inside the carpal tunnel leads to compression. Stated that carpal tunnel syndrome is considered as an inflammatory disorder caused by medical conditions, physical injury or repetitive stress. Stated that carpal tunnel syndrome CTS is caused predominantly by median nerve compression at the wrist because of hypertrophy or oedema of the flexor synovium. Pain is thought to be secondary to nerve ischemia rather than direct physical damage of the nerve. Explained that degree of the carpal tunnel syndrome as dynamic, mild moderate and severe.
In mild cases, patients has intermittent symptoms, decreased light touch, positive digital compression test and positive tinel sign or phalen test may or may not be present. In moderate cases, patients have frequent symptoms, decreased vibratory sense, muscle weakness, positive tinel sign, phalen test and digital compression test. Stated that carpal tunnel syndrome CTS is caused by median nerve compression at the wrist and is considered to be the more common entrapment neuropathy. Symptoms of carpal tunnel syndrome include pain, numbness or tingling sensation, paraesthesia, involving the fingers innervated by the median nerve.
Fracture callus, osteophytes, anomalous muscle bodies, tumours, hypertrophic synovium, and infection as well as gout and other inflammatory conditions can produce increased pressure within the carpal tunnel. Extremes of wrist flexion and extension also elevate pressure within the carpal tunnel.
Carpal Tunnel Syndrome Essay
Intraneural blood flow is affected by compression on nerve. Venular blood flow in a nerve is reduced by pressure as low as twenty to thirty mm Hg. At level of thirty mm Hg, axonal transport is impaired. At forty mm Hg, neurophysiologic changes manifested as sensory and motor dysfunctions are present. Any further increase in pressure will produce sensory and motor block.
At level of sixty to eighty mm Hg, complete cessation of intraneural blood flow is seen. In one study, the carpal tunnel pressure in patients with carpal tunnel syndrome averaged thirty two mm Hg, compared with only about two mm Hg in control subjects. Measured intra carpal canal pressures with the wick catheter in 15 patients with carpal tunnel syndrome and in 12 control subjects. The average pressure in the carpal tunnel was raised significantly in the patients with carpal tunnel syndrome. When the wrist was in neutral position, the mean pressure was 32 millimeters of mercury.
With ninety degrees of wrist flexion the pressure raised to 94 millimeters of mercury. While with ninety degrees of wrist extension the average pressure was millimeters of mercury. The pressure of carpal canal in the control subjects with the neutral position of wrist was 2. Stated that diagnosed Carpal tunnel syndrome has been made in hands of patients during the last seventeen years. The typical patient with this syndrome is a middle-aged housewife with numbness and tingling in the thumb and index, long, and ring fingers, which is worse at night and worse after excessive activity of the hands.
The sensory disturbances both objective and subjective must be directly related to the sensory distribution of the median nerve distal to the wrist but pain may be referred proximal to the wrist as high as the shoulder. There is usually a positive tinel sign over the median nerve at the wrist, and the wrist flexion test is also usually positive. About half of the patients also have some degree of thenar atrophy. Symptoms are worst during night time and often wakeup the patient.
Stated that the cause of the carpal tunnel syndrome is unknown. Any condition which causes pressure on the median nerve at the wrist will result in carpal tunnel syndrome. Common conditions such as obesity, pregnancy, hypothyroidism, arthritis, diabetes, and trauma can lead to carpal tunnel syndrome. Repetitive work such as uninterrupted typing result in tendon inflammation can also cause Carpal tunnel symptoms. Stated that throughout the extremity movement, mobility of the peripheral nerve changes and longitudinal movement of the median nerve mostly occur in the carpal tunnel.
In Carpal tunnel syndrome, this physiologic mobility of the median nerve disappears. Stated that during the exercise there may be redistribution of the point of maximal compression on the median nerve. Carpal tunnel syndrome; 17 years experience in diagnosis and treatment of hands. PubMed Google Scholar. The carpal tunnel syndrome: Clinical evaluation of hands. Clin Orthop ; 29— Sub-clinical entrapment neuropathy in man. Neurol Sci ; — Intramural connective tissue proliferation of median nerve in carpal tunnel.
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