December 2005

Getting the Upper Hand

By Christine Muhleman, OTR, CHT

Therapists are working hard to stem the tide of carpal tunnel syndrome cases

Carpal tunnel syndrome (CTS) has been a hot topic in the news for some time, and cases are increasing nationwide. Americans are working longer hours on computers and using more agile workforce technology such as laptops, cell phones, and handheld electronics, which empowers us to work just about anytime, anywhere, often without breaks. While some may hail this trend of always being in touch as a useful convenience, hand therapists are raising warnings that these habits may contribute to an increase in hand ailments like CTS for Americans.

Carpal tunnel syndrome is a painful, progressive condition caused by the compression of the median nerve, a key nerve that travels through the carpal tunnel—the area between a ligament and bones—in the wrist. This constriction, caused by factors including swelling or positional changes, disturbs conduction of the nerve as it passes through the carpal tunnel. Patient-detected symptoms usually start gradually with pain or numbness in the hand and fingers, often initially at night, as well as pain travelling up through the arm. As the condition progresses, patients often feel a consistent tingling, pain, and numbness, or note decreased grip strength and difficulty in using the hand for coordination or manual tasks.

Few direct causes of CTS have been determined or identified. In some people, the carpal tunnel is simply smaller, which can cause stress to the median nerve in the carpal tunnel area. Hand traumas and injuries, such as fractures or sprains, can also lead to CTS. There is a high correlation between incidence of CTS and pregnancy as well.

CAUSES OF CTS
Repetitive overuse of handheld electronics, long periods of time on the computer, or extended video game play also appear to play a role in the inflammation and strain of tendons and muscles. The American Society of Hand Therapists (ASHT) has released several consumer education alerts to build awareness of these CTS threats.

Posture is a major factor related to the development of CTS. Many people work in a forward head posture when using some of these devices, which may contribute to risk factors in cumulative trauma disorders. As the head shifts forward, its weight forces the neck and upper back muscles to work harder. Furthermore, the structural integrity of muscle groups in these regions can become imbalanced, which often compromises proper biomechanical activity and can cause compression on nerves or vessel structures that lie beneath.

According to the US Department of Labor's Occupational Safety and Health Administration (OSHA), repetitive strain injuries are the nation's most common and costly occupational health problem, affecting hundreds of thousands of American workers and costing more than $20 billion a year in workers' compensation. The Bureau of Labor and Statistics and the National Institute for Occupational Safety and Health (NIOSH) have found that CTS accounts for about 50% of all work-related injuries. More than 8 million people are affected by carpal tunnel syndrome each year, with women being twice as likely to develop CTS than men.

TREATMENT SPECIALIZATION
More patients are looking into the specialized practice of hand therapy to treat their painful CTS conditions. Services provided by hand therapists in collaboration with physician care can streamline, expedite, and customize a patient's healing process.

Innovative methods for evaluating and treating CTS have come about in conjunction with rising awareness and concern among hand therapists, insurers, employers, and the public. Hand therapists have been exploring new techniques to address the increasing incidence of this common workforce ailment and are working to develop new treatments and interventions for CTS.

Patients with carpal tunnel syndrome experience a variety of symptoms; until recently, however, no method or scale was in place to systematically and concretely quantify and assess these CTS indicators.

The CTS3 Scale was designed and introduced to professional hand therapists at the September combined Annual Meeting of the American Society of Hand Therapists and the American Society for Surgery of the Hand. CTS3 methodically measures the severity of symptoms as perceived by patients. This scale may someday become the "gold standard" by which severity of symptoms can be assessed, and may lead to better delineation of the best treatment options for each individual.

HAND-TAILORED THERAPY
Traditionally, resting the wrist in a splint has helped to decrease symptoms by minimizing further stress of provocative positions such as extremes of wrist flexion or extension. Hand therapists have been fabricating custom wrist orthoses for patients with CTS for years. Splints are definitely not a one-size-fits-all type of therapy. Hand therapists often tailor the splint to the individual patient's needs and the characteristics of their condition and treatment.

A research study recently unveiled at the national ASHT gathering showed that a slightly different orthosis, a full-hand resting splint placing the wrist in a neutral pose and the MCP (metacarpal) joints in slight flexion, minimizes the pressure in the carpal tunnel. It has been shown to help decrease the severity of carpal tunnel symptoms and increase function in patients suffering with the condition, possibly better than the traditional wrist splint. Outpatients reported improved hand, wrist, and arm function and less severity of their symptoms after 6 weeks of wearing a full-hand resting splint at night.

Cold laser therapy, a noninvasive alternative therapy for CTS patients, has been yielding positive results. The cold laser stimulates new cell growth, relieves inflammation, and encourages the healing process. According to the North American Association for Laser Therapy, cold laser therapy combined with hand therapy can produce favorable effects on 70% of patients.

Many patients prefer conservative, nonsurgical treatment. However, in severe carpal tunnel cases, if pain continues for several months, physicians may recommend surgery to release the transverse carpal ligament, the band of tissue over the carpal tunnel, to reduce and relieve the pressure, as well as give the affected tendons and median nerve room to expand without compression.

During postoperative rehabilitation, hand therapists can assist patients with wound care, and the management of scar and pain. They also may help people regain movement in the fingers and wrists, and help strengthen hands and wrists with tendon and nerve glides and other customized exercises. Rehabilitation timing depends on the procedure, the condition of the patient, and physician protocol. A hand therapist will work closely with the surgeon and the patient to plan and implement the rehabilitation process. Some patients can begin postoperative therapy very quickly after the surgery. Others will have to wait a longer time period as prescribed by their physician.

ASHT issues preventive tips (available at www.asht.org) to address the high incidence of hand and wrist injuries that may result from overuse of handheld electronics and other workforce technologies. ASHT's ongoing awareness campaign includes informing patients and physicians on the potential for these problems and offering exercises, stretches, and strategies to minimize their occurrence and impact. Hand therapists may also work with the employer, patient, and physician to investigate work habits, determine probable contributing factors to CTS, and provide treatment and direction to prevent further injury incidence.

Professional hand therapists strive to help patients be productive workers while developing healthier work routines and lifestyles, which may help decrease the occurrence of carpal tunnel syndrome cases.

Christine Muhleman, OTR, CHT, is the 2006 president of the American Society of Hand Therapists, a Chicago-based nonprofit organization with the goal to advance the science of hand therapy. For more information on hand therapy or to find a hand therapist in your area, visit www.asht.org.

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