Introduction

Carpal tunnel syndrome (CTS) as some other similar diseases belong to the group of so-called overuse injuries. This is a manifestation of nerve and tissue damage from fast, forceful and seemingly harmless repetitive wrist and hand movements (prolong repetitive trauma), which result in swelling, tenderness and pain.

Carpal tunnel syndrome occurs mostly in middle-aged women, who does repetitive labor work (eg typing) and mostly in dominant hand. It is also often seen in production and manufacturing workplaces (with repetitive activities such as cutting meat, dressing poultry and assembling automobiles). The condition is very common among musicians, who play string instruments and piano. During last 10-15 years people can get this problem as a result of extensive computer work (computer manufacturers now use warning labels to alert consumers that keyboard use may increase the risk of CTS). This is second most common (after lower back pain) for both males and female reason for seeking for medical attention. According to recent studies, around 1% of population sufferers from CTS. Statistics from the National Center for Health indicate that 2.4 million visits were made to physicians in 1999 because of CTS, of which 1 million were made to orthopedic surgeons. American Academy of Orthopedic Surgeons (AAOS) published data, that approximately 366,000 CTS surgeries were performed in 1999, a 300% increase from 1991.

The carpal tunnel is a narrow tunnel on the inner surface of the wrist where tendons for flexing muscles of the digits travel. It bordered anterioly by transverse carpal ligament, medially by pisiform bone and hook of hamate bone, laterally by the tuberculle of trapezium bone and posterioly by the carpals. Along with these muscles lie medium nerve, which innervate the skin on palmar surface of the palm as well as palmar surfaces of 1,2,3 and half of 4th finger. When a person does repetitive and long (for hours) work with his wrist or fingers, the tendons become inflamed, which causes their swapping and compression of the median nerve. The same symptoms may occur after wrist trauma (eg Colles fracture – fall on extended wrist) or when one of the wrist bones (lunate) displaced (subluxation) and compress medium nerve. This may also occur with osteoarthritis of the wrist, at the last trimester of pregnancy, with hypothyroidism or acromegaly. This is so-called carpal tunnel syndrome.

Symptoms

People usually complain about numbness, tingling or pain in their hands along the median nerve distribution. The symptoms mostly occur at night and aggravate with repetitive hand motion. Thenar atrophy may also be seen. Careful questioning may determine, that little finger is spared (distribution of median nerve). Without treatment hand muscles deteriorate and lose their ability to grip. CTS sufferers may become permanently disabled if they ignore the symptoms.

Diagnosis

Diagnosis is made based on clinical symptoms. Tapping over carpal tunnel reproducing pain within median nerve distribution (positive Tinel symptom). Passive maximal flexion of the wrist for 1 minute cause tingling along median nerve distribution (positive Phalen symptom). Boston questionnaire may be useful to evaluate symptoms of CTS.
American Association of Orthopedic surgeons also recommend wrist X-ray to rule out other things.

Differential diagnosis

There are several similar to CTS conditions. One of them is De Quervian's disease. This problem is usually seen in people who does repetitive forceful sentences together with ulnar deviation. Eg wrist in playing tennis (squash) or repetitive use thumb in work-related situations. Pain localized to the radial aspect of the wrist (inflammation of the tendons of the thumb muscles).

Treatment

The earlier time of diagnosis and treatment will benefit in shorter duration of treatment and in treatment cost.

Initial treatment includes include immobilization, ice packs and non-steroidal anti-inflammatory drugs.

Wrist splints and braces used for immobilization. Wrist splints stabilize the wrist in neutral position, protecting the nerve from being compressed, take the inflammation down. It usually take from 6 to 8 weeks.

Surgery performed in the most severe cases, in order to enlarge the Carpal Tunnel and repair ligaments

Physical therapy is the corner stone in managing CTS. The goal is to avoid the surgery, and in most cases we can do this. Physical therapy includes combine manual therapy along with special modalities, which provide reduction of swelling and inflammation as well as relief pain and other symptoms of carpal tunnel syndrome.
Our experience extends more then 30 years working with string musicians and pianists. Perform the manual therapy only is not enough to successfully cure the disease. Because of repetitive chronic microtrauma, physical therapists have to use various modalities to reduce swelling, pain and other symptoms of CTS and speed up process of healing. According to our data, we found so-called cold laser is most useful among different modalities.
Laser (Light amplification by stimulated emission of radiation) was produced in the previous century and first experimental applications of low-level laser therapy (LLLT) were reported in 1968, when researchers used ruby ​​and argon lasers on non-healing or slow-to- heal ulcers. Later research substantiated the efficiency of laser treatment to accelerate the healing of wounds, attenuate pain, and reduce tissue inflammation in both humans and animals. One of the human body's reactions to the soft tissue trauma is to “splint” the injury with edema, which is accumulation of the fluid in tissue spaces or cell interstices, causing a swelling. This swelling advances excessive movement of the damaged tissue and results in secondary pain (primary pain is from actual trauma itself). Laser with special wavelengths (820-840 nanometers) have an extremely low absorption rate in human tissue, so allowing deep penetration of laser light. Low-level laser (LLLT) therapy first targets the lymphatic system, because it contains the fluid balance in the body and also improves reabsorbtion of the edema. With LLLT, waving is reduced, allowing movement to return to the treated area.

Evaluation

Subjectively patient will have decreed pain, paresthesia, objectively it'll be increase strength of thenar muscles (electromyography studies), negative Tinel and Phalen signs.

Prevention

Prevention is the corner stone in CTS. Educational programs for patients as well as for employees and employers can help to avoid development of this particular problem. It may be postural education, work site modification, wrist supports for keyboard along with exercises for upper extremity (hand, forearm, shoulder) and neck. Exercises like flexion-extension, rotation and stretchening will provide adequate blood supply and get relief for tensile muscle and tendons. This should help to avoid the development of CTS or speed up the treatment of the condition.