CARPAL TUNNEL SYNDROME

CARPAL TUNNEL SYNDROME AND ITS AYURVEDA MANAGEMENT

Carpal tunnel syndrome or median neuropathy at the wrist, is a medical condition in which the median nerve is compressed at the wrist leading to paresthesia numbness, pain and muscle weakness in the hand.It is caused by an inflammation or collapse of carpal tunnel that allows nerves to passes through the wrist.It is a common complaint of office workers,drivers and is usually associated with repetitive activities such as typing,etc.Because the nerves of the tunnel run through the neck and arms before reaching the wrist.Tension in the neck and shoulders can also aggravate the condition.Some predisposing factors like diabetics, pregnancy, hypothyroidism, and heavy manual work or work with vibrating tools may also cause the symptoms.

Anatomy of wrist:

For understanding more about CTS, it is important to know the part of the hand wrist.

The Carpal Tunnel: The carpal tunnel is a passageway that forms beneath the strong, broad transverse ligament. This ligament is a bridge that extends across the lower palm and connects the bones of the wrist (carpals) that form an arch below the tunnel.

The Median Nerve and Flexor Tendons: The median nerve and nine flexor tendons pass under the ligament bridge and through the carpal tunnel (similar to a river). They extend from the forearm and up into the hand:

• • The flexor tendons are fibrous cords that connect the muscles in the forearm to the fingers (two to each finger) and one to the thumb. They allow flexing of the fingers and clenching of the fist.

  • The median nerve plays two important roles. It supplies sensation to the palm to side of the thumb, index, middle, and ring fingers, and to the flexor tendons. It provides function for the muscles at the base of the thumb (the thenar muscle).

The median nerve travels through a compartment in the wrist called the carpal tunnel. The ligaments that transverse the nerve are not very flexible. Any swelling within the wrist compartment can put excessive pressure on structures such as the blood vessels and the median nerve. Excessive pressure can constrict blood flow and cause nerve damage. The symptoms from the compression cause pain, loss of sensation, and decreased function in the hand.

Pathophysiology of Carpal Tunnel Syndrome:

In general, carpal tunnel syndrome develops when the tissues around the median nerve swell and press on the nerve. Early in the disorder, the process is reversible. Over time, however, the insulation on the nerves may wear away, and permanent nerve damage may develop.

The following events have been observed in the hands of people with carpal tunnel syndrome:

• • The protective lining of tendons (called the tenosynovium) swells within the carpal tunnel. Some research suggests that this swelling is caused by build-up of fluid (called synovial fluid) under the lining. Synovial fluid lubricates and protects the tendons.

  • The transverse ligament, the band of fibrous tissue that forms the roof over the median nerve, becomes thicker and broader.

  • The swollen tendons and thickened ligament compress the median nerve fibers, just as stepping on a hose slows the flow of water through it. This compression reduces blood flow and oxygen supply to the nerve, and slows the transmission of nerve signals through the carpal tunnel. Some cases of carpal tunnel syndrome may be due to enlargement of the median nerve rather than compression by surrounding tissues.

The result is pain, numbness, and tingling in the wrist, hand, and fingers. Only the little finger is unaffected by the median nerve.

Compression of the median nerve as it runs deep to the transverse carpal ligament (TCL) causes atrophy of the thenar eminence, weakness of the flexor pollicis brevis, opponens pollicis, abductor pollicis brevis, as well as sensory loss in the digits supplied by the median nerve. The superficial sensory branch of the median nerve, which provides sensation to the base of the palm, branches proximal to the TCL and travels superficial to it. Thus, this branch spared in carpal tunnel syndrome, and there is no loss of palmar sensation.

Symptoms:

The level of discomfort varies from a simple dull ache to complete numbness of the hand.Symptoms starts with mild discomfort or pain in the wrist region and slowly spreads to the hand and fore arm.The first symptoms of CTS may appear while sleeping and typically include numbness and paresthesia (burning and tingling sensation),in the thumb ,index and middle finger. Some patients express the symptoms as well.Symptoms of CTS usually progress gradually over weeks and months ,and sometimes years.

• Tingling and burning sensation of the hand.

• wrist pain that often shoots up till the elbow and at times up till the shoulder.

• clumsiness caused by sense of weakness only in the affected hand.

• Difficulty or lose of finger coordination and movement.

• weak grip.

• weakness in the hand.

• Pin increase during driving,doing job and also at night.

• frequency accompanied by sharp pains radiating through arm.

In Chronic Cases:

• wasting of thenar muscles (muscles which connected to the thumb.

• weakness of palmar abduction of the thumb(difficulty bringing the thumb away from the hand).

• symptoms are usually worse at night and after prolonged use of the hand.

• Decreased grip,unable to tell cold and hot in touch.

Causes of Carpal Tunnel Syndrome:

CTS can be the result of overuse,strain,forceful or stressed motions of hand and wrists.Clinically IT professionals, architects and computer users are reported to have this condition in high numbers compared to common people. Incidence in women is as much as 3 times higher than in men.

• work related.

• high force and vibrations: work that involves high force or vibrations as is repetitive hand and wrist work in cold temperature.

• hand arm vibrations syndrome- tingling and numbness that present even after the vibration stops.

• typing for prolonged period on the keyboard.

• driving continuously.

• playing a hand dominated musical instrument and sports.

• Sewing,writing for a prolonged period.

• improper sitting in front of computer.

• improper use of key board and mouse.

Due to some Medical Conditions:

A number of medical conditions increase the risk for or even cause CTS. The main conditions associated with CTS re diabetes, hypothyroidism, rheumatoid arthritis, osteoarthritis, obesity, and pregnancy. Many of the underlying diseases that contribute to the development of CTS are also associated with more severe forms of CTS.

• • Diabetes: CTS is a very common feature of diabetic neuropathy, one of the major complications of diabetes. Neuropathy is decreased or distorted nerve function; it particularly affects sensation. Symptoms include numbness, tingling, weakness, and burning sensations, usually starting in the fingers and toes and moving up to the arms and legs. About 6% of patients with CTS have diabetes. Up to 85% of patients with type 1 diabetes develop CTS. Development of CTS symptoms is related to the patient's age, and the length of time they had diabetes.

  • Autoimmune Diseases: In autoimmune diseases, the body's immune system abnormally attacks its own tissue, causing widespread inflammation, which, in many cases, affects the carpal tunnel of the hand. Such autoimmune diseases include rheumatoid arthritis, systemic lupus erythematosus, and thyroiditis, which can lead to hypothyroidism.. Some experts believe that CTS may actually be one of the first symptoms in a number of these diseases. Studies also suggest that CTS patients with these disorders are more likely to have severe CTS that requires surgery.

  • Diseases that Affect Muscle and Bones: Arthritis, gout, and other medical conditions that damage the muscles, joints, or bones in the hand may cause changes that lead to CTS.

  • Structural Abnormalities: Inborn abnormalities in the bones of the hand, wrist, or forearm may contribute to CTS.

  • Chronic Kidney Insufficiency:People who undergo hemodialysis for chronic kidney damage often experience a build-up of a certain type of protein, called beta 2-microglobulin, in the hand. This build-up can result in CTS. The longer the person has been receiving hemodialysis, the greater the risk of CTS. Certain drugs and procedures (particularly one procedure called hemodiafiltration) are being investigated as having the potential to reduce microglobulin build-up. It is hoped such new methods will delay the need for carpal tunnel surgery in patients undergoing long-term hemodialysis.

  • Other Diseases: A number of other medical conditions may cause or increase susceptibility to CTS:

  • Down syndrome

  • Amyloidosis (a progressive disorder of the connective tissues)

  • Acromegaly (a disease that leads to abnormally large hands and feet due to excessive growth hormone)

  • Tumor on the median nerve (removal of the tumor often resolves the CTS in such cases)

  • due to some medications.

  • due to injury,dislocations and fracture.

  • hormonal changes- Hormonal fluctuations in women play a role in CTS. Such fluctuations may cause fluid retention and other changes that cause swelling in the body. Fluid retention is one reason that CTS may develop during pregnancy

Risk factors of Carpal tunnel Syndrome:

• • Age: older peoples are at very higher risk than younger.

  • Sex: women have more risk than men,especially at a time like pregnancy,after delivery,menopause,etc

  • Obesity and lack of fitness.

• Very High-Risk Workers. Workers in the meat and fish packing industries and those who assemble air planes have the highest risk for CTS

• Computer Users and Typists. Repetitive typing and key entry has traditionally been associated with missing work due to CTS (as opposed to repetitive stress symptoms, which are unrelated to nerve impingement).

• Musicians. Musicians are at very high risk for CTS and other problems related to the muscles and nerves in the hands, upper trunk, and neck.

• Smoking and Alcoholism: Cigarette smoking slows down blood flow, so that smokers have worse symptoms and slower recovery than nonsmokers do. Increased alcohol intake has been associated with CTS in people with other risk factors.

• Poor nutrition,etc

Prognosis:

Many cases of CTS are mild, and when symptoms don't last long, they often resolve (disappear) on their own. Once a woman with pregnancy-associated CTS gives birth, for instance, the swelling in her wrists and other symptoms almost always subside. Proper treatment of other medical conditions that cause CTS can often help reduce wrist swelling.

In severe untreated cases, however, the muscles at the base of the thumb may whither, and loss of sensation may be permanent. CTS can become so crippling that people can no longer do their jobs or even perform simple tasks at home.

How to Diagnose:

Carpal tunnel syndrome are diagnosed based on the symptoms and the distribution of the hand numbness,pain,nocturnal symptoms,thenar muscle wasting, etc.Examine the wrist for any swelling,warmth,tenderness deformity,etc.Examine the neck,shoulder,pulse,etc to exclude other conditions.

one diagnostic key is if the numbness in the finger does not include the little finger.The median nerve does not provide sensation to this finger.

Test strength of the muscles of the hand,thumb,fingers,etc.Each finger should be tested for sensation and the muscles at the base of the hand should be examined for strength and signs of atrophy.

The following findings are helpful in identifying carpal tunnel syndrome:

• • Less sensitivity to pain where the median nerve runs through to the fingers

  • Thumb weakness

  • Inability to tell the difference between one and two sharp points on the fingertips (this is a late sign of carpal tunnel)

Flick Signal. One important and simple test of carpal tunnel is the "flick" signal:

• • The patient is asked, "What do you do when your symptoms are worse?"

  • If the patient responds with a motion that resembles shaking a thermometer, the doctor can strongly suspect carpal tunnel.

Testing for Thumb Weakness. Two questions are useful in determining thumb weakness:

• • Can the thumb rise up from the plane of the palm?

  • Can the thumb stretch so that its pad rests on the pad of the little finger pad?

Phalen's test:

Bend wrist and maintain hands in a 90 degree angle,pushing the back of both hands together,for about one minute.If not feel any pain or numbness,then the patient are on the safe level.Actually it is not a definite test to diagnose but help to know the condition.

Tinel's Test:

A classic though less sensitive test is a way to detect irritated nerves. Tinel's is performed by lightly tapping the skin over the flexor retinaculum to elicit a sensation of tingling or "pins and needles" in the nerve distribution. Tinel's sign (pain and/or paresthesias of the median-innervated fingers with percussion over the median nerve) is less sensitive, but slightly more specific than Phalen's sign.

tinel's test

Durkan Test:

carpal compression test, or applying firm pressure to the palm over the nerve for up to 30 seconds to elicit symptoms has also been proposed.

Durkan test

• • Tourniquet Test. This test employs an inflatable cuff that applies pressure over the median nerve to produce tingling or small shocks.

  • Hand Elevation Test. The patient raises their hand overhead for 2 minutes to produce symptoms of CTS. The test was recently proven to be accurate and may provide useful information when combined with the Tinel's and Phalen's tests.

As a note, a patient with true carpal tunnel syndrome (entrapment of the median nerve within the carpal tunnel) will not have any sensory loss over the thenar eminence (bulge of muscles in the palm of hand and at the base of the thumb). This is because the palmar branch of the median nerve, which innervates that area of the palm, branches off of the median nerve and passes over the carpal tunnel.This feature of the median nerve can help separate carpal tunnel syndrome from thoracic outlet syndrome, orpronator teres syndrome

Other tests incorporated are nerve conduction study,electromyography,ultra sound imaging,and magnetic resonance imaging,etc.

There are many electrodiagnostic tests used to make a diagnosis of CTS, but the most sensitive, specific, and reliable test is the Combined Sensory Index (also known as Robinson index).

Electrodiagnosis rests upon demonstrating impaired median nerve conduction across the carpal tunnel in context of normal conduction elsewhere. Compression results in damage to the myelin sheath and manifests as delayed latencies and slowed conduction velocities However, normal electrodiagnostic studies do not preclude the presence of carpal tunnel syndrome, as a threshold of nerve injury must be reached before study results become abnormal and cut-off values for abnormality are variable. Carpal tunnel syndrome with normal electrodiagnostic tests is very, very mild at worst.

Differential diagnosis:

One of the most important first steps in diagnosing CTS is to rule out any underlying medical disorders that may be contributing to the condition. Experts emphasize the need to fully examine patients presenting with symptoms of CTS. Relying only on CTS symptoms, and personal or work histories may result in the failure to detect (and thus properly treat) underlying medical conditions that could be serious. If the doctor suspects that an underlying medical condition may be exacerbating the symptoms of CTS, laboratory tests will be performed. Tests for thyroid disease and rheumatoid arthritis may be helpful. The doctor may take an x-ray, for example, to check for arthritis or fractured bones.

Arthritic Conditions. Arthritic conditions, including rheumatoid arthritis, gout, and osteoarthritis, can all cause pain in the hands and fingers that may mimic carpal tunnel disease. The treatment for these conditions, however, is different.

Muscle and Nerve Diseases. Any disease or abnormality that affects the muscles and nerves, including those in the spine, may produce symptoms in the hand that mimic carpal tunnel syndrome.

• Brachial neuritis:Due to cervical intra vertebral disc prolapse at C5-C6 level.

• Care must be taken to exclude other causes especially those arising in the neck from interference with the brachial plexus and lesions of median nerve elsewhere in its cause.