Could carpal tunnel syndrome—in addition to being the musculoskeletal bane of workers the world over—also be an early warning sign of poorer health to come? Perhaps so. Writing in the August, 2006 issue of Diabetes Care, researchers from King’s College in London postulate that carpal tunnel syndrome may be a harbinger of type 2 diabetes in certain patients. Their examination of the medical records of more than 600,000 English and Welsh patients uncovered an apparent correlation between repetitive motion injury of the wrist and the onset of diabetes that can follow by as much as a decade.
Obviously, more investigation and testing will be needed to confirm this claim, but already beyond debate is the knowledge that carpal tunnel syndrome is a repetitive motion injury requiring good diagnosis and even better rehab treatment.
Jonathan (Joey) Jove, MPT, senior physical therapist at the James Donaldson Fitness and Physical Therapy Centers in Tacoma, Wash, sees an abundance of carpal tunnel cases. He says that while treatment may vary by patient, the objectives underlying rehabilitation are consistent.
“The first thing we always do is stop the injured person from continuing the strenuous activity responsible for causing the injury,” Jove explains. “In most of the repetitive motion injuries I’ve encountered there is a stress to a ligament, muscle, or tendon. This happens when the other muscles or tissues in the group are not providing enough flexibility, or when one or more joints are not providing enough movement. In response to this dysfunction, you’ll have another tissue trying to compensate for it. That leads to nerve entrapment and pain.”
Jove explains that repetitive motion injuries of the hand tend to be more easily acquired than those of other parts of the body. “For instance, the hand is a smaller structure than the arm; it therefore receives less vascular supply, so it is naturally more vulnerable to the effects of repetitive daily stresses,” he says.
One way to address the dysfunction is with surgery—a solution becoming more common and at earlier stages, according to Romina Astifidis, MSPT, CHT, clinic manager of the Curtis National Hand Center at Lutherville in Lutherville, Md.
“Increasingly, surgeons are opting for minimally invasive approaches,” she adds. “They’re performing these surgeries now with endoscopic techniques that, for about 90% of patients, make postoperative rehab unnecessary.”
When postop rehab turns out to be necessary, Astifidis says one of the most frequently used treatment methodologies is scar management. “This involves massaging and stretching the soft tissues of the affected areas during sessions covering a period of 4 to 6 weeks,” she says.
Astifidis also finds value in gel sheets—thin layers of silicon that put pressure on a postoperative scar to decrease blood flow to the scar tissue. “In cases of carpal tunnel release surgery, most people are tender at the incision site, so the gel sheet also helps by preventing the ends of shirt sleeves or wristwatch bands from rubbing up against the scar. The sheet also forms a cushion to protect the hand if it’s rested against the edge of a tabletop or desk.”
Some of Astifidis’ patients never undergo surgery. For them, conservative treatments are appropriate. Splinting and bracing are first choices owing to their effectiveness, she says.
Among other modalities to be considered for treatment are continuous passive motion therapies, ultrasound, hot and cold therapies, and iontophoresis.
Jove, meanwhile, relies on a trio of modalities in the early stages of rehab for non-surgery patients. He uses them in the course of about the first half-dozen treatment sessions, but almost never in concert with one another.
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“Ultrasound is very good [to start sessions] because it loosens up hardened and scarred tissues,” he explains. “During the acute stages of injury, the affected tissues are sufficiently painful that manual softening techniques are not well tolerated. Ultrasound softens without application of physical pressure.”
Paraffin baths are also favored by Jove for initial treatment of carpal tunnel syndrome. “Dipping the hand in carefully temperature-controlled melted wax provides a means to uniformly heat the entire hand,” he says. “The warmth increases vascular supply, which promotes healing. It also relaxes the tissues to help decrease pain. The treatment is performed for 15 to 20 minutes toward the end of the session as a way to make the hand feel not so sore after other modalities and techniques have been applied.”
Then there is iontophoresis. Jove finds this advantageous too. “The basic idea is electricity applied to the skin causes steroid medication to penetrate down to the inflamed or tender tissues of the injury,” he offers.
NEED FOR PATIENT EDUCATION
Later, after the acute phase, the focus of rehab shifts to manual techniques to strengthen the involved muscles and to increase range-of-motion.
“Here at the Curtis National Hand Center we strive to increase the endurance of carpal tunnel patients by trying to recreate as much of their work and home environments as possible,” says Astifidis. “For example, if at work they do a significant amount of tasks involving use of a screw driver, then that’s what we have them practice within the controlled setting of our simulated work environment. The purpose of the exercise would be to strengthen their grip and improve their ability to pinch. We can also accomplish this by having them open and close a jar multiple times during a period of one or two minutes at a stretch. Or we could have them repeatedly squeeze a pair of pliers.”
However, no amount of rehabing of carpal tunnel syndrome can be truly effective without the inclusion of patient education, Jove points out. “We want the patient to learn which movements to improve so as not to aggravate the injury or cause re-injury later on,” he says.
Astifidis agrees: “It’s important to educate about proper positioning of the injured hand—avoiding resting it in such a way that it bends backward for any length of time, avoiding leaning on that wrist when typing or writing.”
Jove says education should feature instruction designed also to elicit behavioral changes. “Some patients are workaholics; if we can’t get them to take rest, then that’s going to be self-defeating,” he says.
Convincing patients to engage in at-home exercises for the wrist is another aspect of behavior modification that Jove and his colleagues attempt to encourage .
CUTTING RIGHT TO THE CHASE
Also helpful for that purpose are nerve conduction tests, Astifidis reports. And Jove says hand dynomometers are likewise beneficial (an evaluation tool Jove shares that he would love to see is a squeeze ball with a built-in digital readout of the patient’s grip strength).
Meanwhile, on the decidedly low-tech side is the paper-based evaluation form Jove uses. Simple though it is as a diagnostic tool, Jove says the form has been refined to the point that he can cut right to the chase and identify problems without unnecessary expenditures of time, effort and ink. “It doesn’t ask for long narratives about medical history,” he says. “All it wants to know is what I’ve found, what are the measurements, what’s my goal and what’s my plan for reaching that goal. I like this because it speeds up my documenting and allows me to spend more time working with the patient.”
Rich Smith is a contributing writer for Rehab Management. For more information, contact .