CARPAL TUNNEL SYNDROME AND ITS AYURVEDA MANAGEMENT

CARPAL TUNNEL SYNDROME AND ITS AYURVEDA MANAGEMENT

Carpal Tunnel Syndrome

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.

anatomy of 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.

symptoms

• 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:

thenar muscle wasting

• 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, or pronator 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.

Other Cumulative Trauma Disorders
Location	Description
The Median Nerve in Other Locations	Repetitive work can cause pressure on the median nerve in locations other than the wrist and can also affect other nerves in the arm and hand. The branch of the median nerve that runs through the palm of the hand can be damaged directly by repeated pounding or by the use of certain tools requiring a strong grip using the palm, such as needle-nosed pliers. The median nerve can also be pinched in the forearm.
Guyon Canal Syndrome (Commonly called ulnar tunnel syndrome)	The ulnar nerve can, like the median nerve, can be trapped as a result of repetitive stress. When this nerve is trapped, the condition is sometimes referred to as ulnar tunnel syndrome. It is more correctly known as Guyon canal syndrome, however, since this is the name of the passage through which the ulnar nerve passes. General symptoms are similar to carpal tunnel syndrome, but patients experience loss of sensation in the ring and little finger and in the outer half of the palm. It can be a separate problem, although it commonly occurs with CTS. In such cases, release surgery for CTS usually also relieves the ulnar nerve entrapment. The ulnar nerve can also be affected at the elbow.
De Quervain's Tenosynovitis	Tenosynovitis is swelling of the slippery covering of the tendons that move the thumb. When it causes pain on the side of the wrist and forearm right below the base of the thumb, it is known as De Quervain's tenosynovitis. (Finklestein's Test may help identify this. Make a fist that encloses the thumb, and bend the wrist sideways and down away from the thumb. If it causes pain, it is likely to be De Quervain's tenosynovitis.) It may be treated with splints or corticosteroid injections. In severe cases release surgery is effective.
Digital Flexor Tenosynovitis (Trigger or Snapping Finger)	Digital flexor tenosynovitis, commonly called trigger or snapping finger, is brought on when a tendon thickens, leaving the finger or thumb in a bent position. This disorder usually occurs when the tendons form a knot and may arise in those with hypothyroidism, diabetes, gout, rheumatoid arthritis, or connective tissue disorders. It can cause pain and a clicking sound when the trigger finger or thumb is bent and straightened. It can be effectively treated with corticosteroid injections.
Thoracic Outlet Syndrome	Thoracic outlet syndrome is caused by compression of nerves or blood vessels running down the neck into the arm. It can produce symptoms very similar to CTS. Other symptoms may include Raynaud's phenomenon (changes in sensation and temperature in the hand). The compression occurs at the first rib in the front of the shoulder. This may happen after an accident or simply from chronic slouching posture. A doctor may be able to diagnose the condition by detecting diminished blood flow in the arm as the patient raises the affected hand and turns his or her head toward the opposite side. Although the condition is uncommon, a correct diagnosis is important to differentiate it from CTS, since treatments differ. Surgery may be required to relieve pressure on the nerves and blood vessels.

 

Treatments for Carpal tunnel Syndrome: 

It is critical to begin treating early phases of carpal tunnel syndrome before the damage progresses. A conservative approach to CTS, which may include corticosteroid injections and splinting, is the first step in treating this disorder. The conservative approach is most successful in patients with mild carpal tunnel syndrome.
Studies suggest that surgery is a better option for severe CTS. Surgery is also more likely to be necessary for patients with underlying conditions such as diabetes. Even among patients with mild CTS, there is a high risk of relapse. Some researchers are reporting better results when specific exercises for carpal tunnel syndrome are added to the program of treatments.
Limiting Movement. If possible, the patient should avoid activities at work or home that may aggravate the syndrome. The affected hand and wrist should be rested for 2 - 6 weeks. This allows the swollen, inflamed tissues to shrink and relieves pressure on the median nerve. If the injury is work related, the worker should ask to see if other jobs are available that will not involve the same hand or wrist actions. Few studies have been conducted on ergonomically designed furniture or equipment, or on frequent rest breaks. However, it is reasonable to ask for these if other work is not available.
Conservative Treatment Approach. The following conservative approaches have been shown to provide symptom relief:

• Wrist splints
• Corticosteroids (steroids). Injected or short-term oral corticosteroids may be tried if other methods fail.

A major analysis of other conservative approaches found that patients had no significant relief from nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs include common pain relievers such as aspirin and ibuprofen (Advil). The same report also found no benefits from diuretics, magnet therapy, laser acupuncture, vitamin B6, exercise, or chiropractic care. Other approaches being investigated include omega-3 fatty acid supplements.
Underlying Conditions. It is important to treat any underlying medical condition that might be causing carpal tunnel syndrome. For example, reducing inflammation in rheumatoid arthritis or other forms of inflammatory disorders that directly cause CTS is very helpful. Hypothyroidism and diabetes are diseases associated with an increased risk of CTS. The treatments for such diseases may offer some relief for CTS symptoms.

Wrist Splints

Wrist splints can keep the wrist from bending. They are not as beneficial as surgery for patients with moderate-to-severe CTS, but they appear to be helpful in specific patients, such as those with mild-to-moderate nighttime symptoms of less than a year's duration. In selected patients, up to 80% reported fewer symptoms, usually within days of wearing the splint.

Typically the splint is worn at night or during sports. The splint is used for several weeks or months, depending on the severity of the problem, and may be combined with hand and finger exercises. Benefits may last even after the patient stops wearing the splint.

Other Conservative Approaches

Ice and Warmth. Ice may provide benefit for acute pain. Some patients have reported that alternating warm and cold soaks have been beneficial. (If hot applications relieve pain, most likely the problem is not caused by CTS but by another condition producing similar symptoms.)
Low-Level Laser Therapy. Some investigators are working with low-level laser therapy (LLLT), which generates extremely pure light in a single wavelength. The procedure is painless. Two trials comparing laser therapy to conservative treatment or a placebo laser treatment from no real benefit for this therapy.

Alternative Therapies

Many alternative therapies are offered to sufferers of carpal tunnel syndrome and other repetitive stress disorders. Few, however, have any proven benefit. People should carefully educate themselves about how alternative therapies may interact with other medications or impact other medical conditions, and should check with their doctor before trying any of them.
Vitamin B6. Vitamin B6 (pyridoxine) is often used for carpal tunnel syndrome. Studies have not supported its benefits, however, either in oral or cream form. It should also be noted that excessively high doses of vitamin B6 can be toxic and cause nerve damage.
Acupuncture. A very limited amount of evidence shows that acupuncture may be useful as a supplement to standard treatment.
Chiropractic Therapies. Chiropractic techniques have been useful for some people whose condition is produced by pinched nerves. There is little evidence, however, to support its use for carpal tunnel syndrome.
Magnets. Magnets are a popular but unproven therapy for pain relief.
Botulinum toxin type A. Intracarpal injections of botulinum toxin type A (Botox) has not been well studied.

Surgery for CTS:

Surgery is a better option for severe CTS. Surgery is also more likely to be necessary for patients with underlying conditions such as diabetes. Even among patients with mild CTS, there is a high risk of relapse.


In general, patients with the following characteristics are less likely to respond to conservative treatment and, therefore, might benefit from surgery:

• Symptoms lasting 10 months or longer
• Continual numbness
• Muscles in the base of the palm have begun to shrink
• Symptoms occur within 30 seconds during a Phalen's test
• Above 50 years of age

Surgery does not cure all patients, and because it permanently cuts the carpal ligament, some wrist strength may be lost, but it rarely has any effect on function. A number of experts believe that release surgery is performed too often. They recommend aggressive conservative treatment (such as splints, anti-inflammatory agents, and physical therapy) before choosing surgery. Nevertheless, other experts argue that CTS is often progressive and will worsen over time without surgery. Furthermore, evidence now shows that surgery is better than splints and conservative measures for the relief of pain.
 

Standard Release Surgical Procedures

open release surgery

Open Release Surgery. Traditionally, surgery for CTS entails an open surgical procedure performed in an outpatient facility. In this procedure, the carpal ligament is cut free (released) from the median nerve. The pressure on the median nerve is therefore relieved. The surgery is straightforward.
In treating carpal tunnel syndrome, surgery may be required to release the compressed median nerve. The open release procedure involves simply cutting the transverse carpal ligament. The Mini-Open Approach. In recent years, more surgeons have adopted a "mini" open -- also called short-incision -- procedure. This surgery requires only a one-inch incision, but it still allows a direct view of the area (unlike endoscopy, which is viewed on a monitor). The mini-open approach may allow for quicker recovery while avoiding some of the complications of endoscopy, although few studies have investigated its benefits and risks. The recovery time in patients receiving the mini-open approach may be shorter than with the open approach, and results are generally the same.
Endoscopy. Endoscopy for carpal tunnel syndrome is a less invasive procedure than standard open release.

• A surgeon makes one or two 1/2-inch incisions in the wrist and palm, and inserts one or two endoscopes (pencil-thin tubes).
• The surgeon then inserts a tiny camera and a knife through the lighted tubes.
• While observing the underside of the carpal ligament on a screen, the surgeon cuts the ligament to free the compressed median nerve.

Patients report less pain than those who had the open release procedure, and return to normal activities in about half the time. Nevertheless, at this time the best evidence available does not show any significant long-term advantages of endoscopy over open release in terms of muscle, grip strength, or dexterity. The endoscopic approach may even carry a slightly higher risk of pain after ward. This may be due to a more limited view of the hand with endoscopy. (In the open release procedure, the surgeon has a full view of the structures in the hand.) Concerns of irreversible nerve injury with endoscopic carpal tunnel release, when compared with open carpal tunnel release, exist because of this reduced visibility. However, larger studies have shown an extremely low number of complications following the procedure, when performed by physicians experienced in the technique.

Complications of Surgery:

Treatment failure and complication rates of CTS surgery vary.
Complications after surgery may include the following:

• Nerve damage with tingling and numbness (usually temporary)
• Infection
• Scarring
• Pain
• Stiffness
• Loss of some wrist strength is a complication that affects 10% to a third of patients. Endoscopy may have better results than open release. Some patients who have jobs requiring significant strength of the hand and wrist may not be able to perform them after surgery. These workers may also have problems in other parts of the upper body, including elbows and shoulders. These problems do not go away with surgery and can persist. Studies indicate that 10 - 15% of patients change jobs after a CTS operation.

If pain and symptoms return, the release procedure may be repeated.
Reasons for procedure failure include:

• Incomplete release of the ligament
• Extensive scarring
• Recurrence of the disorder due to underlying medical conditions

Patients who had open release surgery appear more likely to require repeat operations compared with those who have had endoscopic surgery.

Complications and Long-Term Outcome

Treatment failure and complication rates of CTS surgery vary.
Complications after surgery may include the following:

• Nerve damage with tingling and numbness (usually temporary)
• Infection
• Scarring
• Pain
• Stiffness
• Loss of some wrist strength is a complication that affects 10% to a third of patients. Endoscopy may have better results than open release. Some patients who have jobs requiring significant strength of the hand and wrist may not be able to perform them after surgery. These workers may also have problems in other parts of the upper body, including elbows and shoulders. These problems do not go away with surgery and can persist. Studies indicate that 10 - 15% of patients change jobs after a CTS operation.

If pain and symptoms return, the release procedure may be repeated.
Reasons for procedure failure include:

• Incomplete release of the ligament
• Extensive scarring
• Recurrence of the disorder due to underlying medical conditions

Patients who had open release surgery appear more likely to require repeat operations compared with those who have had endoscopic surgery.

Exercise to get pain relief and CTS:

People who are physically fit, including athletes, joggers, and swimmers, have a lower risk for cumulative trauma disorders. A regular exercise regimen using a combination of aerobic and resistance training techniques strengthens the muscles in the shoulders, arms, and back, helps reduce weight, and improves overall health and well-being.

Performing the simple exercises described below for 4 - 5 minutes every hour may be helpful.

Wrist Exercise:

Exercise- 1:

• Make a loose right fist, palm up, and use the left hand to press gently down against the clenched hand.
• Resist the force with the closed right hand for 5 seconds. Be sure to keep the wrist straight.
• Turn the right fist palm down, and press the knuckles against the left open palm for 5 seconds.
• Finally, turn the right palm so the thumb-side of the fist is up, and press down again for 5 seconds.
•  Repeat with the left hand

Exercise 2.

• Hold one hand straight up shoulder-high with fingers together and palm facing outward. (The position looks like a shoulder-high salute.)
• With the other hand, bend the hand being exercised backward with the fingers still held together and hold for 5 seconds.
• Spread the fingers and thumb open while the hand is still bent back and hold for 5 seconds.

Repeat five times for each hand.

Exercise 3. (Wrist Circle)

• Hold the second and third fingers up, and close the others.
• Draw five clockwise circles in the air with the two finger tips.
• Draw five more counterclockwise circles.

Repeat with the other hand.

 For Fingers and Hand:

Exercise 1.

• Clench the fingers of one hand into a fist tightly.
• Release, fanning out the fingers.

Do this five times. Repeat with the other hand.

Exercise 2.

• To exercise the thumb, bend it against the palm beneath the little finger, and hold for 5 seconds.
• Spread the fingers apart, palm up, and hold for 5 seconds.

Repeat five to 10 times with each hand.

Exercise 3.

• Gently pull the thumb out and back and hold for 5 seconds.

Repeat five to 10 times with each hand.

Forearms (stretching these muscles will reduce tension in the wrist):

• Place the hands together in front of the chest, fingers pointed upward in a prayer-like position.
• Keeping the palms flat together, raise the elbows to stretch the forearm muscles.
• Stretch for 10 seconds.
• Gently shake the hands limp for a few seconds to loosen them.

Repeat frequently when the hands or arms tire from activity.

For Neck and Shoulders:

Exercise 1.

• Sit upright and place the right hand on top of the left shoulder.
• Hold that shoulder down, and slowly tip the head down toward the right.
• Keep the face pointed forward, or even turned slightly toward the right.
• Hold this stretch gently for 5 seconds.

Repeat on the other side.

Exercise 2.

• Stand in a relaxed position with the arms at the side.
• Shrug the shoulders up, then squeeze the shoulders back, then stretch the shoulders down, and then press them forward.

The entire exercise should take about 7 seconds.

How to Prevent Carpal Tunnel Syndrome? 

"PREVENTION IS BETTER THAN CURE"

Many factors can contribute to carpal tunnel syndrome, there is no single mode of prevention. Treating any underlying medical condition is certainly important. Simple common sense may help minimize some risk factors predisposing a person to work-related CTS or other cumulative trauma disorders. A patient can learn how to adjust the work area, handle tools, or perform tasks in ways that put less stress on the hands and wrists. Proper posture and exercise programs to strengthen the fingers, hands, wrists, forearms, shoulders, and neck may help prevent CTS.


Suggested healthy habits such as avoiding repetitive stress, work modification through use of ergonomic equipment (wrist rest, mouse pad), taking proper breaks, using keyboard alternatives (digital pen, voice recognition, and dictation), and employing early treatments such as taking turmeric (anti-inflammatory), omega-3 fatty acids, and B vitamins have been proposed as methods to help prevent carpal tunnel syndrome. The potential role of B-vitamins in preventing or treating carpal tunnel syndrome has not been proven.
Biological factors such as genetic predisposition and anthropometric had significantly stronger causal association with carpal tunnel syndrome than occupational/environmental factors such as repetitive hand use and stressful manual work.This suggests that carpal tunnel syndrome might not be preventable simply by avoiding certain activities or types of work/activities.

Tips for keyboard workers to prevent CTS:

Altering the way a person performs repetitive activities may help prevent inflammation in the hand and wrist. Most of the interventions described below have been found to reduce repetitive motion problems in the muscles and tendons of the hand and arm. They may reduce the incidence of carpal tunnel syndrome, although there is no definite proof of this effect.

Replacing old tools with ergonomically designed new ones can be very helpful.

1.Rest Periods and Avoiding Repetition. Anyone who does repetitive tasks should begin with a short warm-up period, take frequent breaks, and avoid overexertion of the hand and finger muscles whenever possible. Employers should be urged to vary the tasks and work content of their employees.
Taking multiple "macro breaks" (about 3 minutes each) reduces strain and discomfort without decreasing productivity. Such breaks may include the following:

• Shaking or stretching the limbs
• Leaning back in the chair
• Squeezing the shoulder blades together.
• Taking deep breaths

2.Good Office Furniture: Poorly designed office furniture is a major contributor to bad posture. Chairs should be adjustable for height, with a supportive backrest. Custom-designed chairs, made for people who do not fit in standard chairs, can be expensive. However, the costs are often offset by the savings in medical expenses that follow injuries related to bad posture.

3.Voice Recognition Software: For CTS patients who must use a computer frequently, a variety of voice recognition software packages (Via Voice, Voice X press, Dragon Naturally Speaking, I Listen) are now available, enabling virtually hands-free computer use.



4.Good Posture: Good posture is extremely important in preventing carpal tunnel syndrome, particularly for typists and computer users.

• The worker should sit with the spine against the back of the chair with the shoulders relaxed.
• The elbows should rest along the sides of the body, with wrists straight.
• The feet should be firmly on the floor or on a footrest.
• Typing materials should be at eye level so that the neck does not bend over the work.
• Keeping the neck flexible and head upright maintains circulation and nerve function to the arms and hands. One method for finding the correct head position is the "pigeon" movement. Keeping the chin level, glide the head slowly and gently forward and backward in small movements, avoiding neck discomfort.

PROPER SITTING POSTURE

5.Keyboard and Mouse Tips: Anyone using a keyboard and mouse has some options that may help protect the hands.

• The tension of the keys should be adjusted so they can be depressed without excessive force.
• The hands and wrists should remain in a relaxed position to avoid excessive force on the keyboard.
• A 2003 study suggested that mouse-use poses a higher risk than keyboard use. Replacing the mouse with a trackball device and the standard keyboard with a jointed-type keyboard are helpful substitutions.
• Wrist rests, which fit under most keyboards, can help keep the wrists and fingers in a comfortable position.
• Some people recommend keeping the computer mouse as close to the keyboard and the user's body as possible, to reduce shoulder muscle movement.
• The mouse should be held lightly, with the wrist and forearm relaxed. New mouse supports are also available that relieve stress on the hand and support the wrist.
• Some people cut their mouse pads in half to reduce movement.

Innovative keyboard designs may reduce hand stress:

• Alternative geometry keyboards (Microsoft Natural Keyboard, Apple Adjustable Keyboard) allow the user to adjust and modify hand positions as well as adjust key tension. Most have a split or "slanted" keyboard that places the wrists at an angle. Studies suggest they are useful in promoting a neutral position for the wrist.
• The continuous passive motion (CPM) keyboard lifts and declines gently and automatically every 3 minutes to break tension on the hands and wrist.

A key less keyboard is an innovative device that uses two domes. The typist covers the domes with their hands and slides them into different positions that represent letters.

Reducing Force from Hand Tools

The force placed on the fingers, hands, and wrists by a repetitive task is an important contributor to CTS. To alleviate the effect of force on the wrist, tools and tasks should be designed so that the wrist position is the same as it would be if the arms dangled in a relaxed manner at the sides.

• No task should require the wrist to deviate from side to side or to remain flexed or highly extended for long periods.
• The handles of hand tools such as screwdrivers, scrapers, paint brushes, and buffers should be designed so that the force of the worker's grip is distributed across the muscle between the base of the thumb and the little finger, not just in the centre of the palm.
• People who need to hold tools (including pencils and steering wheels) for long periods of time should grip them as loosely as possible.
• In order to apply force appropriately, the ability to feel an object is extremely important. Tools with textured handles are helpful.
• If possible, people should avoid working at low temperatures, which reduces sensation in hands and fingers.
• Power tools and machines should be designed to minimise vibrations.
• Wearing thick gloves, when possible, may lessen the shock transmitted to the hands and wrists.

 CTS - AYURVEDA MANAGEMENTS

According to Ayurveda the health is maintained by balancing of three Doshas namely Vata,Pitta,and Kapha.if any disturbance in this normalcy due to any food habit,seasonal change will lead to disease.thus treatment in Ayurveda mainly based on the balancing of these doshas and some other factors,etc.

So according to Ayurveda,VATA Dosha is the deranged dosha in this particular condition.Can see that the characteristics like numbness,pain etc all are same as that of vata dosha.

In Ayurveda management of Carpal Tunnel Syndrome means management if Vitiated Vata dosha.Ayurveda itself recommends a holistic approach with medicines and therapies, a Vatahara lifestyle and diet, yoga and exercises.

Ayurveda therapies like Swedana,Abhyanga,Pizchil, Navara Kizhi, Ela Kizhi, Mamsa Navara Kizhi, etc. are very effective in reducing the pain and numbness. A 7-21 day therapy program comprises of general massage with herbal steam to Mamsa Navara Kizhi (meat based external application) to bring back normalcy.
(characteristics of vata dosha,aggravating factors,disease,etc)

The Ayurvedic herbal treatment for carpal tunnel syndrome involves giving symptomatic relief for pain and swelling as well as for the numbness and burning sensation.  Treatment is also given to reduce the swelling in the fibrous tissue situated in the wrist.  Ayurvedic herbal medicines have a good anti- inflammatory action, which get relief from pain, swelling, as well as other symptoms related to carpal tunnel syndrome. This treatment can also be supported by local treatment in the form of local applications as well as fomentation.  Ayurvedic herbal ointments, pastes, and medicated oils are used as local therapy.  Local therapy also helps in quickly reducing pain and swelling related to the condition.

Most people affected with carpal tunnel syndrome need to take Ayurvedic herbal treatment for about 1 to 2 months in order to get complete relief from the condition.  People who present with an advanced condition also report symptoms of nerve damage.  Such patients may require longer treatment, typically lasting for about four to six months.  However, almost all patients affected with carpal tunnel syndrome recover completely with Ayurvedic herbal treatment.  It is equally important for the patient to reduce the cause of the condition, in order to get earlier relief and to prevent recurrence of the condition

 

Treatment Approach:(according to the condition of the patient)

• ruksha sweda like Manal kizhi (fomentation with potali made with sand) for two or three days as prior to the oil application will help to get fast relief from symptoms from pain and swellings.
• Abhyanga sweda or oil massage and fomentation will help to relive symptoms.
• Elakkizhi (bolus made with anti Vata property drugs.
• If any wasting of muscles in there or for chronic cases Mamsa kizhi, Navara kizhi,etc will help to reduce wasting and for increasing blood circulation.
• etc.

All these therapies with internal medicines will help to regain the muscle strength,power,and also help s to get relief from symptoms like pain,swelling,numbness,etc.

Blood-letting with the application of leeches in the wrist or ankle area is also a good way of reducing numbness and pain, especially for patients who do not respond to other conventional treatment .

Internal Medicines:

Kashaya:

• Maharasnadi kashaya
• Punarnavadi kashaya
• prasaranyadi kashaya
• Sundi baladi kashaya
• rasnadi kashaya,etc

Gulikas/Tablets:

• Yogaraja gulgulu.
• Kaisora gulgulu.
• Punarnavadi gulgulu
• Chandraprabha Vati
• Zeotone
• Cervilone
• Lakshadi gulgulu
• Trayodashanga gulgulu,etc.

Arishta: 

• Dasamoolarishta
• Punarnavasavam,etc

 Ghritas:

• Rasnadashamoola ghrtham
• Rasnadi ghrtham.,etc

Oils/Taila: 

• Sahacharadi Taila
• Bala Taila
• Murivanna+Dhanwantaram Tailam
• Mahanarayana Taila,etc

Yoga for Carpal Tunnel Syndrome: 

Nowadays doctors have been using Yoga to successfully treat carpal tunnel syndrome.Tightness in the neck,chest and shoulders may be a contributing factor to carpal tunnel syndrome, and stretching these areas through Yoga therapy will help to prevent carpal tunnel syndrome.

Some of the Asanas/postures are :

1.Gomukhasana:  

Fold the left leg across the right leg.Fold the right hand abobe the shoilder and bring the left hand behind the neck and make a finger lock.Breath deeply.Repeat on the other side.

Benefits:

Its massages the heart and lungs and relieve hip,back,shoulder and joint pain.It is a good exercise for problems of high blood pressure,prostate gland,piles,asthma,respiratory disorders,CTS,etc.

Gomukhasana

2.Garudasana:

1) Wrap one arm under the other, first crossing at the elbows and then again at the wrists. 2) Lift your elbows up and draw your shoulders away from your ears. 3) After several breaths, unwrap and repeat with the other arm underneath.

Garudasana

Namaskarasana (Prayer Position): 

Bring your hands-palms together in Namaste (Prayer Position) in front of your chest. Keep heels of your hands together. Keep fingers pointing up

Gently press hands down toward your waist. Keep heels of hands together, do not let them come apart; if you do, you'll lose the wrist stretch. Hold stretch for a minute or two while focusing on your breath

As your yoga practice continues, you will gradually be able to move the wrists into deeper extension. 

Mudras, or yogic hand gestures, can also be good hand stretches to prevent carpal tunnel syndrome.  
Pran Mudra:  
1) Extend your index finger and middle finger 2) Bring the finger pads of your ring and pinkie fingers to touch the finger pad of your thumb. Do this with both hands and then sit quietly and feel the effects of the hand stretch. Explore other mudras to see which stretches feel best.

Some Home remedies: 

• Take a tablespoon of flax seed oil every day, and give it at least two weeks to have an effect. Flax seed oil is extremely rich in omega-3 fatty acids, which reduce inflammation. Take it with food for better absorption. If you like, you can mix it into your orange juice or add it to your salad dressing.
• Curcumin(Turmeric) is an anti-inflammatory component found in the spice turmeric. In Ayurvedic medicine,, turmeric has a long history of use as a medicine for pain and inflammation. 
• Hot water treatment is also helpful. You can hold a warm compress or a heating pad against your wrists as the heat will help to increase circulation and decrease inflammation.
• Green tea – take an extract in a dose of 250 to 500 mg a day to help with inflammation and to stimulate the immune system. Green tea also provides antioxidants. Drinking the tea is also effective.
• 
  
• Deep Breathing exercise like Pranayamam helps in boosting blood circulation and speed up recovery of damaged cells by providing anti-oxidants.
• Drink Milk Luke warm 200 ml and add a pinch of turmeric. Turmeric is nature's best antiseptic. It helps in speedy recovery
• Ashwagandha herb is a nerve tonic, it can be taken orally as powder or capsule.  

Diet management

• Weight Loss focus for Obese people
• Specific Nutrition Supplement Key Benefit: Weight loss brings relief to carpal tunnel problem & Nutrition supplement for faster recovery
• Avoid excess hot and spicy food items.
• avoid junk foods,etc.

By:Dr.Rimin Razak
Ref:Wikipedia,Adams,Ayurveda medical texts,etc