MUSCULO- SKELETAL


out more strenuous activities.8 SYMPTOMS


CTS encompasses a collection of symptoms including intermittent tingling, altered sensation, pain, weakness and impaired fi ne manipulation.7


Paraesthesia (pins and needles) is typically the fi rst symptom to develop. This sensory loss is within the distribution area of the affected median nerve (see diagram 1). This area consists of the thumb, index and middle fi nger and half of the ring fi nger. Pain in the same area may then present and can radiate up the arm into the wrist or as far as the shoulder. Numbness in the hand, wrist or forearm can develop if the condition progresses. Symptoms tend to worsen when the hand or wrist is in action, for example when gripping an object or fl exing the wrist.5,6,7


In severe cases,


weakness of some muscles in the fi ngers and/or thumb can occur. This may cause poor grip and eventually lead to muscle atrophy and reduced strength at the base of the thumb. The skin around the thumb, index and middle fi ngers can also become dry.7


Symptoms often occur in both hands, but they are usually worse in one hand than the other. Most cases affect both hands eventually. Typically, CTS sensations present intermittently to begin with and develop gradually over time with most noticing their fi rst symptoms occur at night - this can cause the sufferer to awaken.6 CTS can lead to diffi culties with daily activities, including work, and sleep. It is therefore a recognised cause of reduced productivity in the workplace.7


If the condition becomes severe, symptoms can persist all day.6


DIAGRAM 1 – CTS SYMPTOM DISTRIBUTION.


Shaded areas show where symptoms typically occur.5


DIAGNOSIS Symptom presentation alone is often enough for a positive CTS diagnosis. Although not a stand-alone test to diagnose CTS, a positive Phalen’s test can help in the identifi cation of this musculoskeletal disorder. Phalen’s test is positive if fl exing the wrist for 60 seconds causes pain and paraesthesia in the median nerve distribution area (ie, thumb, index and middle fi ngers and half of the ring fi nger). Blood tests or nerve conduction studies are reserved for where there is diagnostic doubt, in complex cases or where examination suggests a specifi c secondary cause.7


TREATMENT OPTIONS In up to one in four cases of CTS, symptoms resolve without treatment within one year. With regards to those cases of CTS that develop during pregnancy, symptoms disappear in about two out of three cases three months postpartum.5,8


Symptoms are


most likely to spontaneously resolve in people aged under 30, those with pregnancy-related CTS, persons with only unilateral involvement and those with a negative Phalen’s test.5,7


The goal of treatment for CTS is to restore the patient’s normal functions and activities in addition to preventing nerve damage and loss of muscle strength in the fi ngers and hand. Treatment options are generally divided into three main categories: home treatment, medication and surgery.6


Strong evidence supports immobilisation of the wrist with the use of a removable wrist splint.7 The aim of the splint is to maintain the wrist at a neutral angle without applying any force over the carpal tunnel. Splints are designed to hold the wrist in the position where the carpal tunnel pressure is lowest, ultimately relieving pressure on the median nerve. The stiff metal support which gives these devices rigidity should be bent specifi cally to fi t the patient’s wrist and should be arched over the carpal tunnel area itself so that it doesn’t apply direct pressure to the median nerve from the outside. Splints should be worn whenever they


HOME TREATMENT - If CTS is mild, two to four weeks of home treatment is likely to relieve symptoms. The aim here is to ease pain and prevent further or permanent damage to the median nerve. Symptoms can be completely relieved if treatment is started when symptoms fi rst occur.6,8


33 - SCOTTISH PHARMACIST


do not obstruct activities. In particular, they are helpful with night-time symptoms, with use of the device at night alone often suffi cient to provide relief after a few weeks of use.6,8


Lifestyle modifi cations such as the use of ergonomic equipment like wrist rests, taking breaks from repetitive tasks and alternating job functions are all traditionally advocated in the management of CTS, but the evidence supporting their effectiveness is inconsistent.8


Icing the wrist for ten or fi fteen minutes at intervals during the day can temporarily help to relieve pain.6


due to persistent loss of feeling, reduced thumb strength or if sleep is severely disturbed


At


the very least, patients can be advised to rest the fi ngers, hand and wrist whilst stopping activities that cause numbness and pain. When symptoms have improved activities can gradually be resumed, with wrists kept straight or only slightly bent.6


MEDICATION - Although theoretically reducing infl ammation in the carpal tunnel, there is little evidence to support the use of non-steroidal anti- infl ammatory drugs (NSAIDs) such as ibuprofen to treat CTS. NSAIDS should not be recommended. Additionally, doctors should not prescribe diuretics as part of a treatment plan for this condition.7,8


There is strong evidence to support the administration of a corticosteroid injection into the wrist for chronic CTS.7


This measure should only


be considered after conservative treatment such as rest, ice and splints have been tried for several weeks with no improvement. Corticosteroid injections often provide temporary relief lasting several weeks or more, but rarely provide permanent relief from carpal tunnel symptoms.6


There is no evidence to support the use of complementary medicine such as acupuncture or dietary supplements like pyridoxine in the management of CTS.6


SURGERY - Only a minority of patients with CTS are treated with surgery. This form of treatment is only considered in specifi c circumstances. For example:


• If symptoms have not improved after several months of non-surgical


treatment, assuming there is no nerve damage


• If nerve test results show damage to the median nerve


• If symptoms are extreme enough to restrict normal daily activities


The most common CTS surgery involves cutting the carpal ligament to reduce pressure on the median nerve in the wrist. This is performed under local anaesthetic. The procedure can either be carried out as open or endoscopic surgery. Open carpal tunnel release surgery requires a longer recovery period and leaves a large scar, but there is less incidence of complications. Conversely, endoscopic carpal tunnel release surgery is quicker and leaves a smaller scar, but there is a small increased chance of requiring further surgery. There are no long- term differences in the outcomes of these two approaches.6,8


• REFERENCES


1. Ergonomics Plus. The defi nition and causes of musculoskeletal disorders. http://ergo-plus.com/ musculoskeletal-disorders-msd/ [Online]


2. Health and Safety Executive. Work-related musculoskeletal disorder statistics, Great Britain 2016. http://www.hse.gov.uk/ Statistics/causdis/musculoskeletal/ msd.pdf [Online]


3. Musculoskeletal conditions and physical activity in Scotland- Arthritis Research UK. http://www. arthritisresearchuk.org/policy-and- public-affairs/our-policy-positions/ physical-activity.aspx [Online]


4. BMJ. Clinical Review: Carpal tunnel syndrome. http://www. bmj.com/content/349/bmj.g6437 [Online]


5. Patient: Carpal tunnel syndrome. http://patient.info/health/carpal- tunnel-syndrome-leafl et [Online]


6. WebMD: Carpal tunnel syndrome health centre. http:// www.webmd.com/pain- management/carpal-tunnel/ default.htm [Online]


7. NICE Clinical Knowledge Summaries. Carpal tunnel syndrome. https://cks.nice.org.uk/ carpal-tunnel-syndrome [Online]


8. NHS Choices. Carpal tunnel syndrome. http://www.nhs. uk/Conditions/Carpal-tunnel- syndrome/Pages/Whatisit.aspx [Online]


SCOTTISH PHARMACIST - 33


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