Carpal Tunnel Syndrome

Nonoperative carpal tunnel syndrome treatmentA. Lee Osterman, MDa,b, Marc Whitman, PTc,1,

Linda Della Porta, OTR, CHTc,2,*aPhiladelphia Hand Center, 834 Chestnut street, Philadelphia, PA, USA

bDepartment of Orthopedic and Hand Surgery, Thomas Jefferson University Hospital, USAcRecipient of the Evelyn J Mackin Hand Therapy Fellowship, 834 Chestnut Street, Philadelphia, PA, USA

Carpal tunnel syndrome (CTS) has been cited

as the most common of the upper extremity com-

pression neuropathies [1–3]. A recent study exam-

ined the prevalence osf CTS in a Swedish general

population. The authors found, in a population

of 170,000, self-reported sensory changes and/or

pain in the median nerve (MN) distribution in

14.4%, clinical and electrophysiologically con-

firmed CTS in 2.7% [4]. Among workers, the inci-

dence of CTS, based on claim data, was reported

as 24.5 per 10,000 full-time employees in Washing-

ton State [5]. In addition, the Bureau of Labor

Statistics (BLS) reported 1,702,500 work-related

injuries involving time away from work, and of

those 27,900 cases or 1.6% were CTS [6].

In terms of cost and time away from work, CTS

has resulted in lost revenue for the employer and

employee. The BLS considers median days away

from work a key indicator as to the severity of

occupational injury. In 1999, CTS required the

highest time away at 27 days, followed by fracture

(20 days) and amputations (18 days) [7]. In Wash-

ington State, there were 27,148 claims filed for

CTS at an average cost of $12,627 per claim

between 1992 and 1998 [5]. This resulted in more

than $300,000,000 for the management of CTS

and may not include other costs such as litigation,

lost productivity, lost wages, or retraining.

As CTS continues to manifest itself as a signifi-

cant economic and debilitating entity, it will be

more important to research and develop treatment

approaches. We believe that nonoperative treat-

ment is a viable option for the management of

CTS. The following discussion will explore the

various treatment options presented in the litera-

ture and the rationale behind their use.

Why choose nonsurgical treatments? There are

several reasons:

1. Conservative management can cost less than

surgical management. In California (1993),

the average cost of surgical intervention was

$20,925, as compared with $5,246 for nonop-

erative intervention [8].

2. Various nonsurgical treatments for CTS have

been shown to ameliorate symptoms in 13–

92% of patients [3,9–16]. These studies docu-

ment that conservative management is

effective.

3. There is a population of CTS patients that is

appropriate for conservative treatment

[17,18]. Patients with carpal tunnel symptoms

can generally be categorized based on chron-

icity and severity of signs and symptoms.

[1,19,20]. Those patients with underlying sys-

temic disease or severe changes indicative of

MN compromise need surgical decompres-

sion or further medical management [18,21].

But as recommended by several authors

[10,11,13,14,22], conservative treatment is

indicated for mild to moderate symptoms

with early intervention generally more predic-

tive of satisfactory outcomes.

4. It has been speculated [16] that many patients

with the signs and symptoms of CTS are now

* Corresponding author.

E-mail address: [email protected] (L. Della

Porta).1 Present address: P.O. Box 112192, Anchorage, AK

99511-21922 Present address: 56 Parkton Road #1, Jamaica

Plain, MA 02130

0749-0712/02/$ - see front matter � 2002, Elsevier Science (USA). All rights reserved.

PII: S 0 7 4 9 - 0 7 1 2 ( 0 2 ) 0 0 0 2 3 - 9

Hand Clin 18 (2002) 279–289

seeking treatment earlier caused by the

improved access to information by various

media sources. If this is the case, then nonsur-

gical intervention will continue to be instru-

mental in treatment of this condition.

5. Finally, as with any surgery, there are risks

associated with the procedure to release the

carpal tunnel. These include infection, stiff-

ness, reflex sympathetic dystrophy, and nerve

or tendon injury [19], which makes nonoper-

ative management a more appealing first line

of treatment.

We are not advocating that surgical interven-

tion for CTS is unncessary or warranted, but,

potentially, surgery may be avoided and overall

cost and time away from work may be reduced

through the use of nonoperative treatment strat-

egies if applied consistently and early in the course

of treatment (see Box 1).

Overview

CTS generally is considered a compressive neu-

ropathy of theMN as it courses through the carpal

tunnel of the wrist. Currently, there is a debate

regarding whether ischemia or mechanical forces

exerts the greatest impact on changes to the MN

[17,19,22–26]. Controversy also exists about the

role of inflammation. Although tissue studies do

not support inflammation as a precursor to CTS

[27,28], strategies to ‘‘reduce inflammation’’ have

been used with some success [29,30]. CTS is

regarded as a multifaceted syndrome, and causal-

ity is largely unknown. It has been associated,

however, with various conditions that can pre-

dispose individuals to its development. These

conditions are as follows: 1) acute trauma,

2) endocrine disorders, 3) inflammatory arthritis,

4) chronic renal failure, 5) pregnancy, 6) mass

lesions within the carpal canal, 7) occupational/

recreational factors, 8) lifestyle, 9) traction injury,

and 10) double crush [1,31–33]. The development

of this neuropathy can also occur for seemingly

no reason at all and is thus labeled ‘‘idiopathic

carpal tunnel syndrome.’’

Treatment

The first course of treatment for CTS generally

consists of prescribed medication consisting of

nonsteroidal anti-inflammatory drugs (NSAIDs)

and/or steroids that can be delivered orally or by

injection. The action of these medications is to

inhibit the chemical mediators of inflammation in

response to injury. By limiting the inflammatory

response, they also suppress pain by desensitizing

nociceptors to these same chemicals [34]. The effec-

tiveness of NSAIDs versus steroids for treatment

of CTS was examined in a 1998 study. In a 4-week

trial evaluating effect of medication as the sole

treatment short-term, low-dose oral steroids were

more effective than NSAIDs, diuretics, and pla-

cebo [35]. This was supported in another study,

which also found low-dose, short-term oral ste-

roids more effective than placebo only. This trial

period was 8 weeks, however, and demonstrated

that the initial improvement provided by the ste-

roid was temporary with a return in symptoms

[36]. Oral steroids seem to show more promise in

the short-term management of CTS than NSAIDs

but are associated with negative side-effects if used

for long periods.

Local steroid injection into the carpal canal is

an option to avoid the systemic actions of oral

steroids. The injectable steroid of choice is water-

soluble and can be combined with an anesthetic

to reduce injection discomfort. A study examining

Box 1 Current nonoperative

treatment

Medicinal

• NSAIDs• Steroids

InjectibleOral

• Pyridoxine (B6)

Modalities

• Ultrasound• Iontophoresis

Splinting

Activity modification

• Ergonomic intervention• Avocational assessment

Exercise

• Tendon gliding• Nerve gliding• General conditioning

YogaStretching

280 A.L. Osterman et al / Hand Clin 18 (2002) 279–289

injections [12] found long-term relief of symptoms

(‡1 year) in only 24% of subjects. An additional

27% responded initially but then had a reoccur-

rence of symptoms within 1 year. Various other

studies have reported success rates from 13% to

92% utilizing injections alone or combined with

splinting [10,14,16]. Success rates were defined as

lasting improvement in symptoms 11–18 months

in duration. Response to an injection can also cor-

relate and predict the response to surgical release

[13]. This is particularly true when there are con-

founding conditions, such as double crush syn-

drome [32], diabetes, and discrepancies on the

cervical spine exam. Complications and risks asso-

ciated with injection of the carpal canal include

tendon rupture, nerve injuries, pain, transient gly-

cemic elevation in diabetics, skin atrophy, and

depigmentation.

Controversy still exists regarding the role of

pyridoxine (Vitamin B6) as a component in the

treatment of CTS [37–40]. The current literature

does not clearly support or detract from the use

of vitamin B6. Therefore, if utilized, it should be

in conjunction with other treatments (Box 1).

Splinting

Immobilization of the wrist through splinting is

a component of nonoperative treatment. Individu-

als are instructed to wear splints while sleeping

because that is when symptoms tend to be most

pronounced. In addition, it is more difficult to

maintain the wrist in a neutral position at this

time. During wakening hours, individuals can be

instructed to monitor wrist position with activity

and to maintain the wrist in a neutral alignment,

avoiding ulnar deviation.

Carpal tunnel pressures have been studied with

flexion and extension to determine the position of

the wrist that results in the lowest carpal canal

pressures. It was reported that 2þ/�9� of exten-sion and 2þ/�6� of ulnar deviation is the positionwith the lowest carpal canal pressure. Immobiliza-

tion of the wrist closest to neutral was recom-

mended [41]. Symptom relief at neutral and at

20� of wrist extension have been compared.

Results indicated that symptom relief was found

to be greater at neutral than with 20 degrees of

wrist extension [42]. With immobilization of the

wrist, the angle of the splint should be carefully

evaluated, as even small differences can affect

carpal canal pressures and symptom relief. Fre-

quently, prefabricated splints position the wrist

at 20–30� of extension (Fig. 1). Ideally, a thermo-plastic splint should be custom-fit to ensure that

the wrist is at a neutral angle (Fig. 2). It has been

reported that individuals will experience a decrease

in symptoms after wearing a splint for 2 weeks [42].

Optimal results with splints were obtained if

applied within the first 3 months of onset [43].

But a 2-week trial is worthwhile regardless of

how long the individual has been experiencing

symptoms [42]. The effect of lumbrical incursion

with finger position has been studied. It was deter-

mined that increased finger flexion increases carpal

canal pressures. Therefore, it was concluded that

finger motion as well as wrist position plays a role

in carpal canal pressure [44]. A study of cadaveric

dissections confirmed that the lumbrical muscles

originate distal to the carpal canal with the fingers

extended. With fingers flexed, lumbrical muscles

were found within the carpal canal. It was sug-

gested that the lumbricals can contribute to com-

pression within the carpal tunnel [45]. Because

increased finger flexion as well as wrist position

play a role in carpal canal pressures, a metacarpal

block may be a consideration if symptoms do not

subside with a standard wrist splint.

Fig. 1. Commercially available splint.

281A.L. Osterman et al / Hand Clin 18 (2002) 279–289

Therapeutic modalities

Therapeutic ultrasound is a modality that pro-

duces acoustical high-frequency vibrations with

both thermal and nonthermal effects [46]. It has

been observed, ‘‘The literature suggest[s] that low

intensity pulsed ultrasound is the most appropriate

to promote healing of open wounds, to resolve

acute and subacute inflammation, and to enhance

repair in tendon, nerve and bone’’ [47]. With CTS,

flexor tendons may be inflamed. If ultrasound is

used, pulsed or nonthermal mode would be the

most appropriate as continuous or thermal mode

may irritate inflamed tendons.

Recently, the effects of ultrasound for the treat-

ment of mild to moderate idiopathic CTS were

studied. Twenty treatments of pulsed ultrasound

were applied to the area over the carpal tunnel.

Results suggested satisfying short- to medium-

term effects. Individuals receiving ultrasound

treatments experienced reduced symptoms and

improved nerve conduction compared with results

in a placebo control group [48]. This study utilized

ultrasound as the sole treatment. Our opinion,

however, is that if ultrasound is used for carpal

tunnel treatment, it should be in conjunction with

other conservative measures. It would also be ben-

eficial to study the effects of fewer ultrasound

treatments as 20 treatments may be costly.

Iontophoresis is an electrical modality used

to deliver medication in an ion form with the

objective of delivering a higher local concentra-

tion, minimizing systemic concentration [49]. In a

study by Banta, a standard treatment protocol was

utilized using wrist splinting, NSAIDs, and ionto-

phoresis with dexamethasone sodium phosphate

[9]. The study revealed a success rate comparable

with splinting plus injection of dexamethasone

into the carpal tunnel space. It should be noted

that the study had several shortcomings: a small

sample size, lack of randomization and blinding,

and no use of a sham iontophoresis group. In those

individuals that are unable to tolerate steroid

injections into the carpal canal, however, the use

of iontophoresis may be an option.

Ergonomic factors

Pressure over the carpal canal [23], wrist posi-

tioning [41–43], low temperatures [50], vibration

[51,52], and high force with high repetition [30]

have been cited as occupationally related risk fac-

tors in the development of CTS. Nonoccupational

risk factors such as diabetes, rheumatoid arthritis,

thyroid disease, and obesity have also been cited as

risks [50,53]. Weight and body mass have been cor-

related with slowing of sensory conduction of the

median nerve [53]. It was suggested that individual

characteristics, not job-related factors, were pri-

mary determinants of CTS. The development of

carpal tunnel syndrome is multifactorial, therefore

controversy remains regarding the primary influ-

encing and etiologic factors [54].

Despite this controversy regarding primary

influencing factors, it may be beneficial to address

individuals’ occupational and nonoccupational

risk factors in order to maximize the effectiveness

of conservative treatment. Though ergonomic

measures have not been shown to influence the

development of CTS, they have been useful in

the conservative management of those patients

with established mild CTS.

Mechanical stress or direct pressure over the

carpal canal has been shown to increase carpal

canal pressures [23]. Wrist positioning with tool

use can be modified when indicated. If a keyboard

or tool is positioned incorrectly, direct pressure

may be placed over the carpal canal, causing an

increase in carpal canal pressures. Rounding and

padding edges of workstations can be helpful.

Fig. 2. Custom-made splint by hand therapist.


Positioning the wrist closest to a neutral align-

ment helps to achieve the lowest possible carpal

canal pressure [41–43]; therefore, this neutral wrist

alignment should be maintained with work and

avocational activities. With the increasing use of

computers at home, it is insufficient to consider

keyboard positioning for work needs only. Indi-

viduals should be encouraged to apply ergonomic

principles with all other daily activities. Ulnar

deviation in excess of 20� has been associated

with increased carpal tunnel pressures [41]. Ergo-

nomic tools that are designed with bent handles or

adaptations can decrease ulnar deviation. An

ergonomic split keyboard maintains the wrist

as straight, decreasing wrist deviation. But because

an item is labeled ergonomic does not mean that

it is the most appropriate. Items should be care-

fully evaluated and basic principles applied. An

ergonomic keyboard will not be as effective if it

is placed at a level where the individual is unable

to maintain the wrist in neutral alignment. In a

recent study, it was found that in many partici-

pants, carpal tunnel pressures measured during

mouse use were greater than pressures known to

alter nerve function and structure. Although not

clinically demonstrated, authors’ recommenda-

tions include minimizing wrist extension, pro-

longed mouse dragging, and performing other

tasks with the mousing hand [55].

It was reported by Silverstein that high force

combined with high repetitiveness increases the

risk more than 5· that of either factor alone [30].Strategies to decrease repetitiveness may include

alternating repetitive with nonrepetitive work

activity, stretch breaks, or job rotation. In order

to change force requirements, the tool itself may

need to be changed. Whenever possible, educate

the individual to avoid overuse of flexors or

exerting more muscle force than is required. Bio-

feedback can be helpful in increasing an indivi-

dual’s awareness of hand postures. In a study

comparing the effects of biofeedback with CTS,

individuals reported that this feedback was help-

ful in improving awareness. There was no direct

objective evidence, however, that biofeedback

was helpful in reducing the symptoms of CTS

[59]. There is a correlation between carpal tunnel

syndrome and prolonged exposure to environ-

mental conditions such as vibration [51,56] and/

or cold temperature exposure [50]. Work gloves

may be helpful but need to be carefully evaluated.

An individual may grip more forcefully secondary

to a decrease in sensory feedback. When possible,

modify the tool to dampen vibration. Reduction

of exposure to environmental factors through

job rotation or elimination of aggravating factor

may be necessary.

Exercises

An evaluation of upper extremity musculature

and cervical screen should be completed prior to

prescribing exercises or stretches for CTS. A prox-

imal weakness may be contributing to overuse

of distal musculature. An individual can also pre-

sent with muscle imbalances secondary to overuse

of flexors. In cases where extensor weaknesses

is noted, stretches of flexor musculature and

strengthening of extensors would be the most

appropriate. Repetitive gripping exercises with

grip tools or balls can contribute to further inflam-

mation of flexor musculature and therefore should

be avoided. An assessment of daily activities or

components of work is helpful in determining the

most appropriate stretches or exercises for an indi-

vidual. Stretch breaks from repetitive activities

should be encouraged. In a recent study, signifi-

cant decreases in carpal tunnel pressures were

noted following 1 minute of hand and wrist exer-

cises. Brief intermittent wrist and hand exercises

were recommended to reduce intratunnel pressure

[57]. Based on these findings, specific exercises

were developed for CTS [29,57].

Tendon gliding exercises and median nerve

gliding exercises

The effectiveness of nerve and tendon gliding

exercises for the conservative treatment of CTS

has been studied (Fig. 3 and Fig. 4). The study indi-

cated that43%of thosewhoperformed the exercises

did not undergo surgery, whereas 71.2% of those

who did not perform the exercises underwent sur-

gery. The experimental and control groups both

received traditional conservative treatment with

splinting, nonsteroidal anti-inflammatory medica-

tion, and steroid injections. The difference was that

the experimental group also performed tendon and

nerve gliding exercises as developed by Totten and

Hunter [15,58]. The authors of this studypostulated

that guiding the wrist and fingers through this pro-

gram of nerve and tendon gliding exercises would

help tomaximizeMNexcursion in the carpal tunnel

and excursion of the flexor tendons relative to one

another. They proposed that a ‘‘ milking’’ effect

would promote venous return and decrease the

pressure inside the perineurium [15,58]. Further


Fig. 3. (A–D) Tendon gliding exercises. (From Totten PA, Hunter JM. Therapeutic techniques to enhance nerve gliding

in the thoracic outlet and carpal tunnel syndrome. Hand Clin 1991;7(3):505)


Fig. 4. (A–E) Wrist level median nerve gliding exercises. (From Totten PA, Hunter JM. Therapeutic techniques to

enhance nerve gliding in the thoracic outlet and carpal tunnel syndrome. Hand Clin 1991;7(3):505.)


research is needed to evaluate the most effective

exercises and nerve gliding techniques for CTS.

Brachial plexus gliding program

The median nerve has been shown to move

within the carpal tunnel and the upper extremity

with various positions. McLellan and Swash dem-

onstrated movement of the MN longitudinally in

the upper extremity, depending on joint position

[60]. They also demonstrated longitudinal move-

ment of the MN with proximal joint motion of

the shoulder and elbow. It was theorized that this

longitudinal sliding is necessary to minimize local

stretching and to prevent entrapment along the

course of the nerve as the limb moves.

In work by Butler, this longitudinal movement

of the peripheral nervous system is recognized.

Butler describes selective tensioning of the upper

limb for treatment of neural entrapment. He has

elaborated on Elveys brachial plexus tension test,

with median ulnar and radial nerve bias [61,62].

A brachial plexus gliding program has also been

described to facilitate nerve gliding from proximal

to distal. With this program, the individual

attempts to move to the point of tension, not pain,

to avoid aggravating symptoms. As symptoms

decrease, the individual can progressively perform

the remaining movements of the sequence [62].

Double crush syndrome, originally described

by Upton and McComas [63], refers to the co-

existence of dual lesions along the course of a nerve.

They proposed that a more proximal lesion would

lessen the ability of the nerve to withstand a more

distal compressive force. The coexistence of CTS

with cervical radiculopathy has been reported in

the literature [32,64]. If the individual being

treated for CTS presents with a more proximal

lesion, performing wrist level median nerve gliding

exercises only may be insufficient. Proximal

shoulder or cervical issues should be evaluated.

The effects of performing brachial plexus nerve

glides have not been studied for the treatment of

CTS. Further research on proximal as well as dis-

tal stretches, nerve glides, or exercises would be

beneficial to determine potential benefit in the

treatment of CTS.

Yoga

Recently, a preliminary study compared effects

of a yoga-based regimen in the treatment of CTS

[65]. Subjects assigned to the yoga group per-

formed 11 yoga postures along with relaxation

twice weekly for 1–1.5 hour sessions. Subjects in

the yoga groups demonstrated improvements in

grip strength, pain reduction, and improvements

with Phalen’s sign. Significant differences were

not demonstrated with Tinel’s sign, sleep disturb-

ance, or in motor and sensory conduction time.

This study demonstrated improvements with the

use of yoga postures; however, several limitations

exist. In addition to small sample size, medication

use, and splint angle for controls were not

recorded.

It is important to realize that specific postures

were utilized; therefore, it is difficult to generalize

that all of yoga may be effective in improving car-

pal tunnel symptoms. There are many different

schools of yoga, and varieties of teaching. Each

type of yoga emphasizes different postures, relaxa-

tion, and breathing techniques. Hatha yoga is the

branch of yoga involved with movement. There

are forms of yoga that do not involve movement

and emphasize relaxation or attainment of spiri-

tual goals. The yoga utilized in this study is based

on movement or hatha yoga along with relaxation

techniques. The exercises utilized emphasize upper

extremity movements and stretches, both proximal

and distal. In our opinion, this study reinforces the

Fig. 4 (continued )


importance of upper extremity stretching and

attention to proximal upper extremity status as

well as wrist level stretches. Individuals who are

able to incorporate yoga into their life may find

this form of exercise helpful. Further research is

needed to investigate upper extremity stretches or

yoga postures that would be most beneficial in

the treatment of CTS.

Roslyn Evans’ approach

Roslyn Evans’ nonoperative approach to CTS

includes splinting and activity modification. Exer-

cise putty and hand grippers are not recommended

as they may contribute to increased pressure on the

MN from lumbrical incursion. Tendon gliding

exercises and median nerve gliding are not

included as a component of nonoperative treat-

ment [66].

Specific splinting guidelines are suggested [66]:

1. Splinting the wrist in 2� of wrist flexion, 3� ofulnar deviation.

2. For individuals with positive lumbrical incur-

sion and flexor tenosynovitis, and with pa-

tients who inadvertently flex fingers against

the splint in an attempt to relieve symptoms,

a metacarpal block is suggested. Recommen-

dation is to splint the wrist in 2� of wrist flex-ion, 3� of ulnar deviation, MP joints at 0–20�of flexion, and IP joints free.

3. For individuals with severe symptoms and

pain, a full resting pan splint is recommended.

Positioning recommendation is for wrist in

2� of wrist flexion, 3� of ulnar deviation, MPjoints in flexion, IP joints in extension, and

to rest carpal metacarpal (CMC) joint and

thumb in neutral to slight extension.

Summary

Many factors influence the development of

CTS; therefore, nonoperative treatment should

not be limited to only one intervention. Nonoper-

ative treatment is most effective in the early stages,

prior to irreparable damage to the nerve. Early

intervention combined with a comprehensive

treatment plan can help improve effectiveness of

treatment during this phase. We do not endorse

any one particular conservative treatment/pro-

gram as the solution for CTS, but our purpose

is to explore potential options. Further study

is needed to determine the most beneficial and

cost-effective treatments.

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