Looking with Paraplegic & Quadriplegic Eyes

 06.09.06 Paralinks:
garyis@charter.net

What is Carpal Tunnel Syndrome (CTS)?
If you have CTS or have had surgery on CTS we would like your feedback.
CTS is a common problem for Para's and Quad's. I myself knew little about it until five months ago.
This page is here for you information only; if you have CTS symptoms, see a doctor ASAP! -Gary
The early signs of carpal tunnel syndrome should not be ignored.
Early denial of carpal tunnel symptoms is a sure way to lead to progressive symptoms.
(Wikipedia)

My left hand had been bothering me for well over 6 months and was depriving me of sleep for over 3 months. My left hand and arm would go to sleep in the night time causing pain waking me up and then massaging my hand and arm for 15 minutes to over 2 hours effectively depriving me of sleep. During the day I'd wheel around like a zombie, irritable and not thinking clearly. This condition was clearly affecting my ability to function.  -Gary

I had the Open release surgery on my left hand. Not sure yet as to how to approach the right hand as the thumb is the main problem at this point in time. I may want to go the Endoscopic surgery route. As you read the difference between the two surgeries (below) you will see why I will consider the Endoscopic next time. We Para's need full use without pain of the palm of our hands although my left hand seems okay so far. This writing is the first draft, I'll get back here soon and clean up the errors and up-date my recovery.

My left hand was rated a 9 on a scale of 10. The right hand is a 7 on a scale of 10. This is determined by a nerve conduction velocity test and electromyogram done by Physiatrist's, Physical medicine and sports injury doctors and other specialists.

I am interested because both hands are affected! I had my left hand done two weeks ago as it was the worst. My right hand has an injured thumb along with the CTS. Six months ago I banged my right hand/palm/thumb on a solid oak table when I slipped during a transfer causing the breaking up of an arthritic condition in my thumb. After six months the thumb is still painful and needs a bone fusion is what a hand specialist (a Plastic Surgeon) told me.

If you have CTS now, or have had surgery done for CTS,  please contact us and tell your story. What method was used, open release or endoscopic, do you have any problems, or was the surgery a complete success? Most importantly, are you able to use the hand in question as you did before surgery? How is the strength in that hand?

I found the information below on four different medical websites and then condensed to get the basics of CTS into an easily understood format. The URL's are on the bottom of this page. What we'd like to do is get response from readers as to how they dealt with their own CTS. Some folks claim that it can be fixed (cured) without surgery, some say that surgery is the only way.

Carpal tunnel release is one of the most common surgical procedures in the United States. Generally recommended if symptoms last for 6 months, surgery involves severing the band of tissue around the wrist to reduce pressure on the median nerve. Surgery is done under local anesthesia and does not require an overnight hospital stay. Many patients require surgery on both hands. The following are types of carpal tunnel release surgery:

Open release surgery, the traditional procedure used to correct carpal tunnel syndrome, consists of making an incision up to 2 inches in the wrist and then cutting the carpal ligament to enlarge the carpal tunnel. The procedure is generally done under local anesthesia on an outpatient basis, unless there are unusual medical considerations.

Endoscopic surgery may allow faster functional recovery and less postoperative discomfort than traditional open release surgery. The surgeon makes two incisions (about " each) in the wrist and palm, inserts a camera attached to a tube, observes the tissue on a screen, and cuts the carpal ligament (the tissue that holds joints together). This two-portal endoscopic surgery, generally performed under local anesthesia, is effective and minimizes scarring and scar tenderness, if any. One-portal endoscopic surgery for carpal tunnel syndrome is also available.

Although symptoms may be relieved immediately after surgery, full recovery from carpal tunnel surgery can take months. Some patients may have infection, nerve damage, stiffness, and pain at the scar. Occasionally the wrist loses strength because the carpal ligament is cut. Patients should undergo physical therapy after surgery to restore wrist strength. Some patients may need to adjust job duties or even change jobs after recovery from surgery.

Recurrence of carpal tunnel syndrome following treatment is rare. The majority of patients recover completely.

The carpal tunnel receives its name from the 8 bones in the wrist, called carpals, that form a tunnellike structure. The tunnel is filled with flexor tendons which control finger movement. It also provides a pathway for the median nerve to reach sensory cells in the hand. Repetitive flexing and extension of the wrist may cause a thickening of the protective sheaths which surround each of the tendons. The swollen tendon sheaths, or tenosynovitis, apply increased pressure on the median nerve and produce Carpal Tunnel Syndrome (CTS).

What Causes CTS?

As stated earlier, swelling of the tendons that line the carpal tunnel causes CTS. Although there are many reasons for developing this swelling of the tendon, it can result from repetitive and forceful movements of the wrist during work and leisure activities. Research conducted by the National Institute for Occupational Safety and Health (NIOSH) indicates that job tasks involving highly repetitive manual acts, or necessitating wrist bending or other stressful wrist postures, are connected with incidents of CTS or related problems. The use of vibrating tools also may contribute to CTS. Moreover, it is apparent that this hazard is not confined to a single industry or job but occurs in many occupations especially those in the manufacturing sector. Indeed, jobs involving cutting, small parts assembly, finishing, sewing, and cleaning seem predominantly associated with the syndrome. The factor common in these jobs is the repetitive use of small hand tools.

Prevention

NIOSH recommendations for controlling carpal tunnel syndrome have focused on ways to relieve awkward wrist positions and repetitive hand movements, and to reduce vibration from hand tools. NIOSH recommends redesigning tools or tool handles to enable the user's wrist to maintain a more natural position during work. Other recommendations have involved modified layouts of work stations. Still other approaches include altering the existing method for performing the job task, providing more frequent rest breaks, and rotating workers across jobs. As a means of prevention, tool and process redesign are preferable to administrative means such as job rotation.

Paralinks does not recommend any solution, surgery, or any method to correct CTS. You must see a doctor if you have symptoms of CTS. This page is here for one reason: If you have CTS symptoms: Read below and then see a doctor ASAP!

What are the Symptoms of CTS?

The symptoms of CTS often first appear as painful tingling in one or both hands during the night, frequently painful enough to disturb sleep. Accompanying this is a feeling of uselessness in the fingers, which are sometimes described as feeling swollen, even though little or no swelling is apparent. As symptoms increase, tingling may develop during the day, commonly in the thumb, index, and ring fingers. A decreased ability and power to squeeze things may follow. In advanced cases, the thenar muscle at the base of the thumb atrophies, and strength is lost.

Many patients with CTS are unable to differentiate hot from cold by touch, and experience an apparent loss of strength in their fingers. They appear clumsy in that they have trouble performing simple tasks such as tying their shoes or picking up small objects.

Long term recovery from Wikipedia
Important Information, a must read for folks suspecting CTS
(From: http://en.wikipedia.org/wiki/Carpal_tunnel_syndrome)

The early signs of carpal tunnel syndrome should not be ignored. Early denial of carpal tunnel symptoms is a sure way to lead to progessive symptoms.

Most people who find relief of their carpal tunnel symptoms with conservative or surgical management find minimal residual or "nerve damage".[24] Long-term chronic carpal tunnel syndrome (typically seen in the elderly) can result in permanent "nerve damage", i.e. symtoms of numbness, muscle wasting and weakness.

While outcomes are generally good, certain factors can contribute to poorer results that have little to do with nerves, anatomy, or surgery type. One study showed that mental status parameters, alcohol use, and involvement of an attorney yield much poorer overall results of treatment.[25] This really demonstrates how ones mental state, attitude and outlook affect carpal tunnel syndrome and almost any other medical problem that has potential subjective components such as pain and disability status.

Many mild carpal tunnel syndrome sufferers either change their hand use pattern or posture at work or find a conservative, non-surgical treatment that allows them to return to full activity without hand numbness/pain and sleep disruption. Other people end up prioritizing their activities and possibly avoiding certain hand activities so that they can minimize pain and perform the essential tasks.

Changing jobs is also commonly done to avoid continued repetitive stress tasks. Others find success by adjusting their repetitive movements, the frequency with which they do the movements, and the amount of time they rest between periods of performing the movements.

In summary, one has the choice of controlling the symptoms with any of the non-surgical options listed, or correcting the condition with surgery.[26]

While recurrence after surgery is a possibility, true recurrences are uncommon to rare.[27] Non-CTS hand pain is commonly mistaken for recurrence. Such hand pain may have existed prior to the surgery, which is one reason it is very important to get a proper diagnosis.

Exercise/Fitness: Overuse Injuries in Wheelchair Users
The National Center on Physical Activity and Disability
This Fact Sheet is from: http://www.ncpad.org/exercise/fact_sheet.php?sheet=109§ion=822

Carpal Tunnel Syndrome

People with spinal cord injuries place an inordinate amount of weight bearing stress on the upper extremities. This increases the prevalence of carpal tunnel syndrome in this population. The prevalence of carpal tunnel syndrome has been found to increase with the length of time after the injury. Transfers, propelling a wheelchair, and unweighting the sacrum with the upper extremity adducted against the body, the wrist in maximum extension, and the forearm in supination, is the proposed position in which a traumatic event produces carpal instability.

The carpal tunnel is bordered medially by the pisiform bone and the hook of the hamate, and laterally by the crest of the trapezium and the tuberosity of the scaphoid. The floor comprises the lunate and the capitate bones. The transverse carpal ligament forms the roof. The median nerve, along with all the flexor tendons, lies within this anatomical tunnel. Thus, it is easy to see that even the slightest trauma that produces swelling will compress the median nerve.

Compression of the median nerve produces tingling, numbness, and paresthesia over the thumb, index and middle fingers, and the palm of the hand . Pain often occurs at night due to impeded venous return. The thenar muscles (located at the pad of the base of the thumb) may be atrophied, and grip strength may be decreased on the affected side.

Treatment of carpal tunnel syndrome is usually conservative, involving rest, immobilization, and nonsteroidal anti-inflammatories. Most wheelchair users will not undergo any of these treatments due to loss of independence and mobility. Usually the condition worsens to the point where surgery is necessary to release the transverse carpal ligament. Again, wheelchair users are reluctant to undergo surgery due to loss of independence.

In a study by Aljure et. al, the incidence of carpal tunnel syndrome is 27% 1 - 10 years from injury onset; 54% 11 - 20 years from injury onset; around 54% 21 - 30 years from injury onset; and then a significant increase to 90% 31+ years from injury onset. This study suggests median and ulnar nerve functional testing within 5 years of injury even if the person is asymptomatic with periodic re-evaluations after that. The best treatment for carpal tunnel becomes prevention.

Rodgers et al. suggest that carpal tunnel syndrome can occur from fatigue or inappropriate wheelchair use, design and/or prescription. Proper biomechanics will help prevent carpal tunnel syndrome, but further studies to determine proper technique are needed. Wearing padded gloves, similar to cycling gloves, was suggested by Bloomquist because the pressure put on the hands is similar to that of cycling. In his article, he also suggests muscle strengthening, good body mechanics, proper maintenance of wheelchair and equipment, and padding pushrims.

Other preventative measures include applying ice to the wrists for 20 minutes at the end of each day, and adding a flexibility/strengthening program for wrist flexion/extension. There have been no studies showing whether any of these prevention measures will prevent or retard the onset of carpal tunnel syndrome, but these measures will do no harm.

Wrist flexibility and strengthening programs begin with few repetitions and light weights. If nerve/motor involvement prevents holding a weight, use wraparound weights. If hand weights are not available, use household items for weights, such as a 12-oz. soup can.

Note: repetitive strain injury (RSI) is another similar and common condition.

Sources & Sites recommending both surgical and non-surgical solutions

  • http://www.thehandcenter.com/
  • http://www.mycarpaltunnel.com/surgery-release-carpal-tunnel.shtml?
  • http://en.wikipedia.org/wiki/Carpal_tunnel_syndrome
  • http://orthoinfo.aaos.org/brochure/thr_report.cfm?Thread_ID=5&topcategory=Hand
  • http://health.yahoo.com/ency/healthwise/hw213308/hw213456;_ylt=A0Je5_4ufWNEv0wBIhIMhLUF