Carpal Tunnel Syndrome 1

Carpal tunnel syndrome http://en.wikipedia.org/wiki/Carpal_tunnel_syndrome Carpal tunnel syndrome (CTS) is an entrapment median neuropathy, causing paresthesia, pain, numbness, and other symptoms in the distribution of the median nerve due to its compression at the wrist in the carpal tunnel. The pathophysiology is not completely understood but can be considered compression of the median nerve traveling through the carpal tunnel.[1] The National enter for !iotechnology "nformation and highly cited older literature [#] say the most common cause of T$ is typing. [%] &ore recent research by 'o(ano) alder*n has cited genetics as a larger factor than use, [+] and has encouraged caution in ascribing causality. [,] The main symptom of T$ is intermittent numbness of the thumb, inde-, long and radial half of the ring finger. [.] The numbness often occurs at night, with the hypothesis that the wrists are held fle-ed during sleep. /ecent literature suggests that sleep positioning, such as sleeping on one0s side, might be an associated factor. [1] "t can be relieved by wearing a wrist splint that prevents fle-ion.[2] 'ong)standing T$ leads to permanent nerve damage with constant numbness, atrophy of some of the muscles of the thenar eminence, and wea3ness of palmar abduction.[4] 5ain in carpal tunnel syndrome is primarily numbness that is so intense that it wa3es one from sleep. 5ain in electrophysiologically verified T$ is associated with [16] misinterpretation of nociception and depression. 5alliative treatments for T$ include use of night splints and corticosteroid in7ection. The only scientifically established disease modifying treatment is surgery to cut the transverse carpal ligament.[11] Signs and symptoms 5atients with T$ e-perience numbness, tingling, or burning sensations in the thumb and fingers, in particular the inde-, middle fingers, and radial half of the ring fingers, which are innervated by the median nerve. 'ess)specific symptoms may include pain in the wrists or hands and loss of grip strength[1#] (both of which are more characteristic of painful conditions such as arthritis). $ome posit that median nerve symptoms can arise from compression at the level of the thoracic outlet or the area where the median nerve passes between the two heads of the pronator teres in the forearm., [1%] but this is highly debatable. This line of thin3ing is an attempt to e-plain pain and other symptoms not characteristic of carpal tunnel syndrome.[1+] arpal tunnel syndrome is a common diagnosis with an ob7ective, reliable, verifiable pathophysiology, whereas thoracic outlet syndrome and pronator syndrome are defined by a lac3 of verifiable pathophysiology and are usually applied in the conte-t of nonspecific upper e-tremity pain.

Numbness and paresthesias in the median nerve distribution are the hallmar3 neuropathic symptoms (N$) of carpal tunnel entrapment syndrome. 8ea3ness and atrophy of the thenar muscles may occur if the condition remains untreated. [1,] Causes &ost cases of T$ are of un3nown causes, or idiopathic.[1.] arpal Tunnel $yndrome can be associated with any condition that causes pressure on the median nerve at the wrist. $ome common conditions that can lead to T$ include obesity, oral contraceptives, hypothyroidism, arthritis, diabetes, and trauma. [11] arpal tunnel is also a feature of a form of harcot)&arie)Tooth syndrome type 1 called hereditary neuropathy with liability to pressure palsies. 9ther causes of this condition include intrinsic factors that e-ert pressure within the tunnel, and e-trinsic factors (pressure e-erted from outside the tunnel), which include benign tumors such as lipomas, ganglion, and vascular malformation. [12] arpal tunnel syndrome often is a symptom of transthyretin amyloidosis)associated polyneuropathy and prior carpal tunnel syndrome surgery is very common in individuals who later present with transthyretin amyloid)associated cardiomyopathy, suggesting that transthyretin amyloid deposition may cause carpal tunnel syndrome. [14][#6][#1][##][#%][#+][#,] Work related The international debate regarding the relationship between T$ and repetitive motion in wor3 is ongoing. The 9ccupational $afety and :ealth ;dministration (9$:;) has adopted rules and regulations regarding cumulative trauma disorders. 9ccupational ris3 factors of repetitive tas3s, force, posture, and vibration have been cited. :owever, the ;merican $ociety for $urgery of the :and (;$$:) has issued a statement claiming that the current literature does not support a causal relationship between specific wor3 activities and the development of diseases such as T$. [#.] The relationship between wor3 and T$ is controversial< in many locations, wor3ers diagnosed with carpal tunnel syndrome are entitled to time off and compensation. [#1] "n the =$;, carpal tunnel syndrome results in an average of >%6,666 in lifetime costs (medical bills and lost time from wor3). [#2] $ome speculate that carpal tunnel syndrome is provo3ed by repetitive movement and manipulating activities and that the e-posure can be cumulative. "t has also been stated that symptoms are commonly e-acerbated by forceful and repetitive use of the hand and wrists in industrial occupations,[#4] but it is unclear as to whether this refers to pain (which may not be due to carpal tunnel syndrome) or the more typical numbness symptoms.[%6] ; review of available scientific data by the National "nstitute for 9ccupational $afety and :ealth (N"9$:) indicated that 7ob tas3s that involve highly repetitive manual acts or specific wrist postures were associated with incidents of T$, but causation was not

established, and the distinction from wor3)related arm pains that are not carpal tunnel syndrome was not clear. "t has been proposed that repetitive use of the arm can affect the biomechanics of the upper limb or cause damage to tissues. "t has also been proposed that postural and spinal assessment along with ergonomic assessments should be included in the overall determination of the condition. 8hile addressing these factors has been found to improve comfort in some studies, [%1] $peculation that T$ is wor3)related is based on claims such as T$ being found mostly in the wor3ing adult population, though evidence is lac3ing for this. ?or instance, in one recent representative series of a consecutive e-perience, most patients were older and not wor3ing.[%#] !ased on the claimed increased incidence in the wor3place, arm use is implicated, but the weight of evidence suggests that this is an inherent, genetic, slowly but inevitably progressive idiopathic peripheral mononeuropathy. [%%] Associated with other diseases ; variety of patient factors can lead to T$, including heredity, si(e of the carpal tunnel, associated local and systematic diseases, and certain habits. [1] Non)traumatic causes generally happen over a period of time, and are not triggered by one certain event. &any of these factors are manifestations of physiologic aging. [%+] @-amples includeA
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/heumatoid arthritis and other diseases that cause inflammation of the fle-or tendons. 8ith pregnancy fluid is retained in tissues, which swells the tenosynovium. 8ith hypothyroidism, generali(ed my-edema causes deposition of mucopolysaccharides within both the perineurium of the median nerve, as well as the tendons passing through the carpal tunnel. Buring pregnancy women e-perience T$ due to hormonal changes (high progesterone levels) and water retention, which is common during pregnancy. 5revious in7uries including fractures of the wrist. &edical disorders that lead to fluid retention or are associated with inflammation such asA inflammatory arthritis, olles0 fracture, amyloidosis, hypothyroidism, diabetes mellitus, acromegaly, and use of corticosteroids and estrogens. arpal tunnel syndrome is also associated with repetitive activities of the hand and wrist, in particular with a combination of forceful and repetitive activities [11] ;cromegaly, causes e-cessive growth hormones. This causes the soft tissues and bones around the carpel tunnel to grow causes compression of the median nerve.[%,]

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Tumors (usually benign), such as a ganglion or a lipoma, can protrude into the carpal tunnel, reducing the amount of space. This is e-ceedingly rare (less than 1C). 9besity also increases the ris3 of T$A individuals classified as obese (!&" D #4) are #., times more li3ely than slender individuals (!&" E #6) to be diagnosed with T$.[%.] Double-crush syndrome is a debated hypothesis that compression or irritation of nerve branches contributing to the median nerve in the nec3, or anywhere above the wrist, increases sensitivity of the nerve to compression in the wrist. There is little evidence, however, that this syndrome really e-ists. [%1] :etero(ygous mutations in the gene $:%T #, associated with harcot)&arie) Tooth, confer susceptibility to neuropathy, including the carpal tunnel syndrome.
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5arvovirus b14 has been associated with carpel tunnel syndrome

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Diagnosis There is no consensus reference standard for the diagnosis of carpal tunnel syndrome. ; combination of described symptoms, clinical findings, and electrophysiological testing is used by a ma7ority of hand surgeons. Numbness in the distribution of the median nerve, nocturnal symptoms, thenar muscle wea3nessFatrophy, positive Tinel0s sign at the carpal tunnel, and abnormal sensory testing such as two)point discrimination have been standardi(ed as clinical diagnostic criteria by consensus panels of e-perts. [+6][+1] ; predominance of pain rather than numbness is unli3ely to be caused by carpal tunnel syndrome no matter what the result of electrophysiological testing. @lectrodiagnostic testing (electromyography and nerve conduction velocity) can ob7ectively verify the median nerve dysfunction. "f these tests are normal, carpal tunnel syndrome is either absent or very, very mild. linical assessment by history ta3ing and physical e-amination can support a diagnosis of T$.
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5halen0s maneuver is performed by fle-ing the wrist gently as far as possible, then holding this position and awaiting symptoms. [+#] ; positive test is one that results in numbness in the median nerve distribution when holding the wrist in acute fle-ion position within .6 seconds. The Guic3er the numbness starts, the more advanced the condition. 5halen0s sign is defined as pain andFor paresthesias in the median)innervated fingers with one minute of wrist fle-ion. 9nly this test has been shown to correlate with T$ severity when studied prospectively. [1]

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Tinel0s sign, a classic H though less sensitive ) test is a way to detect irritated nerves. Tinel0s is performed by lightly tapping the s3in over the fle-or retinaculum to elicit a sensation of tingling or Ipins and needlesI in the nerve distribution. Tinel0s sign (pain andFor paresthesias of the median)innervated fingers with percussion over the median nerve) is less sensitive, but slightly more specific than 5halenJs sign.[1] Bur3an test, carpal compression test, or applying firm pressure to the palm over the nerve for up to %6 seconds to elicit symptoms has also been proposed. [+%][++]

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;s 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. 9ther conditions may also be misdiagnosed as carpal tunnel syndrome. Thus, if history and physical e-amination suggest T$, patients will sometimes be tested electrodiagnostically with nerve conduction studies and electromyography. The goal of electrodiagnostic testing is to compare the speed of conduction in the median nerve with conduction in other nerves supplying the hand. 8hen the median nerve is compressed, as in T$, it will conduct more slowly than normal and more slowly than other nerves. There are many electrodiagnostic tests used to ma3e a diagnosis of T$, but the most sensitive, specific, and reliable test is the ombined $ensory "nde- (also 3nown as /obinson inde-).[+.] @lectrodiagnosis rests upon demonstrating impaired median nerve conduction across the carpal tunnel in conte-t of normal conduction elsewhere. ompression results in damage to the myelin sheath and manifests as delayed latencies and slowed conduction velocities [1] :owever, normal electrodiagnostic studies do not preclude the presence of carpal tunnel syndrome, as a threshold of nerve in7ury must be reached before study results become abnormal and cut)off values for abnormality are variable. [+1] arpal tunnel syndrome with normal electrodiagnostic tests is very, very mild at worst. The role of &/" or ultrasound imaging in the diagnosis of carpal tunnel syndrome is unclear.[+1][+2][+4] Differential diagnosis There are some who believe that carpal tunnel syndrome is simply a universal label applied to anyone suffering from pain, numbness, swelling, andFor burning in the radial side of the hands andFor wrists. 8hen pain is the primary symptom, carpal tunnel syndrome is unli3ely to be the source of the symptoms. [%6] ;s a whole, the medical community is not currently embracing or accepting trigger point theories due to lac3 of scientific evidence supporting their effectiveness. [,6]

athophysiology The carpal tunnel is an anatomical compartment located at the base of the palm. Nine fle-or tendons and the median nerve pass through the carpal tunnel that is surrounded on three sides by the carpal bones that form an arch. The median nerve provides feeling or sensation to the thumb, inde- finger, long finger, and half of the ring finger. ;t the level of the wrist, the median nerve supplies the muscles at the base of the thumb that allow it to abduct, or move away from the fingers, out of the plane of the palm. The carpal tunnel is located at the middle third of the base of the palm, bounded by the bony prominence of the scaphoid tubercle and trape(ium at the base of the thumb, and the hamate hoo3 that can be palpated along the a-is of the ring finger. The pro-imal boundary is the distal wrist s3in crease, and the distal boundary is appro-imated by a line 3nown as Kaplan0s cardinal line.[,1] This line uses surface landmar3s, and is drawn between the ape- of the s3in fold between the thumb and inde- finger to the palpated hamate hoo3.[,#] The median nerve can be compressed by a decrease in the si(e of the canal, an increase in the si(e of the contents (such as the swelling of lubrication tissue around the fle-or tendons), or both.[,%] $imply fle-ing the wrist to 46 degrees will decrease the si(e of the canal. ompression of the median nerve as it runs deep to the transverse carpal ligament (T ') causes atrophy of the thenar eminence, wea3ness of the fle-or 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 pro-imal to the T ' and travels superficial to it. Thus, this branch spared in carpal tunnel syndrome, and there is no loss of palmar sensation.[,+] re!ention ; systematic review in #661 of the published @nglish)language literature assessed the Guality and strength of articles addressing causes for carpal tunnel syndrome. The authors applied the !radford :ill criteria to papers on various biological and occupational factors that have been proposed to have a causative effect. !iological factors such as genetic predisposition and anthropometrics had significantly stronger causal association with carpal tunnel syndrome than occupationalFenvironmental factors such as repetitive hand use and stressful manual wor3. [,,] This suggests that carpal tunnel syndrome might not be preventable simply by avoiding certain activities or types of wor3Factivities. $uggested healthy habits such as avoiding repetitive stress, wor3 modification through use of ergonomic eGuipment (wrist rest, mouse pad), ta3ing proper brea3s, using 3eyboard alternatives (digital pen, voice recognition, and dictation), and employing early treatments such as ta3ing turmeric (anti)inflammatory), omega)% fatty acids, and ! vitamins have been proposed as methods to help prevent carpal tunnel syndrome. The potential role of !)vitamins in preventing or treating carpal tunnel syndrome has not been proven. [,.][,1] There is little or no data to support the concept that activity ad7ustment prevents carpal tunnel syndrome. [,,]

Treatment There have been numerous scientific papers evaluating treatment efficacy in T$. "t is important to distinguish treatments that are supported in the scientific literature from those that are advocated by any particular device manufacturer or any other party with a vested financial interest. Lenerally accepted treatments, as described below, may include splinting or bracing, steroid in7ection, activity modification, physiotherapy, regular massage therapy treatments,medications, and surgical release of the transverse carpal ligament. ;ccording to the #661 guidelines by the ;merican ;cademy of 9rthopaedic $urgeons, [,2] early surgery with carpal tunnel release is indicated where there is clinical evidence of median nerve denervation or the patient elects to proceed directly to surgical treatment. 9therwise, the main recommended treatments are local corticosteroid in7ection, splinting (immobili(ing braces), oral corticosteroids and ultrasound treatment. The treatment should be switched when the current treatment fails to resolve the symptoms within # to 1 wee3s. :owever, these recommendations have sufficient evidence for carpal tunnel syndrome when found in association with the following conditionsA diabetes mellitus, coe-istent cervical radiculopathy, hypothyroidism, polyneuropathy, pregnancy, rheumatoid arthritis, and carpal tunnel syndrome in the wor3place.[,2] "n a wor3ing population, 'yall demonstrated an earlier return to wor3 and a greater percentage of those able to return to wor3 in patients treated with early carpal tunnel release compared to those who spent time involved in nonoperative treatment, such as in7ections, splinting, ergonomic 7ob analysis, hand therapy. The increased costs from nonoperative treatment were due to longer care and longer time off wor3< these also increased the overall cost of treatment. E 'yall M&, Lliner M, :ubbell &KA Treatment of wor3er0s compensation cases of carpal tunnel syndromeA an outcome study. M :and Ther 1,A#,1)4, #66#.D ; longer duration of symptoms, i.e. a delay to definitive surgical treatment, has also been associated with a longer time to return to wor3, implying that earlier definitive surgical treatment reduces the amount of time off of wor3. E Nancollas &5, 5eimer ;, 8heeler B/, $herwin ?$A 'ong)term results of carpal tunnel release. M :and $urg [!r] #6A+16)+, 144,.D $hin also found carpal tunnel release to be superior to nonoperative management, with decreased disability, and a decreased necessity for 7ob modifications and restrictions compared to those who did not undergo surgical release. E $hin ;N, 5erlman &, $hin 5;, Laray ;;A Bisability outcomes in a wor3er0s compensation populationA surgical versus nonsurgical treatment of carpal tunnel syndrome. ;m M 9rthop #4A114)2+, #666.D "mmo#ili$ing #races The importance of wrist braces and splints in the carpal tunnel syndrome therapy is 3nown, but many people are unwilling to use braces. "n 144%, The ;merican ;cademy of Neurology recommend a non)invasive treatment for the T$ at the beginning (e-cept for sensitive or motor deficit or grave report at @&LF@NL)A a therapy using splints was

indicated for light and moderate pathology. [,4] urrent recommendations generally don0t suggest immobili(ing braces, but instead activity modification and non)steroidal anti) inflammatory drugs as initial therapy, followed by more aggressive options or specialist referral if symptoms do not improve.[.6][.1] &any health professionals suggest that, for best results, one should wear braces at night and, if possible, during the activity primarily causing stress on the wrists. [.#][.%] %ocali$ed corticosteroid in&ections orticosteroid in7ections can be Guite effective for temporary relief from symptoms of T$ for a short time)frame while a patient develops a longterm strategy that fits with hisFher lifestyle.[.+] "n certain patients, an in7ection may also be of diagnostic value. This treatment is not appropriate for e-tended periods, however. "n general, medical professionals prescribe local steroid in7ections only until other treatment options can be identified. ?or most patients, surgery is the only option that will provide permanent relief.
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'ther medication ; more aggressive pharmaceutical option is an in7ection of cortisone, to reduce swelling and nerve pressure within the carpal tunnel. The role of &ethylcobalamin (vitamin !1#) in T$ is debatable and uncertain. [..] Carpal tunnel release surgery /elease of the transverse carpal ligament is 3nown as Icarpal tunnel releaseI surgery. "t is recommended when there is static (constant, not 7ust intermittent) numbness, muscle wea3ness, or atrophy, and when night)splinting no longer controls intermittent symptoms.[.1] "n general, milder cases can be controlled for months to years, but severe cases are unrelenting symptomatically and are li3ely to result in surgical treatment. [.2] Procedure "n carpal tunnel release surgery, the goal is to divide the transverse carpal ligament in two. This is a wide ligament that runs across the hand, from the scaphoid bone to the hamate bone and pisiform. "t forms the roof of the carpal tunnel, and when the surgeon cuts across it (i.e., in a line with the ring finger) it no longer presses down on the nerve inside, relieving the pressure.[.4] There are several carpal tunnel release surgery variationsA @ach surgeon has differences of preference based on his or her personal beliefs and e-perience. ;ll techniGues have several things in common, involving brief outpatient procedures, palm or wrist incision(s), and cutting of the transverse carpal ligament. [citation needed] The two ma7or types of surgery are open carpal tunnel release and endoscopic carpal tunnel release. &ost surgeons historically have performed the open procedure, widely

considered to be the gold standard. :owever, since the 1446s, a growing number of surgeons now offer endoscopic carpal tunnel release. [citation needed] 9pen surgery involves an incision on the palm about an inch or two in length. Through this incision, the s3in and subcutaneous tissue is divided, followed by the palmar fascia, and ultimately the transverse carpal ligament.[citation needed] Endoscopic carpal tunnel release @ndoscopic techniGues or endoscopic carpal tunnel release involve one or two smaller incisions (less than half inch each) through which instrumentation is introduced including a synovial elevator, probes, 3nives, and an endoscope used to visuali(e the underside of the transverse carpal ligament. [16] The endoscopic methods do not divide the subcutaneous tissues or the palmar fascia to the same degree as the open method does.[11] &any studies have been done to determine whether perceived benefits of a limited endoscopic or arthroscopic release are significant. !rown et al. conducted a prospective, randomi(ed, multi)center study and found no significant differences between the two groups with regard to secondary Guantitative outcome measurements. [1#] :owever, the open techniGue resulted in more tenderness of the scar than the endoscopic method. ; prospective randomi(ed study done in #66# by Trumble revealed that good clinical outcomes and patient satisfaction are achieved more Guic3ly with the endoscopic method. $ingle)portal endoscopic surgery is a safe and effective method of treating carpal tunnel syndrome. There was no significant difference in the rate of complications or the cost of surgery between the two groups. :owever, the open techniGue caused greater scar tenderness during the first three months after surgery, and a longer time before the patients could return to wor3. [1%] "n addition, in patients without wor3ers compensation issues, the single)incision endoscopic carpal tunnel release led to less palmar tenderness and a Guic3er return to wor3 compared to the two) incision endoscopic carpal tunnel release (5almer B:, 5aulson M , 'ane)'arsen ', 5eulen OK, 9lson MBA @ndoscopic carpal tunnel releaseA a comparison of two techniGues with open release. ;rthroscopy 4A+42),62, 144%.) &any surgeons have embraced limited incision methods. "t is considered to be the procedure of choice for many of these surgeons with respect to idiopathic carpal tunnel syndrome. $upporting this are the results of some of the previously mentioned series that cite no difference in the rate of complications for either method of surgery. Thus, there has been broad support for either surgical procedure using a variety of devices or incisions. The primary goal of any carpal tunnel release surgery is to divide the transverse carpal ligament and the distal aspect of the volar ante brachial fascia, thereby decompressing the median nerve. [1+] Bespite these views, some surgeons have suggested that in their own hands endoscopic carpal tunnel release has been associated with a higher incidence of median nerve in7ury, and for this reason it has been abandoned at several centers in the =nited $tates. ;t the #661 meeting of the ;merican $ociety for $urgery of the :and, a former advocate of endoscopic carpal tunnel release, Thomas M. ?ischer, &B, retracted his advocacy of the techniGue, based on his own personal assessment that the benefit of the procedure (slightly faster

recovery) did not outweigh the ris3 of in7ury to the median nerve. ontrary to this one or any one opinion of any individual surgeon it has been shown that while there is a learning curve for a hand surgeon who begins to use an endoscopic techniGue to release the transverse carpal ligament no significant safety issues or morbididty associated with the endoscopic method e-ist. [1,] The use of endoscopic carpal tunnel release has continued to spread around the world and clinical and nerve electrophysiological states are significantly improved at the long)term follow)up after endoscopic carpal tunnel release.[1.] ; meta)analysis supports the conclusion that endoscopic carpal tunnel release is favored over the open carpal tunnel release in terms of a reduction in scar tenderness and increase in grip and pinch strength at a 1#) wee3 follow)up [11] Experimental procedures !alloon carpal tunnelplasty is an e-perimental techniGue that uses a minimally invasive balloon catheter director to access the carpal tunnel. ;s with a traditional tissue elevatorFe-pander, balloon carpal tunnelplasty elevates the carpal ligament, increasing the space in the carpal tunnel. The techniGue is performed through a one)centimeter incision at the distal wrist crease. "t is monitored and e-pansion is confirmed by direct or endoscopic visuali(ation. The techniGue0s secondary goals are to avoid to incision in the palm of the hand, to avoid cutting of the transverse carpal ligament, and to maintain the biomechanics of the hand.[12] Efficacy $urgery to correct carpal tunnel syndrome has a high success rate. =p to 46C of patients were able to return to their same 7obs after surgery. [14][26][21] "n general, endoscopic techniGues are as effective as traditional open carpal surgeries, [2#][2%] though the faster recovery time typically noted in endoscopic procedures is felt by some to possibly be offset by higher complication rates. [2+][2,] $uccess is greatest in patients with the most typical symptoms. The most common cause of failure is incorrect diagnosis, and it should be noted that this surgery will only mitigate carpal tunnel syndrome, and will not relieve symptoms with alternative causes. /ecurrence is rare, and apparent recurrence usually results from a misdiagnosis of another problem. [citation needed] omplications can occur, but serious ones are infreGuent to rare. [citation needed] arpal tunnel surgery is usually performed by a hand surgeon, orthopaedic surgeon, or plastic surgeon. $ome neurosurgeons and general surgeons also perform the procedure.[citation needed] (ltrasound physiotherapy treatment $ome claim that ultrasound to the wrist gives significant improvement of symptoms in people with T$.[2.] ; treatment process may consist of #6 sessions of 1, minutes of ultrasound applied to the area over the carpal tunnel at a freGuency of 1 &:(, and a power of 1.6 8Fcm#.[2.]

:owever, many studies have shown no effect. [21][22] Liven these inconsistencies, the role of ultrasound in the treatment of T$ is debatable and it should be considered an e-perimental treatment. hysiotherapy 9ne review of the evidence for possible symptom reduction found good evidence (level ! recommendations) for splinting, ultrasound, 'aser, Tens, nerve gliding e-ercisesFNeural mobili(ation, carpal bone mobili(ation, magnetic therapy, and yoga for people with carpal tunnel syndrome. [24] :owever, a recent evidence based guideline produced by the ;merican ;cademy of 9rthopedic $urgeons assigned lower grades to most of these treatments.[46] ;gain, some claim that pro)active ways to reduce stress on the wrists, which alleviates wrist pain and strain, involve adopting a more ergonomic wor3 and life environment. ?or e-ample, some have claimed that switching from a P8@/TN computer 3eyboard layout to a more optimised ergonomic layout such as Bvora3 was commonly cited as beneficial in early T$ studies, however some meta)analyses of these studies claim that the evidence that they present is limited.[41][4#] rognosis &ost people relieved of their carpal tunnel symptoms with conservative or surgical management find minimal residual or Inerve damageI. [4%] 'ong)term chronic carpal tunnel syndrome (typically seen in the elderly) can result in permanent Inerve damageI, i.e. irreversible numbness, muscle wasting, and wea3ness. 8hile outcomes are generally good, certain factors can contribute to poorer results that have little to do with nerves, anatomy, or surgery type. 9ne study showed that mental status parameters or alcohol use yields much poorer overall results of treatment. [4+] /ecurrence of carpal tunnel syndrome after successful surgery is rare. [4,] "f a person has hand pain after surgery, it is most li3ely not caused by carpal tunnel syndrome. "t may be the case that the illness of a person with hand pain after carpal tunnel release was diagnosed incorrectly, such that the carpal tunnel release has had no positive effect upon the patient0s symptoms.[citation needed] )pidemiology arpal tunnel syndrome can affect anyone. "n the =.$., roughly 1 out of #6 people will suffer from the effects of carpal tunnel syndrome. aucasians have the highest ris3 of T$ compared with other races such as non)white $outh ;fricans. [4.] 8omen suffer more from T$ than men with a ratio of %A1 between the ages of +,Q.6 years. 9nly 16C of reported cases of T$ are younger than %6 years. [4.] "ncreasing age is a ris3 factor. T$ is also common in pregnancy.

*istory The condition 3nown as carpal tunnel syndrome had ma7or appearances throughout the years but it was most commonly heard of in the years following 8orld 8ar "". [41] "ndividuals who had suffered from this condition have been depicted in surgical literature for the mid)14th century. [41] "n 12,+, $ir Mames 5aget was the first to report median nerve compression at the wrist in a distal radius fracture. [42] ?ollowing the early #6th century there were various cases of median nerve compression underneath the transverse carpal ligament.[42] arpal Tunnel $yndrome was most commonly noted in medical literature in the early #6th century but the first use of the term was noted 14%4. 5hysician Br. Leorge $. 5halen of the leveland linic identified the pathology after wor3ing with a group of patients in the 14,6s and 14.6s.

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