Carpal tunnel syndrome is a form of neuropathic pain relates to the criteria of the International Association for the Study of Pain (IASP) which defines it as initiated or caused by a primary lesion or dysfunction of the nervous system.
Neuropathic pain is based on the symptoms (spontaneous or evoked pain, paraesthesia) and signs ( mechanical allodynia, thermal hyperalgesia) which may relate more closely to mechanisms and therefore be more helpful in identifying appropriate treatment. Patients with neuropathic pain typically describe pain of two types: (i) Constant burning pain (ii) intermittent shooting or electric pain. In addition positive symptoms of paraesthesia, numbness and dysasthesia such as itching, crawling and tingling are highly suggestive of neuropathic pain. Results of neurological examination indicate negative signs of sensory, motor and reflex testing. The pain typically occurs adjacent to a region of sensory disturbance and may begin in weeks, months or years following initial insult to the nervous system (1)..
Carpal tunnel syndrome (CTS) is a common peripheral neuropathy, our aim is to review the current literature on carpal tunnel syndrome, its signs and symptoms, diagnosis, differential diagnosis and treatment options, in this case the presentation to our clinic and the outcome of Chiropractic therapy.
In addressing the symptoms and history of the condition of CTS, as clinicians we need to address the age, sex and period of onset. Also needing to clarify the duration and intensity of the condition of which we use the Numerical Rating Scale (NRS) (2). The patient is asked to describe and show where their symptoms are felt. Other setbacks / characteristics would be to assess the ability to hold objects, also would they develop numbness in the hand whilst holding objects.
Other symptoms as does the condition interrupt their sleep pattern (3) would they wake and need to “shake” their hand in attempt to alleviate their symptoms, this would be disrupting their sleep pattern, leading to feeling fatigued during the day. As chronic pain is frequently associated with depression and sleep disturbance (4). Do these symptoms occur on a daily basis, does this affect their quality of life. Do they live at home alone, being in a capacity to look after themselves. Have they used splinting / immobilisation techniques, what are their outcomes, should all be documented.
Noting also of previous assessments / treatment consisting of consultation with a hand surgeon, confirmation of the condition by way of nerve conduction and electromyography, showing any neurophysiological evidence of median neuropathy.
Surgery has the following results / outcomes (5):
- Surgical release of the carpal tunnel
- Would need up to 6 weeks of incapacity with the use of the hand, with a 90-93% success rate.
- Given the choice of a less invasive procedure of cortisone injection into the sheath of the wrist.
- Given 7-10% outcome of not being cured, with possible detrimental injury to the median nerve and associated flexor tendons
- There is a 1/100 chance of suffering an infection.
- A 1/500 chance of abnormal reaction to surgery which may cause pain swelling and stiffness in the whole arm
and last 6 months or more and sometimes leave permanent effects
Previous and current medical history is important as conditions such as diabetes can cause patients to succumb to peripheral neuropathies such as CTS as well as previous trauma such as fractures of the hand / wrist. Are they a social drinker or smoker, as this can be detrimental to tissue healing. Their main interests of recreation, sport, hobbies does the condition prevent them from pursuing these activities. General well being and presentation assessing whether they are anxious, depressed, are they co-operative with history taking and want help with her condition. Assessing status of their family relationships or if it is a compensation case / litigation all need to be considered as this can be a hindrance to positive outcomes. Consideration of the type of employment can have some impact, for example if their work is physical this could affect treatment outcomes.
In forming a pain formulation of the case (6) a barrier to recovery is accepting what procedures are available and their outcomes, having current underlying conditions such as cardiac, are elderly or pregnant can make them a non-candidate for any interventional procedures. Feelings of helplessness in terms of what to do with their condition, prolonging a positive outcome, further perpetuating the existing condition leading to fatigue and feelings of depression.
It is important to explain to the patient the treatment offered at our clinic and what procedures are involved to make it effective so that the patient has a shared understanding of our procedures, that it being non-invasive. Giving a specified time-frame, for two reasons (i) it gives the patient an idea of how Chiropractic treatment works (ii) If the desired outcome is not achieved then treatment would cease, so expectations are met.
However the response would be slower and they would have to be patient and allow the programme of treatment to progress as prescribed, consisting of two sessions per week for four weeks which needed to be followed, this would gain their confidence and hence to participate as the aim is to improve the condition and subsequently their quality of life, this would be assessed by:
i) Pain levels, are they lessening, as the treatment is progressing, currently using NRS.
ii) Functional improvement, sleep without being woken up in numbness and pain.
iii) Holding objects pain free and confidently, for example holding the phone without developing numbness and being able to do their hobbies and recreational activities.
iv) Treatment is meeting the financial cost, cost-benefit efficacy as compared to surgery which involves the use of theatre, surgeon, anaesthetist, nursing staff which is a more expensive option.
In a majority of CTS patients the recommended management options are (8) conservative treatment which include behaviour modifications, medications, including anti-inflammatory drugs and analgesics, immobilisation via splinting or bracing, physical and occupational therapy, oral corticosteroids and ultrasound. There are indications that local injections with corticosteroids are less effective in the long term than surgical interventions. The surgical option, open or endoscopic carpal tunnel surgery entails greater risks of complications.