Carpal Tunnel Syndrome

Course #91953 - $15 • 3 Hours/Credits


Self-Assessment Questions

    1 . Which of the following statements most accurately defines carpal tunnel syndrome?
    A) Pain and abnormal nerve sensations in the neck, shoulder, arm, and/or hand
    B) Painful disorder of the wrist and hand that occurs when the median nerve becomes compressed
    C) Injury to the nerves, muscles, and tendons of the wrist and hand due to the repetitive use of vibrating hand tools
    D) Medial elbow pain, hand fatigue, and sensations in the fourth and fifth fingers resulting from ulnar nerve damage

    CARPAL TUNNEL SYNDROME DEFINED

    Carpal tunnel syndrome is generally associated with such umbrella terms as repetitive stress injuries, work-related upper extremity disorders, musculoskeletal disorders, entrapment neuropathies, and cumulative trauma disorders [16,18]. Specifically, carpal tunnel syndrome is a painful disorder of the wrist and hand that occurs when the median nerve (which runs from the hand to the forearm) becomes compressed [1,19].

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    2 . Health conditions frequently associated with the presence of carpal tunnel syndrome include
    A) rheumatoid arthritis, hypotension, and tophaceous gout.
    B) thyroid disorders, rheumatoid arthritis, and hypotension.
    C) metabolic disorders, thyroid disorders, and rheumatoid arthritis.
    D) hypotension, tophaceous gout, and noninflammatory synovial fibrosis.

    CAUSES AND CONTRIBUTING FACTORS

    Several health conditions are associated with the presence of carpal tunnel syndrome and may be contributing factors in its development. The most commonly noted co-occurring health conditions are noninflammatory synovial fibrosis, metabolic syndrome, diabetes, thyroid disorders, rheumatoid arthritis, pregnancy, and menopause.

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    3 . Which of the following signs and symptoms is more likely in individuals with cubital tunnel syndrome than those with carpal tunnel syndrome?
    A) Clumsiness
    B) Muscle atrophy
    C) Decreased grip strength
    D) Weakness while pinching

    CONDITIONS THAT MIMIC CARPAL TUNNEL SYNDROME

    Cubital tunnel syndrome is caused by pressure on the ulnar nerve at the elbow. When the pressure increases enough to disturb normal nerve function, pain, numbness, and tingling may occur in the forearm or hand. Most often this pain is present in the ring and little fingers. Other symptoms that mirror carpal tunnel syndrome include decreased grip strength, weakness while pinching, and a feeling of clumsiness [1,9,85]. Individuals with cubital tunnel syndrome are more likely than individuals with carpal tunnel syndrome to present with muscle atrophy [23].

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    4 . Phalen's maneuver consists of
    A) pressing or tapping on the median nerve in the patient's wrist.
    B) asking the patient to flex the wrists while extending the fingers.
    C) asking the patient to flick the hand and wrist as if shaking a thermometer.
    D) elevating the patient's hand above his or her head as high as comfortably possible for one minute.

    DIAGNOSING CARPAL TUNNEL SYNDROME

    During Phalen's maneuver (wrist-flexion test), tingling or numbness may be produced by asking the patient to flex the wrists while extending the fingers. If symptoms occur within one minute, the presence of carpal tunnel syndrome is suggested [9,23]. A positive result with Phalen's maneuver may indicate severe carpal tunnel syndrome [92]. The test is not a reliable indicator of carpal tunnel syndrome in the diabetic population [93].

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    5 . The American Academy of Orthopaedic Surgeons (AAOS) recommends that electrodiagnostic studies be conducted
    A) as a first diagnostic step.
    B) when surgery is being considered.
    C) to monitor the efficacy of non-surgical interventions.
    D) only when clinical and other provocative test results are negative.

    DIAGNOSING CARPAL TUNNEL SYNDROME

    Many researchers and clinicians have concluded that for diagnosing carpal tunnel syndrome, EDX studies are most effective when used in conjunction with other diagnostic methods, when the diagnosis of carpal tunnel syndrome is uncertain, or when surgical treatment is being considered [89,109]. In its published guideline on the diagnosis of carpal tunnel syndrome, the American Academy of Orthopaedic Surgeons (AAOS) recommends that EDX studies be conducted only when clinical and other provocative test results are positive or when surgery is being considered. The AAOS finds little evidence to support EDX studies for other purposes, such as differentiating among diagnoses [101].

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    6 . Which of the following AAOS recommendations for the treatment of carpal tunnel syndrome has the highest associated level of evidence?
    A) Oral steroids
    B) Laser therapy
    C) Therapeutic ultrasound
    D) Carpal tunnel release surgery

    TREATMENT OF CARPAL TUNNEL SYNDROME

    AAOS RECOMMENDATIONS FOR TREATMENT OF CARPAL TUNNEL SYNDROME

    Treatment Method (For)Strength of Recommendationa
    Surgical release of the transverse carpal ligament★★★★
    Surgical treatment of carpal tunnel syndrome should have a greater treatment benefit at 6 and 12 months versus splinting, NSAIDs, and a single steroid injection★★★★
    Simultaneous bilateral or staged endoscopic carpal tunnel release might be performed based on patient and surgeon preference.★★
    Benefit of endoscopic (versus open) carpal tunnel release★★
    Use of buffered lidocaine rather than plain lidocaine for local anesthesia to reduce injection pain★★★
    Use of local anesthesia rather than intravenous regional anesthesia (Bier block) may offer longer pain relief after carpal tunnel release★★
    Wrist immobilization (e.g., brace, splint, orthosis) rather than or prior to surgery★★★★
    Local steroid injections★★★★
    Oral steroids★★★
    Ketoprofen phonophoresis for pain reduction★★★
    Therapeutic ultrasound★★
    Laser therapy★★
    Perioperative use of aspirin★★
    Treatment Method (Against)Strength of Recommendationa
    No benefit of oral treatments (diuretic, gabapentin, astaxanthin capsules, NSAIDs, or pyridoxine) compared to placebo★★★
    No benefit of magnet therapy★★★★
    No benefit of prescription of pre-operative antibiotics★★
    No benefit to routine use of adjunctive techniques, including epineurotomy, neurolysis, flexor tenosynovectomy, and lengthening/reconstruction of the flexor retinaculum (transverse carpal ligament)★★★
    No benefit to routine supervised therapy versus home programs in the immediate postoperative period★★★
    No benefit to routine postoperative immobilization after carpal tunnel release★★★★
    aStrength of Recommendation Descriptions
    Strength VisualEvidence Quality
    ★★★★Evidence from two or more "high" quality studies with consistent findings for recommending for or against the intervention.
    ★★★Evidence from two or more "moderate" quality studies with consistent findings, or evidence from a single "high" quality study for recommending for or against the intervention
    ★★Evidence from two or more "low" quality studies with consistent findings or evidence from a single "moderate" quality study recommending for against the intervention or diagnostic or the evidence is insufficient or conflicting and does not allow a recommendation for or against the intervention.
    There is no supporting evidence. In the absence of reliable evidence, the guideline development group is making a recommendation based on their clinical opinion. Consensus statements are published in a separate, complimentary document.
    aLevels of Evidence
    Strength VisualOverall Strength of Evidence
    ★★★★Strong
    ★★★Moderate
    ★★Low strength evidence or conflicting evidence
    No evidence
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    7 . Which of the following instruments is NOT recommended to determine patients' responses to carpal tunnel syndrome treatments?
    A) Patient Evaluation Measure
    B) Chicago Carpal Tunnel Questionnaire
    C) Michigan Hand Outcomes Questionnaire
    D) Disabilities of the arm shoulder, and hand (DASH) tool

    TREATMENT OF CARPAL TUNNEL SYNDROME

    In addition to discussing desired outcomes, patient response to treatment should be assessed by one or more of the following instruments [64,65,66,71]:

    • Boston Carpal Tunnel Questionnaire: A disease-specific, patient-based outcome questionnaire measuring symptom severity and functional status of patients with carpal tunnel syndrome

    • Disabilities of the arm, shoulder, and hand (DASH) tool: A region-specific outcome measure of upper limb function

    • Michigan Hand Outcomes Questionnaire (MHQ): A region-specific (hand/wrist) instrument designed to evaluate patients prior to and after hand surgery

    • Patient Evaluation Measure (PEM): A patient-completed questionnaire

    • Short Form Health Survey (SF-36 or SF-12): The SF-36 is a generic measure of overall physical health used to assess the health of general populations; the SF-12 is a shorter alternative of the SF-36 frequently used in large population health surveys

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    8 . As an intervention for carpal tunnel syndrome, splinting
    A) is of clear benefit as postoperative rehabilitation.
    B) has only been shown to improve patient function after 16 weeks.
    C) should be begun immediately after routine carpal tunnel release surgery.
    D) may be particularly helpful when weighing the risks of surgery versus the benefits.

    TREATMENT OF CARPAL TUNNEL SYNDROME

    Splinting has been found to improve patient satisfaction, symptoms, and function when measured at intervals of 2, 4, and 12 weeks. The AAOS suggests that splinting be considered before surgery. This may be particularly helpful when weighing the risks of surgery versus the benefits. Splinting is not recommended for use after routine carpal tunnel release surgery. The benefit of splinting for postoperative rehabilitation is undetermined [63; 101; 106].

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    9 . Carpal tunnel release, the preferred treatment for patients with chronic or severe carpal tunnel syndrome, involves transection of the
    A) median nerve.
    B) ulnar collateral ligament.
    C) transverse carpal ligament.
    D) dorsal metacarpal ligament.

    TREATMENT OF CARPAL TUNNEL SYNDROME

    Carpal tunnel release is the preferred treatment for patients with chronic or severe carpal tunnel syndrome. It is achieved by either an open or endoscopic procedure [9; 99; 101; 106]. Both types of surgery are generally performed on an outpatient basis under local anesthesia. Open release surgery involves making an incision of up to 2 inches at the base of the palm of the hand and cutting the transverse carpal ligament, which releases pressure on the median nerve [9,45]. Endoscopic surgery involves making a small, one-half inch incision at the wrist and introducing an arthroscope beneath the transverse carpal ligament. Using the scope as a guide, the ligament is cut, relieving pressure on the median nerve [9,17,45].

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    10 . Which of the following strategies has NOT been studied or recommended for the prevention of carpal tunnel syndrome?
    A) Acupuncture
    B) Exercise regimens
    C) Patient education and safety models
    D) Use of ergonomically sound equipment

    PREVENTION STRATEGIES

    Although the number of cases of carpal tunnel syndrome among U.S. workers has been declining, the resulting number of reported days away from work remains high [13]. This lost work time and decreased employee productivity have led employers to develop organizational approaches to managing employee health, safety, and productivity, with an emphasis on prevention and returning employees to work as quickly as possible [29,30]. Rising healthcare costs and the focus on preventing carpal tunnel syndrome have led researchers to study and recommend a variety of prevention strategies, including the application of ergonomic principles to job and workstation design, the use of ergonomically sound equipment (including ergonomic keyboards and dual numeric keyboards), the development of predictive models, and the use of exercise regimens and patient education and safety programs [17,22,24].

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