GP management of carpal tunnel syndrome

Dr Mareeni Raymond and physiotherapist Greg Turpin discuss a collaborative approach.

The 'prayer sign' test assesses wrist flexion and extension. If the patient's history and examination suggest carpal tunnel syndrome, Phalen's test (forced flexion of the wrist for 60 seconds) may reproduce the symtoms
The 'prayer sign' test assesses wrist flexion and extension. If the patient's history and examination suggest carpal tunnel syndrome, Phalen's test (forced flexion of the wrist for 60 seconds) may reproduce the symtoms

Carpal tunnel syndrome is a condition in which the median nerve is squeezed where it passes through the wrist. This often happens because the tendons in the wrist have become swollen and they press on the nerve.

History

Patients will normally report pain, tingling or numbness in a median nerve distribution, in the thumb, forefinger, middle finger and radial side of the ring finger. The pain can radiate up to the elbow.

Early symptoms reported may be intermittent paraesthesia and altered sensation, which is probably worse at night as fluid accumulates. Later stages may include weakness and constant pain.

A job, a hobby or an activity of daily living that regularly involves repeated movement of the wrist may be reported.

Patients with a previous history of arthritis, diabetes, fluid retention or gout are at higher risk of compression of the carpal tunnel.

A history of trauma to the wrist and carpal tunnel syndrome-like symptoms may be indicative of a malaligned fracture. Pregnancy can also result in compression of the median nerve.

Carpal tunnel syndrome symptoms can present similarly to neurogenic pain of cervical origin. A history of when the symptoms occur, the activity involved and any indication of stress on the neck or wrist can also provide a potential differentiator.

Examination

An examination of the neck's passive range of movement with overpressure can clear the cervical spine if symptoms are not reproduced. Upper limb nerve tension or tethering/entrapment at various points along the nerve should also be considered.

A positive Phalen's test or reverse Phalen's that reproduces the patient's symptoms can be indicative of carpal tunnel syndrome.

A Tinel's test along the course of the median nerve that produces tingling may also indicate carpal tunnel syndrome. On examination, there may be some muscle wasting.

Management

Minor symptoms may be well managed with NSAIDs and advice to cease any activity that increases the pressure in the carpal tunnel. A splint may be effective to relieve symptoms at night or during essential aggravating activity that cannot be avoided.

For patients who are unlikely or unable to comply with simple activity modifying advice, a single corticosteroid injection may be effective.

Patients with more persistent chronic symptoms may require a surgical carpal tunnel release.

Physiotherapy

In the early stages of the condition, the physiotherapist would provide advice on activity modification and suggest a 'rest, ice, compression, elevation' protocol.

They may also suggest that the patient discusses anti-inflammatory medication with their GP.

If indicated, joint mobilisation may increase the pain-free range of movement of the wrist.

Stretching the wrist will help to increase blood flow, therefore promoting healing, and may relieve some of the painful symptoms of carpal tunnel syndrome.

Simple exercises, such as wrist bend, wrist lift and wrist flex, can also help to improve the patient's strength and flexibility.

Nerve glide exercises may help to improve the mobility of the median nerve, reducing pain and increasing the pain-free range of movement.

To optimise the patient's recovery, exercises may be offered to improve strength, particularly of the thumb.

It is important that exercises are prescribed by a physiotherapist on an individual basis, as the reasons for compression of the median nerve in the carpal tunnel differ between patients. Some exercises may exacerbate a patient's symptoms.

How to work together

Keeping a small stock of splints for patients to wear at night may provide some relief, or advising them to buy a splint from a local chemist can promote nerve healing before referral to a physiotherapist.

An early referral, if conventional NSAIDs and advice have not altered the patient's symptoms, will allow management to commence before the nerve becomes overly sensitive. Patients requiring more education and advice on how to manage carpal tunnel syndrome will benefit from the time a physiotherapist has to provide such advice.

Those patients who are very reluctant to use their hand and display fear avoidance behaviour may also need further intervention.

Who to refer to physiotherapy
  • Patients who have not responded to NSAIDs and rest may benefit from further investigation from a physiotherapist, who has more time to delve into their presentation and history.
  • Cases where the doctor is not sure of the source of the pain (neck or carpal tunnel).
  • Patients whose hobbies, work or activities of daily living are an aggravating factor that they cannot cease. The physiotherapist can identify alternative techniques or use splints or taping to take pressure off the wrist. Any weakness or muscle imbalances that affect the function of the wrist during these activities can also be rectified.
  • Dr Raymond is a GP in east London and Mr Turpin is a physiotherapist in Lymington, Hampshire

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