Ep 20: Pain Relief for Your Hands: Understanding Carpal Tunnel Syndrome

Understanding Carpal Tunnel Syndrome is crucial for anyone experiencing discomfort in their hands. Our latest episode dives deep into the anatomy and management strategies for this common condition. Listen to gain insights on pain management and anatomical understanding.

- Details the anatomy of the carpal tunnel and its importance 
- Discusses typical symptoms, including numbness and tingling 
- Offers conservative management techniques like cold therapy and nerve flossing 

Call to Action: Keep an eye out for our next episode where we will discuss more about surgical options and their indications for Carpal Tunnel Syndrome!

Chapters

• 0:34 Introduction and Overview of Carpal Tunnel Syndrome
• 20:00 Understanding the Anatomy of the Carpal Tunnel
• 6:28:17 Effective Techniques for Managing Symptoms and Pain Relief

Transcript

Speaker 1: 0:00

Welcome back to the Hands and Shoulders Solution. Giving Pain the Middle Finger. I'm your host, carl Petito. I'm an occupational therapist and a board-certified hand therapist. As a hand therapist, I specialize in the rehabilitation of orthopedic conditions that affect the fingertips through the shoulder, anything having to do with the muscles, the nerves, the bones.

Speaker 1: 0:20

Today I want to talk about carpal tunnel syndrome and I want to make a point to state that this is not treatment or treatment advice. This is information sharing for the public so that you can be well informed, so that you can make the best decision for yourself when seeking care and you know exactly what kind of services to seek out. So carpal tunnel syndrome is very common, affects a lot of people. Some of the hallmark signs are numbness and tingling of the fingertips, mostly on the thumb side of the hand, deep ache, sometimes clumsiness and advanced stages of the disease also shrinking or wasting or some degeneration of this group of muscles within the thumb. So let's first talk about what is the carpal tunnel. The carpal tunnel is the anatomic structure in the wrist and the nerves. When the nerves come out of between the vertebrae of the spinal cord, it traveled down the arm. That's the wiring system for your body. So there's nerves that come out of. Firstly let's go upstream a little bit your spinal cord comes out of the brain, travels down the spinal column and then out of the spinal cord branches what we call the peripheral nerves, and those nerves are the wiring system for the body. Why do we need those? Because it's the nerves that carry an electrical signal that make the muscle tissue contract. Muscles only pull, they don't push. So when the muscle contracts, muscles attach themselves to the skeleton by tendons, pulls on the tendons and these tendons that travel through the carpal tunnel they attach to the fingers and they close the fist On the backside, they contract in the forearm and open the hand. We'll get into a little bit more detail on that and also a little more detail in future episodes. The nerves they travel through tunnels and let's talk today about the median M-E-D-I-A-N median nerve that travels through the carpal tunnel. It goes through the carpal tunnel, which, if you look at the heel of your palm, that's where your carpal tunnel is located. And then the nerve branches out and innervates or plugs into the thumb index finger, your middle finger and half of your ring finger. So if someone is having numbness and tingling on their pinky, for example, it's not the median nerve, it's the ulnar nerve, and that's another episode that we'll be talking about.

Speaker 1: 2:41

So I want to show you on the skeleton, the carpal tunnel and, as I mentioned, it's on the skeleton, the carpal tunnel, and, as I mentioned, it's on the heel of the palm. So this right here, the right hand, and we overlay it, there's the bones of the heel of the palm and there's eight carpal bones and when you look at the carpal bones from the palm or surface, if you look at your palm, look at the heel of your palm, you're looking at this right here. So let me point the fingertips toward you and you can see that it's kind of curved like this and that forms the bottom of the tunnel and then on the top surface is a thick, heavy ligament that forms the roof of the tunnel. So the tendons which connect the muscles to the bones travel through this. There's nine tendons, because there's two tendons that go to each finger and one tendon that goes through the thumb that pass through the tunnel, the median nerve. The nerve is about as wide as a pencil or a pen and thick like a noodle, so it's pretty big and it lives sort of on the surface just below that thick, heavy ligament. And you're hearing the word ligament. So ligaments connect bone to bone. So these have just bony attachments. Tendons connect muscle to bone.

Speaker 1: 4:06

So if I show you on the model that now we're adding the muscles and the tendons, the muscles are red, the tendons are white or gray in color, the nerve tissue is yellow. So here's the pinky side. We have the ulnar nerve, which we mentioned. Thumb side we have the median nerve. It's not that well represented on the model, it's much bigger in real life and there's a thick, heavy ligament that goes over the top. The muscles that bend your fingers are below these wrist muscles and if we take these muscles off we can see there's more muscles underneath. So there's one muscle that bends this joint and this joint and then there's a whole separate muscle that bends the tip of the finger and they lie on top of each other in layers within the forearm. So that's how we can have such a tight grip, because there's two different muscles that bend the fingers into a fist and there's also muscles between the bones of your hand that assist in flexion or bending the fingers. Now there's a lot of structures passing through that tunnel and the tunnel. It doesn't look very big because it isn't, it's relatively small.

Speaker 1: 5:27

So if we review briefly, there are nine tendons traveling through that carpal tunnel along with the median nerve. And remember, the nerve is about as wide as a pencil and thick like a noodle. So if the tendons start to swell up, or if a person is resting on a wrist rest while they're typing and that's causing increased friction on the nerves, or any pressure, any weight on the nerve which the nerve does not like, it will start to cause numbness and tingling because the nerve is getting pinched off, if you will. So when the nerves travel to different tunnels for example the ulnar nerve and the cubital tunnel and of course we're talking about the median nerve and the carpal tunnel those are all pinch points.

Speaker 1: 6:10

I treat a lot of patients at night through sleeping like this, or they're sleeping like this and it's tensioning or pinching off the nerve in the tunnel and causing those symptoms laterally, what we have to do is relieve the pressure from the nerve. So the best thing to do is to decrease inflammation. So if those tendons are aggravated and irritated from a lot of movement or a lot of pressure on the carpal tunnel, we need to reduce inflammation by, for example, perhaps using an ice cube on just barely touching the skin only until it's deeply cold, 10 to 20 seconds, and that reduces inflammation and studies have shown that that's more effective than an ice pack for 10 minutes. And I wouldn't want to use an ice pack anyway because again, that's putting laying pressure on that. We don't want any pressure on it. Another really good technique is I'll have some of my patients use cold running water just circumferentially around the wrist. Again, there's no pressure, but the cold running water is deeply penetrating and reduces inflammation very effectively and in a short amount of time only takes 10 to 20 seconds. It's not very often in life that something easier is more effective, but this is one of those situations. Another thing I'll have folks do is nerve flossing techniques very specific movements to get the nerve to glide through the tunnel and stretch it out a bit and restore some health to the nerve and get that gliding very slightly, very specifically, to even move any thick, heavy fluid that tends to build up within the tunnel. Also, something that's effective is we instruct differential tendon gliding techniques to patients to get those. Remember we talked about two tendons going to each finger. They're moving differentially from each other and that also helps work out any thick buildup of fluid that's within the tunnel and that, in turn, reduces pressure on the nerve. It's all about taking pressure away from the nerve. Now, for nighttime, folks aren't sleeping like this, which is pinching off the nerve, okay, sleeping like this, which is overstretching the nerve, and just Sleeping like this, which is overstretching the nerve and just causing pressure in the tunnel. Because, again, it's all about let's remove pressure. So when you have a surgery which we're going to talk about later if a person has to end up having carpal tunnel release surgery, it's called release because it's releasing pressure from the nerve. So that's a reason why we must never rub the carpal tunnel.

Speaker 1: 8:50

It's natural that when something hurts we want to rub it, and here's the reason. If you hit your shin on the coffee table, what's the first thing you want to do? Reach down and rub your shin. Deep pressure actually releases chemicals that slow the pain response to the brain. So deep pressure releases chemicals that decreases pain. As with the brain, so deep pressure releases chemicals that decreases pain, as with anything else.

Speaker 1: 9:10

There's an exception to every rule. The exception here is that now you're putting extra pressure on the nerve and the trap. It's a trap because every time you're rubbing it, yep, makes it feel a little bit better and it's soothing for a second. Now the immediate after effect is now you've increased the inflammation. So first aid tips here is no extra pressure on the nerve.

Speaker 1: 9:36

We don't want to rub that when you're typing. You don't want to rest on a wrist rest. You want to ideally have the keyboard right to the edge of the desk so you're typing at a comfortable position We'll talk about ergonomics later so that your wrist is off the edge of the desk. There's nothing but air here You're typing and you won't have any problems. And you shouldn't be typing down like this, because again, that's pinching off the wrist. Shouldn't be up high like this. Should just be at what we call neutral, just a straight wrist. Basically, in typing Now at night, should I? Should I use a split at night? Should I use a brace Hand?

Speaker 1: 10:12

Therapists fabricate custom splints and the reason is over-the-counter splints. Most of them are, are your big, bulky, they're nylon and they have a stiffener bar in there. The stiffener bar guess what? Goes right over the carpal tunnel and it's a thick, heavy aluminum bar. I'm going to be doing a video about over-the-counter splints. I went to a big box store. I bought five or six or seven splints and I'm going to talk about the quote-unquote dark side of over-the-counter splints which are designed, you know, one size fits all. Every hand is different. My left hand is different from my right. I can have 10 people in here and I have 20 different hands.

Speaker 1: 10:49

It's really important to have a custom splint. Sometimes we can get away with a big, bulky splint that's from over the counter. We can just pull the stiffener bar out and it's enough to block full flexion. During sleeping is in full extension to take the pressure off. But the idea is during sleeping hours we don't want anything touching this, but we want that wrist straight or a little bit bent toward the little finger and toward the palm. We used to think that 30 degrees of wrist extension maintained the maximum diameter of the carpal tunnel, but no, it's actually about 10 degrees of flexion and ulnar deviation that maintains the maximal diameter of the carpal tunnel. Because of the slope of the bones we have the end of the radius. It slopes toward a little bit and then you can see it slopes toward the little finger. So that position really helps relieve pressure on the nerve. So when I fabricate a custom splint. I want to make it that position and I make it on the back of the forearm in hand and there's just a little plastic piece that comes around here and there's nothing, nothing touching the carpal tunnel. So that ends up being very effective.

Speaker 1: 11:55

And I, you know, I ended up talking fast because I get really excited about this and really excited to be able to tell the whole public about it. Often during the day, I'm telling you know, I work with one patient at a time. One-on-one personalized care is very important to me and I'm talking to one person. I'm so excited that I'm talking to a lot of people. I'm getting the word out about this. So very, very good, I hope this information is helpful. So let's summarize Positioning properly at night, so there's no pressure on the nerve.

Speaker 1: 12:23

Positioning properly during working hours. Even if you're exercising, doing push-ups, you just don't want to be on the heel of the palm, you don't want all your weight there on the heel of the palm. So no pressure, no pinching off at night. We want a brace, a nice custom split to properly position that wrist. Then we want to reduce inflammation. If we reduce inflammation, reducing swelling, reducing internal pressure on that nerve, we're going to use cold because cold shrinks in nature Cold. Every time something gets cold it shrinks down. So a combination of things.

Speaker 1: 12:59

In the clinic we can use ultrasound which penetrates the tissues with high-frequency sound waves. You can think of it like having a little massage, internal massage in the carpal tunnel, without the pressure of massage. So if somebody comes in and they're pretty swollen or they've had this pretty chronic, which means longstanding, it's been ongoing for quite a while we can set the ultrasound. It's like diagnostic ultrasound but more intense to have a therapeutic benefit. We can set that at the appropriate depth, the appropriate intensity. It takes about eight minutes.

Speaker 1: 13:33

Another really good tool in the toolbox is cold laser treatment. We call it cold laser because it's not a hot, cutting laser. It's within the correct spectrum of red to stimulate the mitochondria or the powerhouse of the cells to produce more ATP or healing chemical. And the red light or cold laser is really interesting because it does. It's the best of both worlds between heat and cold. So if I use a heating pad I'm going to increase blood flow. Why do I want more blood flow? I want blood flow because blood carries oxygen and nutrients, which is crucial for healing. But the side effect of heating pad is that it heat expands, increases inflammation. Now, cold will decrease inflammation, but the side effect of that is that, or the unwanted effect is that it causes basal constriction or constriction of the blood vessels, which decreases blood flow, means less oxygen and nutrients. Cold laser increases blood flow but at the same time reduces inflammation. So that's another very important tool, and I mentioned nerve flossing and differential tendon gliding techniques. So there's a lot of tools in the toolbox for what we call conservative treatment.

Speaker 1: 14:42

Conservative treatment is not treatment with surgery. Surgical treatment is something that we're going to get to in the next video and we're going to talk about the do's and don'ts. When you need surgery, how does a surgeon determine? Is your nerve pinched off at the carpal tunnel? Is it pinched off somewhere in the neck? Is it pinched off somewhere in the neck? Is it pinched off somewhere in between?

Speaker 1: 15:05

When a patient is in front of me in the office and also in front of the surgeon or the physician assistant, we're doing orthopedic testing. For example, phalen's maneuver hold it for 30 seconds, and does pitching off the nerve at this location cause numbness and tingling through that median nerve distribution or area that it affects? I'll also do what's called Tenel's sign and tap on it and does it send zingers through there. Also, I'll do just a manual compression, not real hard but just light, and then see if that increases the symptoms. And those are all indicating factors. So let's talk about this some more. So future videos carpal tunnel syndrome. It's affecting a lot of people and it's very important that people understand the basics of it. It's a very mechanical condition. It's pressure on the nerve, the median M-E-D-I-A-N nerve. We need to release the pressure, either with conservative means or, if that doesn't work, with surgical means. So we'll talk about it soon, all right, thank you.