How many times have you heard clients complain about chronic pain in their wrists or hands when performing a certain exercise? Chances are, a majority of these complaints are coming from people diagnosed with carpal tunnel syndrome (CTS). According to the National Institute of Neurological Disorders and Stroke (NINDS), part of the National Institutes of Health, 3 out of every 10,000 workers lost time from work in 1998 because of CTS (NINDS 2004). Half of these workers missed more than 10 days of work due to the condition. The average lifetime cost of CTS–counting medical expenses and lost work time–is about $30,000 per person (NINDS 2004).
Fitness professionals, who are encountering more and more clients with CTS, need to understand the underlying causes of the condition and the ways exercise can benefit sufferers. This article will review common causes and symptoms of the condition, identify which clients are at risk and offer conservative exercises to incorporate at different stages of postrehabilitation. Also included are general ergonomic recommendations that can help clients prevent the recurrence of CTS.
Sometimes the nerve can be irritated higher up at the shoulder or neck, with the pain radiating to the wrist. If treatment focuses on treating only the wrist, the underlying cause in the shoulder or neck will not be addressed and the client will not respond to treatment. That’s why getting an accurate diagnosis from a physician is key in treating CTS most efficiently and effectively.
Such tasks are most commonly performed in the workplace, but housework, excessive use of home computers and improper use of exercise equipment can also contribute to CTS. Women are three times more likely than men to develop the condition, perhaps because women have smaller carpal tunnels (NINDS 2004).
What Causes CTS?
CTS typically occurs when the median nerve, which runs from the forearm into the hand, becomes pressed or squeezed at the wrist (NINDS 2004). This nerve controls sensations in, and impulses to, the small muscles in the hand, allowing certain fingers and the thumb to move.
The median nerve is contained in the carpal tunnel, a narrow, rigid passageway of ligament and bones at the base of the hand. If irritated or swollen, the tunnel narrows, compressing the median nerve. This results in pain, weakness or numbness in the affected hand and wrist, symptoms that can radiate, or spread, up the arm.
Compression of the median nerve can be caused by trauma, arthritis, decreased mobility of the wrist and hand bones, or swelling that results from excess pressure on, or use of, the flexor tendons. The condition can also be congenital (i.e., the carpal tunnel is simply too small in some people) or the result of hypothyroidism, cysts/tumors, or fluid retention during pregnancy or menopause (NINDS 2004).
Symptoms of CTS
The most common symptoms of CTS include pain and numbness in the hand(s); weakness or lack of coordination in the hand(s); and change in sensation in the thumb, index and middle fingers. Sensation can also be affected in the radial region of the ring finger.
Symptoms of CTS usually begin gradually with a burning, tingling or itching in the palm of the hand or fingers (NINDS 2004). These symptoms are often first noticed in the morning, since many people sleep with their wrists flexed. The dominant hand is usually the one affected first.
As symptoms worsen, these sensations start to occur during the day. A decline in grip strength can make it difficult to perform simple tasks, such as forming a fist or grasping small objects.
The condition can sometimes be managed with conservative measures, such as exercise and altered workplace ergonomics, but in severe cases surgery may be the only alternative to alleviate the symptoms and prevent permanent nerve damage.
Who Is at Risk for CTS?
CTS is most likely to affect people who perform repetitive fine-motor activities. The symptoms typically increase with heavy computer use. Other factors that contribute to the condition include performing tasks that involve an awkward wrist angle (such as using a calculator or computer mouse); gripping an item with excessive force; doing work that requires the arms to be elevated with constant tension in the shoulders (painting, housework or even some yoga poses that place the wrist in excess flexion or extension); or performing any movement that places repeated force on the palm of the hand.
Management of CTS
Once CTS is diagnosed, treatment should begin as soon as possible under a doctor’s supervision. The main goals in treating CTS are to reduce the compression of the median nerve, decrease the inflammation within the carpal tunnel, and reduce the pressure on the flexor tendons in the forearm. These goals can be accomplished in many ways.
To start with, any irritating, repetitive motion at the wrist and hand must be reduced or possibly eliminated for 1 to 2 weeks. (The time frame will vary depending on the severity of symptoms.) The goal is to give the client a reprieve from overuse in the affected hand or wrist. Some physicians recommend splinting the affected wrist, but other experts say that immobilization can result in atrophy of the forearm and/or a dependency on the splint.
During this initial management phase, care must be taken to improve the client’s overall posture to enhance circulation from the neck to the affected shoulder, arm and hand. Correcting wrist and hand postures is also imperative to keep pressure off the median nerve. This strategy will help prevent the injury from recurring and may also improve the client’s immediate symptoms.
In addition, fitness professionals should teach clients how to keep their lumbar and cervical spine neutral to enhance healthy innervation to the muscles of the shoulder, arm and hand. (The lumbar spine should be in neutral position relative to the pelvic girdle, with no tension in the soft-tissue structures. The cervical spine should be in neutral position relative to the shoulder girdle, with the ear lobe directly in line with the midline of the shoulder from a lateral perspective.)
As the client’s pain and numbness begin to subside, strengthening of the muscles of the shoulder and arm can be initiated. Examples of the muscle groups to focus on include the rotator cuff group and scapula stabilizers. However, it is important to progress conservatively, paying diligent attention to the posture and position of the client’s neck, arm and wrist. Again, neutral spine for the neck and low back should be reinforced throughout all activities during this phase.
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