‘Carpal tunnel syndrome’ can be cured with medication
By Dr. Kamal Gunarathne
Carpal tunnel syndrome describes a very common and progressively
painful/benumbed hand condition caused by a pinched nerve in your wrist.
This is commonly referred as “CTS” in medical jargon. Several factors
can contribute to carpal tunnel syndrome, including the structure of
your wrist, certain underlying health problems and possibly patterns of
hand use.
Carpal tunnel is a narrow passageway on the palm side of the wrist
bound by bones and ligaments. The tunnel protects a main nerve to your
hand and nine tendons that bend your fingers. Pinching of this nerve
produces the numbness, pain and, eventually, hand weakness leading to
“carpal tunnel symptoms”.
For most people who develop carpal tunnel syndrome, proper treatment
usually can relieve the pain and numbness and restore normal use of
their wrists and hands.
What are the symptoms?
Carpal tunnel syndrome typically starts gradually with a vague aching
in your wrist that can extend to your hand or forearm. The common carpal
tunnel symptoms include: Tingling or numbness in your fingers or hand,
especially your thumb and index, middle or ring fingers, but not your
little finger. This sensation often occurs while holding a steering
wheel, phone or newspaper or upon awakening. Many people “shake out”
their hands to try to relieve their symptoms.
As the disorder progresses, the numb feeling may become constant.
Pain radiating or extending from your wrist up your arm to your shoulder
or down into your palm or fingers, especially after forceful or
repetitive use. This usually occurs on the palm side of your forearm.
This can get confused with another common neurological problem in
hand due to pinched nerve in the neck, called cervical radiculopathy. A
sense of weakness in your hands and a tendency to drop objects:
If you have persistent signs and symptoms suggestive of carpal tunnel
syndrome, especially if they interfere with your normal activities and
sleep patterns, you need to see your doctor. If you leave the condition
untreated for long time, nerve and muscle damage can occur.
Risk factors
A number of factors has been associated with carpal tunnel syndrome.
Although by themselves they don't cause carpal tunnel syndrome, they may
increase your chances of developing or aggravating median nerve damage.
These include: Structural abnormalities. A wrist fracture or dislocation
that alters the space within the carpal tunnel can create extraneous
pressure on the median nerve. Also, carpal tunnel syndrome is generally
more common in women. This may be because the carpal tunnel area is
relatively smaller than in men. Women who have carpal tunnel syndrome
may also have smaller carpal tunnels than women who don't have the
condition.
Nerve-damaging conditions
Some chronic illnesses, such as diabetes and alcoholism, increase
your risk of nerve damage, including damage to your median nerve.
Inflammatory conditions
Illnesses that are characterised by inflammation, such as rheumatoid
arthritis or an infection, can affect the tendons in your wrist,
exerting pressure on your median nerve. Increase of body fluids. Certain
conditions such as pregnancy, menopause, obesity, thyroid disorders and
kidney failure, can affect the level of fluids in your body. Fluid
retention may increase the pressure within your carpal tunnel,
irritating the median nerve. Carpal tunnel syndrome associated with
pregnancy generally resolves on its own after the pregnancy is over.
Work related factors
It's possible that using vibrating tools or on an assembly line that
needs prolonged or repetitive flexing of the wrist may create harmful
pressure on the median nerve, or worsen existing nerve damage.
These are our general observations but these factors haven't been
established as direct causes of carpal tunnel syndrome. There is also
little evidence to support extensive computer use as a risk factor for
carpal tunnel syndrome, although it may cause a different form of hand
pain.
Treatment
Patients with mild symptoms of carpal tunnel syndrome can reduce
their discomfort by taking more-frequent breaks to rest their hands.
Applying cold packs to reduce occasional swelling is also recommended
temporary measure. If these techniques don't offer relief within a few
weeks, additional treatment options include wrist splinting, medications
and surgery. Splinting and other conservative treatments are more likely
to help you if you've had only mild to moderate symptoms for less than
10 months.
Nonsurgical therapy
If the condition is diagnosed early, nonsurgical methods may help
improve carpal tunnel syndrome. Methods may include:Wrist splinting. A
splint that holds your wrist still while you sleep can help relieve
night time symptoms of tingling and numbness. Nocturnal splinting may be
a good option if you are pregnant and have carpal tunnel syndrome.
Splinting is not widely used in our country.
Drugs
A group of drugs called non-steroidal anti-inflammatory drugs/NSAIDs
may help relieve pain from carpal tunnel syndrome in the short term.
However, there's no evidence, that these drugs can actually improve the
carpal tunnel syndrome itself.
Steroid Injection
Your doctor may inject your carpal tunnel with a steroid, to relieve
your pain. Steroids decrease inflammation and swelling, which relieves
pressure on the median nerve. Oral corticosteroids are not considered as
effective as corticosteroid injections for treating carpal tunnel
syndrome. If carpal tunnel syndrome results from an inflammatory
arthritis, such as rheumatoid arthritis, then treating the underlying
condition may reduce symptoms of carpal tunnel syndrome.
Surgery
If your symptoms are severe or persist after trying non-surgical
therapy, surgery may be the best option. Endoscopic surgery: Carpal
tunnel surgery can be done using an endoscope, a telescope-like device
with a tiny camera attached to it that allows your doctor to see inside
your carpal tunnel and perform the surgery through small incisions in
your hand or wrist. This technique is not widely available in Sri Lanka.
Open surgery
In most cases, surgery involves making a larger incision in the palm
of your hand over the carpal tunnel and cutting through the ligament to
free the nerve. This surgery is a 10 minute minor procedure and can be
done as a day case under local anaesthesia. You will be encouraged to
use your hand after surgery, gradually working back to normal use of
your hand while avoiding forceful hand motions or extreme positions of
your wrist. Soreness or weakness may take from several weeks to as long
as a few months to resolve after surgery. If your symptoms were very
severe before surgery, symptoms may not go away completely after
surgery.
What are the home remedies that can be helpful?
These may help you gain at least temporary relief from your symptoms:
Take quick breaks from repetitive activities involving the use of
your hands. Rotate your wrists and stretch your palms and fingers. Take
a pain reliever, such as ibuprofen or naproxen or others. Try wearing a
wrist splint at night. Wrist splints are generally available at some
pharmacies.
Avoid sleeping on your hands to help ease the pain or numbness in
your wrists and hands. If pain, numbness or weakness recurs and
persists, see your doctor.
Are there any lifestyle changes for prevention?
There are no proven strategies to prevent carpal tunnel syndrome, but
you can minimise stress on your hands and wrists by taking the following
precautions: Reduce your force and relax your grip. Most people use more
force than needed to perform many tasks involving their hands. If your
work involves a cash register, for instance, hit the keys softly. For
prolonged handwriting, use a big pen with an oversized, soft grip
adapter and free-flowing ink. This way you won't have to grip the pen
tightly or press as hard on the paper.
Take frequent breaks. Give your hands and wrists a break by gently
stretching and bending them periodically.
Alternate tasks when possible. If you use equipment that vibrates or
that requires you to exert a great amount of force, taking breaks is
even more important. Watch your hand position. Avoid bending your wrist
all the way up or down. A relaxed middle position is best. If you use a
keyboard, keep it at elbow height or slightly lower.
Improve your posture
Incorrect posture can cause your shoulders to roll forward. When your
shoulders are in this position, your neck and shoulder muscles are
shortened, compressing nerves in your neck. This can affect your wrists,
fingers and hands.
Carpal tunnel syndrome is a very common condition which is easy to
diagnose and treat. If left unattended it can lead to significant
morbidity and disability.
Still significant number of cases are overlooked or misdiagnosed.
Most important step in diagnosing this condition is a proper nerve
conduction study performed by a qualified clinical neurophysiologist.
This will not only confirm the diagnosis but also assess the severity
and exclude any other mimicking conditions. By this way it is assured to
get 100 percent success with surgery.
The writer is Consultant Clinical Neurophysiologist, Teaching
Hospital, Kandy
Artificial livers, a step closer
Prometheus, the mythological figure who stole fire from the gods, was
punished for this theft by being bound to a rock. Each day, an eagle
swept down and fed on his liver, which then grew back to be eaten again
the next day.
Modern scientists know there is a grain of truth to the tale, says
MIT engineer Sangeeta Bhatia: The liver can indeed regenerate itself if
part of it is removed. However, researchers trying to exploit that
ability in hopes of producing artificial liver tissue for
transplantation have repeatedly been stymied: Mature liver cells, known
as hepatocytes, quickly lose their normal function when removed from the
body. “It's a paradox because we know liver cells are capable of
growing, but somehow we can't get them to grow” outside the body, says
Bhatia, a senior associate member of the Broad Institute.
Now, Bhatia and colleagues have taken a step toward that goal. In a
paper appearing in the June 2 issue of Nature Chemical Biology, they
have identified a dozen chemical compounds that can help liver cells not
only maintain their normal function while grown in a lab dish, but also
multiply to produce new tissue. Cells grown this way could help
researchers develop engineered tissue to treat many of the 500 million
people suffering from chronic liver diseases such as hepatitis C,
according to the researchers.
Large-scale screen
Bhatia has previously developed a way to temporarily maintain normal
liver-cell function after those cells are removed from the body, by
precisely intermingling them with mouse fibroblast cells. For this
study, the research team adapted the system so that the liver cells
could grow, in layers with the fibroblast cells, in small depressions in
a lab dish.
This allowed the researchers to perform large-scale, rapid studies of
how 12,500 different chemicals affect liver-cell growth and function.
The liver has about 500 functions, divided into four general
categories: drug detoxification, energy metabolism, protein synthesis
and bile production.
David Thomas, an associate researcher, measured expression levels of
83 liver enzymes representing some of the most finicky functions to
maintain.
After screening thousands of liver cells from eight different tissue
donors, the researchers identified 12 compounds that helped the cells
maintain those functions, promoted liver cell division, or both.
Two of those compounds seemed to work especially well in cells from
younger donors, so the researchers - including Robert Schwartz, and
Stephen Duncan, a professor of human and molecular genetics at the
University of Wisconsin - also tested them in liver cells generated from
induced pluripotent stem cells).Scientists have tried to create
hepatocytes from iPSCs before, but such cells don't usually reach a
fully mature state.
However, when treated with those two compounds, the cells matured
more completely.
Bhatia and her team wonder whether these compounds might launch a
universal maturation program that could influence other types of cells
as well. Other researchers are now testing them in a variety of cell
types generated from iPSCs. In future studies, the MIT team plans to
embed the treated liver cells on polymer tissue scaffolds and implant
them in mice, to test whether they could be used as replacement liver
tissues. They are also pursuing the possibility of developing the
compounds as drugs to help regenerate patients’ own liver tissues.
Making connections
Bhatia and colleagues have also recently made progress towards
solving another challenge of engineering liver tissue, which is getting
the recipient's body to grow blood vessels to supply the new tissue with
oxygen and nutrients. In a paper published in the Proceedings of the
National Academy of Sciences in April, Bhatia and Christopher Chen, a
professor at the University of Pennsylvania, showed that if preformed
cords of endothelial cells are embedded into the tissue, they will
rapidly grow into arrays of blood vessels after the tissue is implanted.
To achieve this, Kelly Stevens in the Bhatia lab worked with Peter
Zandstra at the University of Toronto to design a new system that allows
them to create 3-D engineered tissue and precisely control the placement
of different cell types within the tissue. This approach, described
recently in the journal Nature Communications, allows the engineered
tissue to function better with the host tissue.
“Together, these papers offer a path forward to solve two of the
longstanding challenges in liver tissue engineering - growing a large
supply of liver cells outside the body and getting the tissues to graft
to the transplant recipient,” Bhatia says.
- MNT
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