What medical problem does a carpenter, typist, truck driver, jackhammer operator, violinist, pianist and court stenographer have in common? Carpal tunnel syndrome! Over the past 10-15 years, carpal tunnel syndrome has moved to the forefront in medicine and has become water cooler conversation. So what is carpal tunnel syndrome and how is it treated?

Carpal tunnel syndrome (CTS) is a nerve disorder caused by compression of the median nerve at the wrist. The median nerve is one of three main nerves that provide sensation to the hand. This nerve specifically supplies sensation to the thumb, index, middle, and half of the ring finger. In CTS, compression on the median nerve occurs as it travels through a narrow passage in the wrist called the carpal tunnel. The carpal tunnel is formed by eight bones in the wrist (the floor of the tunnel) and the transverse carpal ligament, a strong ligament traveling across the roof of the tunnel. Within the tunnel there are nine tendons, which are a bit smaller than a pencil. These tendons share this space with the median nerve. In the case where there is swelling on the structures in the carpal tunnel, a person can experience pins and needles, numbness, and aching in the hand.

Common causes of CTS include:

• Repetitive motion of the fingers/wrist
• Vibration from machinery/equipment
• Wrist trauma such as fractures and crush injuries
• Naturally narrow carpal tunnel
• Hormone related conditions including pregnancy and menopause
• Arthritis
• Diabetes
• Medications (i.e. birth control pills and some high blood pressure drugs)

Risk factors for CTS include:

• Gender (more common in females)
• Aging
• Obesity
• Smoking
• Repetitive motion type jobs and activities (i.e. sewing, playing instruments)

Some common symptoms include:

• Tingling, numbness, or burning in the thumb, index, and middle fingers
• Pain or numbness that worsens with use or activity or becomes worse at night
• Cramping/hand stiffness that is relieved after shaking or upon waking
• Dropping objects
• Decreased grip strength

Diagnosis

To be properly diagnosed, a physician will discuss your symptoms and medical history, and examine strength and sensation. A nerve conduction study, electromyography (EMG), and x-ray may be ordered to provide information regarding sensation in the median nerve distribution and confirm compression at the carpal tunnel.

Treatment

Treatment focuses on the causes. Therefore treatment suggestions may include activity modification and postural changes during activities. Other suggestions may include frequent rest periods, elevation, and exercises or stretching. Wrist splints are effective in relieving compression at the carpal tunnel and are typically recommended for night wear. Appropriate fit of the splint is vital. Occupational and physical therapists or certified hand therapists can check the fit of pre-fabricated splints or can fabricate a custom splint. The above mentioned treatments all focus on decreasing inflammation and compression on the median nerve.

Medication

Your physician may order pain relievers or anti-inflammatory medication. A cortisone injection into the carpal tunnel may also be recommended to assist with decreasing inflammation near the carpal tunnel.

Occupational or Physical Therapy

A referral to an occupational or physical therapist or certified hand therapist may be made. A therapist can provide information regarding the diagnosis, appropriate treatment, and symptom reduction. They can make recommendations to introduce into daily activities to allow appropriate positioning of the upper extremities. A therapist will also instruct individuals on helpful stretching exercises or fabricate a wrist splint. Other treatments include ultrasound, iontophoresis, and massage. The focus of therapy is to introduce changes and interventions that reduce inflammation at the carpal tunnel to assist with symptom relief.

Surgery

Surgery, referred to as a carpal tunnel release, may be indicated if symptoms are significant and impair functional activity performance.

Prevention

To reduce your chances of getting CTS:

• Minimize repetitive hand/wrist motion
• Alternate activities
• Avoid prolonged hand use or prolonged positioning
• Keep wrists straight during use when possible
• When working on a computer or at a desk, adjust environment for optimal positioning (back straight, feet flat, knees level with or slightly lower than hips, shoulders straight, elbows at a 90 degrees angle, forearms parallel to floor, and wrists straight)
• Take frequent rests and massage hands
• Exercise regularly
• Reduce smoking and caffeine intake

Guest Contributor: Nancy Naughton, OTD, CHT, is a doctor of occupational therapy and certified hand therapist, specializing in the rehabilitation of the hand and upper extremity at Hand Surgery Associates, Olyphant, PA.

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This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com

Paul J. Mackarey PT, DHSc, OCS is a Doctor  in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at GCSOM. For of Dr. Paul's article, check out our exercise forum!

A local high school teacher came to my office with weakness and numbness on one side of her face. This well-groomed, attractive middle-aged woman was unable to smile, frown, pout, speak, or eat with facial symmetry. She suffered from a cold, on and off, for about two months. It was not a bad cold, but it would not go away. One day in early summer, while engaged in bird watching, one of her favorite pastimes, she noticed that she could not look through her binoculars. She noticed that her eye would not open and close at will. The next day she woke with ear pain, flaccid muscles on one side of her face, and an inability to close her eye. She had difficulty speaking with clarity due to weak mouth muscles and feared she had a stroke.

She immediately saw her family physician who determined that she had shingles in her ear and developed Bell’s palsy. She was prescribed a steroid anti-inflammatory (Prednisone), antiviral medicine (Acyclovir), and a topical cream (Zovirax). Once she got over the initial fear and shock, she was grateful that her problem of facial weakness was not due to a more serious problem, such as a stroke or brain tumor. She began physical therapy and improved slowly. Her story, along with many other patients, reminded me of the need to raise awareness about cause, diagnosis, symptoms, complications and treatment of Bell’s palsy.     

Bell’s palsy, a facial nerve paralysis, occurs when the nerve that is responsible for the movement and sensation of the muscle and skin of the face becomes damaged. The end result of this damage is paralysis of the muscles and numbness of the skin on one side of the face. Typically, the first sign of this disorder is the inability to close one eye or smile on one side of the face. While this problem can occur in any age group, it is rarely seen in people less than 15 or more than 60 years of age. The good news is that most people show signs of improvement within 3-4 weeks and have complete recovery in 4-6 months. The bad news is that reoccurrence can occur on the other side of the face in approximately 10 percent of those affected.

CAUSES OF BELL’S PALSY

Bell’s palsy is caused by a viral infection. The most common virus is the herpes simplex virus, the same virus that causes cold sores and genital herpes. Other viruses that can cause Bell’s palsy are herpes zoster virus that causes chicken pox and shingles and Epstein-Barr virus, which causes mononucleosis, and cytomegalovirus. When one of these viruses causes inflammation to the facial nerve, it becomes swollen and irritated in the narrow tunnel of bone by the ear. As pressure on the facial nerve increases, damage progresses to the point that the muscles and skin of the face are unable to receive messages from the nerve, leading to paralysis, numbness and other symptoms.

SYMPTOMS

The hallmark symptom of Bell’s palsy is sudden onset of facial muscle weakness and numbness on one side of the face. As a result, it is difficult to close the eye and smile on the weak side. Other symptoms on the affected side can include: the inability to make facial expressions, speak clearly (especially vowel sounds), diminished sense of taste, pain in the area of the jaw or ear, sensitivity of sound, headaches, and changes in production of tears and saliva.

RISK FACTORS

While Bell’s palsy can occur in anyone, it is more common among those who are: pregnant, (especially during the third trimester or first week after birth), diabetic, or suffering from a cold or flu. Also, some research suggests that there may be a genetic predisposition to this problem.

COMPLICATIONS  

In mild cases of Bell’s palsy, symptoms are completely resolved within 4-6 weeks. As mentioned before, most cases resolve in 4-6 months. However, recovery for those with complete paralysis may vary. For example, permanent facial weakness, facial muscle twitching, and visual problems due to the inability to close the eye, can occur.

MEDICAL MANAGEMENT

Contact you primary care physician immediately, because these symptoms may be associated with a more serious medical condition such as a stroke. Remember, most people with Bell’s palsy make a complete recovery, but early intervention can expedite the process. In severe cases, a neurologist may be consulted. Two commonly used medications are corticosteroids and antiviral drugs. Corticosteroids such as prednisone are strong anti-inflammatory drugs used to reduce the swelling and inflammation on the facial nerve. Antiviral drugs such as acyclovir are used to stop the viral infection that may have caused the inflammation. Studies show that these drugs, when used in combination, are most effective when administered in the first 3 days of the appearance of symptoms.

Physical therapy can also assist in the restoration of facial muscle recovery. Ultrasound with anti-inflammatory drugs, electric stimulation, massage and exercise are commonly performed. While the use of electric stimulation has limited support in the literature, a home exercise program that concentrates on facial muscles, is an essential part of the therapy program. Some simple exercises performed in front of a mirror are: raise eyebrows, bring eyebrows together, open/close eye, fill cheeks with air, suck in cheeks, smile, frown, whistle, say vowels.

Surgery, to relieve pressure on the nerve by removing bone, is rarely performed. Plastic surgery, to improve the appearance of the face, may be an option in cases with permanent paralysis.    

Sources: Mayo Clinic; WebMD

NEXT WEEK! Read “Health & Exercise Forum” – Every Monday.  This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com

Paul J. Mackarey PT, DHSc, OCS is a Doctor  in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is an Associate Professor of Clinical Medicine at GCSOM.

For all Dr. Paul's articles, visit our exercise forum!

Lung Cancer is a deadly disease. Until recently, there was not an effective and safe screening test. A chest X-ray, often used only after patients developed symptoms, discovered the disease when it was in its late stages. This is about to change. Those who are at high risk for lung cancer can now be screened annually using low-dose spiral CT scans

Lung Cancer Facts:

One of the reasons for the high mortality rate in lung cancer is that the disease is often not discovered until it is advanced and treatment options are limited. Some of the most common signs and symptoms of lung cancer are easily mistaken either for a mild illness or for things such as “smoker’s cough”.  By the time many patients are diagnosed, their disease is advanced and may involve lymph nodes or other organs. 

For some cancers, there are established screening tests that help to identify these cancers at an earlier stage.  For example, routine screenings through colonoscopies, mammograms, and pap smears are well established and have saved thousands of lives.  Until recently, lung cancer has not had such a screening test.

In 2013, The United States Preventative Task Force (USPTF), an independent committee charged by congress to evaluate current data, recommended that all persons who are at high risk for lung cancer should be screened annually using low-dose spiral CT scans.  High risk persons are identified as those who are between the ages of 55 and 79, who have a history of 30 pack years or more of smoking, and who are either still smoking or who have quit within the last 15 years.  A “pack year” is defined as smoking 1 pack of cigarettes a day for a year. For example, a person could have 30 pack years of smoking if they smoke 1 pack of cigarettes a day for 30 years.  Similarly, they could have a 30-pack year history by smoking 2 packs of cigarettes a day for 15 years.

CT, or computed tomography, scans are a form of three-dimensional imaging used by clinicians to visualize the organs and other anatomy of patients.  The scan can detect abnormalities on a patient’s lung with much earlier and with greater sensitivity than an x-ray.  Much like a mammogram, low-dose CT scans do not diagnose cancer but are a way to identify patients with abnormalities that need to be investigated further for the possibility of cancer.  This new screening test will allow physicians to see possibly cancerous abnormalities of the lung before the disease can spread and become impossible to cure.  The scan is non-invasive and generally considered very safe. Low-dose CT scans carry about 5 times less radiation than traditional high-dose CT scans and are equivalent to about 15 x-rays.

This screening practice can save the lives of between 15 and 20% of those diagnosed with lung cancer by detecting cancers before they can progress to the point that they are resistant to medical treatment. While this screening is a major step in the detection and treatment of lung cancer, it is not a substitute for quitting smoking.  The best proven methods to prevent lung cancer and its deadly consequences is to not smoke, use other tobacco products, and avoid exposure to second-hand smoke. If you or a loved one need help quitting tobacco products, you may contact your physician or call 1-800-QUIT-NOW or visit www.lung.org.

Signs and Symptoms of Lung Cancer:

• Cough that does not get better with time
• Chest pain that gets worse with deep breathing
• Hoarseness
• Coughing up blood
• Shortness of breath
• Weight loss and appetite loss
• Tiredness and weakness
• Recurrent respiratory infections
• New onset wheezing

NOTE: These signs and symptoms can be attributed to many different causes and are not exclusive to lung cancer. Always discuss your symptoms with your physician.

Who should be included in annual low-dose spiral CT screening for lung cancer?

Patients who fit all of the below criteria:

• Between the ages of 55 and 79
• 30 pack years of smoking or more*
• Still smoking or having quit within the last 15 years

*A pack year is defined as 1 pack of cigarettes per day for a year

Contributions: Sarah Bashaw, MD: participated in this column as a third year medical student while studying at TCMC (GCSOM).

Medical Reviewer: Greg Cali, DO, Pulmonologist, Dunmore, PA

Read “Health & Exercise Forum” – Every Monday.  This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com

Paul J. Mackarey PT, DHSc, OCS is a Doctor  in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at GCSOM.

Read all of Dr. Mackarey articles in our Health Care Forum at: https://mackareyphysicaltherapy.com/forum/