Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Iyad Salloum. He's the clinical director at Insync Physio in North Burnaby. And we're going to talk about something fairly common, something that I have just learned that I had thought I had, but I didn't have, carpal tunnel syndrome. How are you doing Iyad?

Iyad: Good, how are you doing Mark? 

Mark: Good. So what is it? What is this thing? Carpal tunnel. 

Iyad: Yeah, that's a good question. Probably a good place to start. So most people with carpal tunnel syndrome or people who have been told or think they have carpal tunnel syndrome will present with symptoms along their hand, tends to be a little more kind of towards above the wrist and it'll effect, usually the palm area towards the thumb side.

So usually they'll tell you these three fingers and to go a little fuzzy or numb on occasion and it'll present for different reasons. So people tend to have like different jobs, maybe that involve a lot of wrist work or repetitive work, and they could present that way. We see it in the pregnant population actually, just because of the overall swelling that happens in the body.

So if you have a bit of swelling at the wrist, for example, you could have that. And there are potential also trauma. If you have an impact on that area where it affects the nerve that passes through the carpal tunnel, you can also get that. What it is is it tends to affect the nerve structures most of the time. 

You have a thing called the transverse carpal ligament that goes right through here, and it's really like, not stretchy. So the tissue tends to be very strong and you need it to be strong and rigid and right under there, you have your, your finger tendons that help you do all kinds of stuff with your hands. And then also you have like, you know, your blood supply and your nerve. And then the nerve kind of feeds this fleshy part in your thumb that helps you control your thumb.

So if somebody has had carpal tunnel for awhile, usually we'll see a bit of wasting here. If it's been a long, long time and it's gotten progressively worse. So that's one way we can kind of figure that out if it's been awhile. But in the kind of early onset, acute phase tends to be numbness or burning along this kind of distribution where the thumb, the index and the middle finger are affected.

And sometimes it goes to the ring as well, because there are people, people's differences. Now what it is, and sometimes where people really confuse it. And this is kind of, I guess, to go back to your point, because they say, oh, I have it in the backside of my hand that doesn't tend to be carpal tunnel. It doesn't really go there.

You know, we tend to look at something else because there are other tissue and nerves that can get affected. Or sometimes they'll tell you, yeah, it starts with the elbow and it goes all the way down, you know, where we're starting to probably suspect that there's something else. Even though it feels exactly like carpal tunnel, which is like, all my hand eventually goes numb.

But if it's not a little more restricted to the hand and the assessment will be like only positive on the hands assessment, I would tend to look elsewhere and try to see if there's another area where that nerve is getting sensitized and then giving the people symptom scenarios. 

Mark: So we've talked about the shoulder being a really complex joint, but the wrist is probably right up there with being in terms of all the bones. That even just in the wrist itself, let alone in your hand, et cetera. So there's a lot of stuff trying to glue that all together. 

Iyad: Yeah. Yeah, absolutely. So we have eight bones just in the wrist alone. They're very small called the carpals. And then we have our metacarpals, which are kind of these bones here. And then we have the phalanges which are the fingers. So, yeah, there's layers of muscles. So we have multiple layers. And that kind of layering systems, kind of get to know if you're trying to think of treatment and also trying to think of the movements that the person needs to be able to do with their hand and wrist.

So, yeah, it is complicated, but it also doesn't need to be, as far as treatment goes, like, you know, we will usually try to simplify it as much as possible. We need to make sure the person's able to move safely and normally as possible through that hand and wrist complex. 

Yeah, you're right in that sense, but we don't complicate it. You don't need to be as a patient wants to seek treatment, you don't need to be an expert on how the wrist biomechanics move to actually get that better. 

Mark: So when we're talking about causes, is it generally, or can we almost infer that it's almost always an overuse injury that causes metacarpal tunnel syndrome?

Iyad: I think so. For carpal tunnel syndrome, there are overuse based stuff. There are other things too. So I'd say there's different subsets. So there's the kind of, let's call it the more mechanical irritation group, where it would tend to be from overuse or impact or prolonged positioning in certain areas.

You have other causes, other things that could just sensitize your nerves. Like, so we talked about just, if you have overall swelling in your body, like usually we see this in a pregnancy, especially after second, third trimester, you know, times we'll see that. It doesn't mean it's gonna affect everybody. But if it does happen, you know, not to be too, too alarmed because we could do some treatment for that. 

And then like, obviously there are some conditions that will predispose you to having more nerve related issues. So think about like if you have somebody with diabetes, with diabetic neuropathy, it might present with these symptoms and they tend to start at the fingertips, work their way up and it affects the hands and feet primarily. But that's more of a systemic issue. 

So yeah, I think if we simplify it and say, it's just overuse, I think that's also being a little unfair because sometimes you get people coming in, they're like, I did nothing. I work like, I'm on the phone all day or I'm on this and I'm on that.

So this is where it's kind to useful for us to get a good, detailed history on how it started when they started noticing it. And also the pain pattern, because some people will just tell you, I get got at night. I don't get it any other time except at night. 

Like I had a patient to only got it when she falls, go to sleep and she would sleep like this on her wrist. So she imagined being here for six to eight hours without moving. So you could get that. But then there's the others who, again, look like they have carpal tunnel, but you assess everything. And you're like, there's a little more going on here. So most common one would be potentially an issue in the neck. Where you have sensitized nerves through here, but they feel it in the hand. So if we can change it from the neck, it's probably not carpal tunnel syndrome, even though it's carpal tunnel like.

Mark: So just a point of interest, the carpal tunnel really is that ligament around your wrist? 

Iyad: So there's a cavity under that ligament is the canal. But once you cover with the ligament, it's called the tunnel and you have the structures through it. So that's what it's referring to. And you know, usually people will tell you, yeah whenever I put any pressure here, I start to get symptoms. Again, that's not enough for us to just say, oh, it's only due to this because in some cases we don't have a lot of evidence on this but it happens. But if you have a nerve that's sensitive somewhere else, it could become a little easier for it to get irritated further down. 

So imagine if you have a neck issue at the beginning, that's contributing to this nerve. I'm going to be probably, based on just like our, some studies on animals, we don't have a lot of human data, that it could spread to other areas and it could make it easier for you to develop an issue further down the same line. 

But usually what we do with somebody like that is we will tend to treat both areas together, instead of just saying, oh, we're only going to do the wrist. We'll splint your wrist and we'll do all kinds of mobilizations to that and tendon sliding exercises and stuff. No, we'll tend to treat neck, shoulder, and wrist at the same time.

Mark: So diagnosis is fairly critical. Like always. 

Iyad: It is. It's just good to know, because I mean, I've had two patients now who have had confirmed electric conduction studies, when they actually study if the nerves conducting properly and they've confirmed carpal tunnel syndrome because of reduction in the conduction in the wrist, but they've never had anything else assessed.

They have the surgical release and yes, it helps potentially reduce their symptoms, but they're like, why is it not gone? And it tends to be because that nerve is probably sensitive somewhere else. So, you know, with those two people, we ended up, one of them, it was more somewhere in the neck. So we treat the neck, we gave them a neck and kind of a shoulder rehab program and it eliminated it completely. 

And the other person was a little more persistent. So we needed to do a lot more kind of overall change, I guess. So we had to change just the way they did things and teach them different movement strategies, and treat the neck, treat the shoulder with the mix of therapy and exercise and IMS and different kind of strategies to help them get out of that kind of vortex that they kind of get stuck in sometimes. 

So yeah, you would want to know what you're treating first, instead of here's the three thing to do for carpal tunnel syndrome, because you might have something that looks like it feels like it but probably isn't it.

Mark: And I'm sure there's a range of treatment. So what is that what's included in the range of treatment options that you provide people? 

Iyad: So most important is we try to identify, this is usually what I do in the first days. We'll try to identify what's actually provoking the symptoms. And we try to see if we can modify those stresses. So if it's with changing the way they do things, if it's basically with a mix of maybe bracing and some other exercises, we could do that. So I'll give you an example. I had a tennis player who had it, so we just had to teach them to hit the racket a little more like a tennis racket and a little less like a badminton racket where they would do an extra wrist flick at the end.

So that was a lot of what we did with them. And then there's other people where we would tend to so for example, my client who would sleep on their wrist. We're like, okay, how do we make them not sleep that way? We put them in an overnight brace to prevent that bending. So you got to just identify what's the potential trigger and maybe figure out ways to modify the stress on it.

So that's, I guess, what you could do from a, let's call it a reduction of stress, on the area. The other thing we could do, obviously there's tons of exercises that tend to help a lot here. So the exercise doesn't have to just hand specific. Let's say the tennis player, we'd work a lot on shoulder and upper back, so they can actually learn to swing through their body.

If you have somebody who has a stiff hand, the tendons don't move so well, so we mobilized those, in the planes that they need to move. So it tends to be a mix of that. And then obviously, we have our hands-on techniques where we can do sometimes some mobilizations in their just within their tolerance. And it tends to kind of help with pain relief and with improved range of motion. We just try to match the treatment to what's actually missing because whenever you hear the word syndrome after a condition, it doesn't mean that it's a specific singular contributor, just to kind of like a cluster of symptoms that get presented. So we try to figure out what's causing this here and kind of match the treatment to that. 

Mark: And treatment time range? 

Iyad: It all depends from, I guess, how long you've had it. Whether we can actually stop temporarily or modify the provocative factors, it'll depend on, for example, overall health. So if this person potentially has multiple co-morbidities, and then diabetes and these other things, obviously the recovery tends to be a bit slower, even if they're doing everything right.

So there's a lot of that goes into it. And then if you find it early and you intervene early, you're probably able to move on pretty quick versus if you wait, wait, wait. Until that sensitivity builds up to the point, we probably are looking at longer. So we've seen in clinic anywhere from four weeks to six months to a year, even sometimes. It just depends on the job.

So I'll give you an example of one person. We had a cashier who had this issue, so constantly scanning things. And we just had to change the way they did it, so it would be like move the whole shoulder instead of moving just the wrist. So it's really tough to throw a number on it.

But yeah, some people do really well without anything, which is also the funny part. And some people just persist even six months after the ground zero first day when they experienced symptoms. 

Mark: If you're experiencing any kind of numbness, pain in your hands, the guys to see are Insync Physio. Get experts diagnosing exactly what's going on so you can get it back on the path to recovery and health and feeling better. Insyncphysio.com is where you can book to see them. They have two offices, one in Vancouver at (604) 566-9716 or in North Burnaby, (604) 298-4878. Get, get in there. Get feeling better. Thanks Iyad. 

Iyad: Thanks Mark.

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Iyad Salloum of Insync Physio in North Burnaby. And we're going to talk about specifically, what is carpal tunnel syndrome. How are you doing Iyad? 

Iyad: Good, Mark. How are you today? 

Mark: Good. So, what is it? 

Iyad: So yeah, carpal tunnel syndrome. It happens to be the most common type of entrapment neuropathy out there. It counts for about 90% we think of all neuropathies, because it's so prevalent in their population. And what it is, it's some form of compression of one of our nerves called a branch of the median nerve that feeds the thumb and of our first three or four fingers, depending on the person. So people will tend to come in presenting with varied symptoms, like tension, numbness, tingling, burning. I usually tell people it's kind of what you would feel when you'd hit your funny bone. Those kinds of symptoms, maybe a little less severe, but it tends to be a little more recurrent and debilitating for some people.

Mark: And what do people typically, if people come in and they think, okay, the back of my hand hurts or it hurts when I do this. Is that carpal tunnel? 

Iyad: So the back of the hand tends to be something else. We have another nerve that supplies the back of the hand. You could have something from the neck that affects both. And that's a different story. This position can compress the carpal tunnel, but then we would for us to have what we think is carpal tunnel, we'd have to have some sort of sensory symptom or even maybe a weakness of the thumb for in the palm area. So that's where we would assess because that's what the nerve that passes through the carpal tunnel will innervate and feed. So backside, you know, it could be related to something else, but it definitely wouldn't present that way with carpal tunnel syndrome.

Mark: And so, you hear it a lot about people using mousing and doing that, is that, are they getting it in here or are they getting in like more of the along, in the forearm? 

Iyad: So you could have stuff in the forearm because your nerves have to travel through here. So that same median nerve has to travel through the front of your forearm. So you could potentially get stuff there from repetitive work. For mousing again, on its own, like, I mean, there's a lot of people who can mouse and not have symptoms. And then there are some who just can't cope with it. So there's some individual variability. You can get that. But this is where I think us being very good at looking at where is this thing coming from?

Is really crucial because you have a lot of people who think they have carpal tunnel, but it's actually somewhere else in the forearm, in the neck and the shoulder, where the nerves is getting sensitized. And they just happened to feel a little extra in the hand. But if it's not kind of more limited to that hand and kind of isolated to testing that we do specifically in the hand. We wouldn't be able to just conclusively say that it's carpal tunnel syndrome because they could feel it there, but it's not coming from there.

Mark: Are there any instances where people are kind of in a specific position of some kind that will cause this carpal tunnel syndrome? 

Iyad: Yeah, you can have a lot of compression. So if you're kind of doing a lot of this, which stretches the transverse carpal ligament on the neural structures and the blood supply of the hand and wrist. You can get some of these sensations. Obviously getting tingling once isn't carpal tunnel syndrome. You would have to get this thing where the nerve and the tissue gets repeatedly sensitized, and then you develop a bit of a, let's call it like a lower threshold to, like you'd need a little less to kind of aggravate your symptoms. And then it comes to the point where it's day to day stuff. Some people will tell you like doing day-to-day stuff like brushing their teeth becomes tough sometimes and gripping and basic things like that.

Some yoga athletes that we've seen who are very, you know, dedicated and do this regularly and hold long, long positions. Yeah it's possible, definitely. But again, it's one of those things where just doing it once or feeling it once it doesn't necessarily mean that you're going to have, or that you have carpal tunnel syndrome, but it's definitely something that we would assess.

That's one of the key things we would look at is what is actually the provocative movement or movements and how do we change or offload that potentially as we take them through a treatment.

Mark: Carpal tunnel syndrome. If you need some expert help, the guys to see in Vancouver or in North Burnaby, are Insync Physio. You can book at insyncphysio.com. Either location. Or you can call them. Vancouver's (604) 566-9716. North Burnaby is (604) 298-4878. Get expert help on your hand issues. Thanks Iyad. 

Iyad: Thanks, Mark.

Hey guys, it's Dahra from Insync Physiotherapy here. And I'm here to talk about carpal tunnel syndrome and how physiotherapy can help individuals with this condition. So basically carpal tunnel syndrome is a compression of one of the nerves that travels through your forearm known as the median nerve.

So usually include pain, numbness, or the feeling of pins and needles and tingling in your hands. And typically involves some variation of the thumb, the index finger, middle finger, and one half of the ring finger, the side closest to your thumb. Here's a simple stretch, often prescribed, that stretches out the wrist flexors and decreases the compression of the median nerve.

So you lock your elbow out straight. Use your other hand to pull your wrist back until you feel a stretch in your forearm and hold this position for about 30 seconds and perform it three times a day. 

If you do suffer from this condition, physiotherapist can also give advice about workplace ergonomics and activity modifications that could potentially be exacerbating your symptoms. Physiotherapists can also guide you through therapeutic modalities and prescribe you a gradual progressive exercise program to help relieve your symptoms and get you back to the activities that you enjoy.

In the present day, with the onset of the Covid-19 pandemic, those who now need to work at home or have more free time at home, may find themselves spending more time on electronic devices. The issues that may arise from all this screen time is carpal tunnel syndrome.Generally those who have diabetes or arthritis are vulnerable to carpal tunnel syndrome. This includes: pregnant women (because of water retention), workers in trades or manufacturing jobs, the fishing industry, cleaning, culinary, cashiers, hairdressers, and those who participate in yoga, ultimate, and knit religiously.

Anatomically, the Carpal tunnel is found on the anterior side of the wrist and is known as the narrow passageway for 9 tendons and an important nerve known as the median nerve. When people complain about pain in their wrist, the pain is referred to as carpal tunnel syndrome which the National Institute of Neurological Disorders and Stroke states is“- the result of a combination of factors that increase pressure on the median nerve and tendons in the carpal tunnel, rather than a problem with the nerve itself.”

Carpal tunnel is a result of repetitive hand movements such as typing on your laptop or texting on your phone. It is also associated with improper positioning of the hand, mechanical stress on the palm, and grip holds. The pain felt is due to the lack of lubrication between the tendon and sheaths in the wrist causing friction with movement which leads to inflammation of the tendon area. The inflammation puts pressure on the median nerve in the carpal tunnel. With any injury, improper healing can lead to susceptibility to repeated injury and chronic pain. If carpal tunnel is left untreated the inflammation can lead to the thickening of the tendon and fibrous sheath resulting in decreased mobility in the wrist.

This syndrome causes numbness, tingling and pain in each digit and the thumb which the median nerve innervates. The pain may also radiate to the forearm and is intense enough to wake people or prevent people from sleeping. The median nerve controls the thumb, middle and ring finger, index finger and is vital in carrying movement and stimulus signals from the control centre, our brain.

Prevention Methods:
use of a splint to prevent further compromisation of the median nerve.
holding the wrist in dorsiflexion, having the wrist in a 70 degree angle toward you) overnight to relieve symptoms. Dorsiflexion stretches are a good way to alleviate wrist tightness.
corticosteroid injections into the carpal tunnel can be used.
If surgery is needed a surgical decompression of the carpal tunnel Will be done.

How can a physiotherapist help? Physiotherapists will guide you through a variety of therapeutic modalities and how to properly execute these exercises and stretches to relieve the strain as well as prescribe easy at home or at work exercises for instant relief of pain

Labour-intensive industries get a lot of attention when it comes to work-related injuries, but employees who work in office settings are also at risk. Poor ergonomics and organization can lead to common office injuries such as computer eye strains, falls and most importantly, repetitive use injuries.

Our bones and muscles make up our musculoskeletal system. This system allows us to perform activities such as walking, running, and anything requiring the movement of the body. A repetitive strain injury occurs when repeated movements produce stress on your body. Unfortunately, many office jobs require repetitive motions to fulfill our duties, and for this reason, they are the most common type of injury found in the office (WCB). Examples of repetitive strain injuries include carpal tunnel, tendonitis, radial tunnel syndrome, and others.

Symptoms of repetitive strain injuries include:
  · Dull aching
  · Loss of sensation (numbness) especially at night
  · Tingling and burning sensations
  · Swelling around wrist/hand
  · Clumsiness (impaired dexterity, loss of ability to grasp items, etc.)
  · Muscle weakness, fatigue, and/or spasms

Prevention:
  · Stop or reduce the intensity of activity causing the pain
  · Taking breaks from repetitive tasks
  · While at the desk…
      · Ensure proper ergonomics
      · Avoid slouching
      · Avoid bending the wrists when typing
      · Avoid hitting the keys too hard when typing
      · Don’t grip the mouse too tightly
      · Ensure you are working in an appropriate temperature
Standing up and performing stretches such as the following:

WCB (n.d.) Office Ergonomics. Retrieved from: https://www.wcb.ab.ca/assets/pdfs/public/office_ergo.pdf