Getting the Upper Hand on Pain: Preventing Hand ... - IneedCE.com

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conservative CTS <strong>the</strong>rapies before considering CTS surgery. Surgical patients treated three to five years after <strong>the</strong> onset of symptoms are less likely to have complete symptom resolution. Therefore, early diagnosis and treatment are important. 12 It is far easier to prevent carpal tunnel syndrome than to cure it. Pain Syndromes That Mimic Carpal Tunnel Syndrome Several problems may mimic CTS, including cervical radiculopathy, thoracic outlet syndrome, median nerve entrapment in <strong>the</strong> forearm and trigger points, and poorly fitting gloves. (Fig. 5) Figure 5. Problems that may mimic CTS 1. Cervical radiculopathy, 2. Thoracic outlet syndrome, 3. Median nerve entrapment in <strong>the</strong> forearm and trigger points, 4. CTS, 5. Poorly fitting gloves. Trigger points and nerve entrapment Although muscle-referred pain is a well-documented and researched phenomenon, 15,32 it is often overlooked as a possible source of pain syndromes. Trigger points in certain muscles may refer CTS-like symptoms into <strong>the</strong> hand and wrist. 32 Trigger points in <strong>the</strong> forearm muscles such as <strong>the</strong> pronator teres can cause compression on <strong>the</strong> median nerve and cause CTS-like pain in <strong>the</strong> hand and wrist. Since <strong>the</strong> median nerve runs through <strong>the</strong> pronator teres muscle, dental professionals who operate with <strong>the</strong> forearms in a pronated (palms-down) position are at greater risk for this nerve entrapment. 16,33-34 Neuromuscular technique and myofascial release are two popular approaches that have been used to treat this type of pain. Initially, dental professionals should work with a healthcare professional, such as a certified neuromuscular <strong>the</strong>rapist or a <strong>the</strong>rapist who specializes in trigger point <strong>the</strong>rapy, to resolve pain of this origin. After reduction of symptoms, dentists may learn to self-treat <strong>the</strong>ir trigger points, since <strong>the</strong>ir jobs are a perpetuating factor. 35 Median nerve entrapment in <strong>the</strong> forearm can be treated successfully if a holistic approach is taken to address <strong>the</strong> sum of compression and tension on <strong>the</strong> nerves in <strong>the</strong> upper extremity. 18 Thoracic outlet syndrome (TOS) TOS is a neurovascular disorder resulting from pressure on <strong>the</strong> nerves and/or blood vessels that supply <strong>the</strong> arm, fingers and hand. (Fig. 6) Figure 6. Thoracic outlet The thoracic outlet, showing nerves and arteries that supply <strong>the</strong> arm. Tightness and/or trigger points in <strong>the</strong> pectoralis, anterior or middle scalenes may restrict <strong>the</strong> size of <strong>the</strong> thoracic outlet. 15,33,36 Compression of this neurovascular bundle may cause numbness and tingling that can mimic CTS; however, TOS may also include vascular symptoms (edema, coldness or discoloration) in <strong>the</strong> hands and fingers. A thorough clinical evaluation is <strong>the</strong> most important component for diagnosis of TOS; this should include subjective and objective findings as well as a review of daily activities and work 6 www.ineedce.com
habits. The development of TOS has no involvement with <strong>the</strong> tendons and soft tissues at <strong>the</strong> wrist, but that is where <strong>the</strong> symptoms tend to be perceived. In addition to true TOS, patients may have thoracic outlet symptoms due to forward head posture, working with shoulders on a tilted axis, breathing from <strong>the</strong> chest and improper body mechanics. 15,36 Thoracic outlet symptoms from <strong>the</strong>se sources can often be resolved with physical <strong>the</strong>rapy. Cervical radicular pain (cervical radiculopathy) Pain or pares<strong>the</strong>sia in <strong>the</strong> hand may also originate in <strong>the</strong> cervical spine. 15 Nerve roots that supply <strong>the</strong> arm and hand may become compressed as <strong>the</strong>y exit <strong>the</strong> spinal vertebrae, resulting in cervical radiculopathy. This may occur simultaneously with CTS (also known as “double crush” syndrome 33 ). Numbness in <strong>the</strong> hand may be produced by changes in neck position, and muscle stretch reflexes tend to be diminished. Electrodiagnostic studies in this situation would reveal a normal nerve conduction velocity; however, <strong>the</strong> EMG may be abnormal in <strong>the</strong> distribution of <strong>the</strong> involved nerve root. 15 A skilled electromyographer, usually a neurologist or physiatrist, is essential for accurate test results. The cause of cervical radiculopathy, more often than not, is due to forward head posture combined with degenerative changes in <strong>the</strong> facet joints of <strong>the</strong> cervical spine. Poorly fitted gloves Improperly fitted gloves may cause CTS-type pain, primarily at <strong>the</strong> base of <strong>the</strong> thumb. Ambidextrous gloves are generally molded with <strong>the</strong> hand in a flat (neutral) position and were originally designed for brief medical examinations. 37 When gloves are used for longer procedures, as in dentistry, <strong>the</strong> operator’s hand must pull <strong>the</strong> glove into a working position, which may compress <strong>the</strong> back of <strong>the</strong> hand and strain <strong>the</strong> muscles at <strong>the</strong> base of <strong>the</strong> thumb, simultaneously reducing <strong>the</strong> blood flow to <strong>the</strong> hand. Ambidextrous gloves exert one-third more force than do fitted gloves, 37 and muscle ischemia, nerve compression and pain may result. Older practitioners may be more prone than younger practitioners to glove-related pain in <strong>the</strong> hands. 38 Tight gloves may also result in <strong>the</strong> above symptoms. Summary The cause of hand pain in dental professionals may be multifactorial, and <strong>the</strong> etiology may not necessarily be related to a single structural problem at <strong>the</strong> wrist. There are numerous o<strong>the</strong>r pain syndromes of <strong>the</strong> hand/wrist and elbow to which dental professionals are predisposed, including De Quervain’s syndrome, osteoarthritis of <strong>the</strong> carpometacarpal joint of <strong>the</strong> thumb, lateral epicondylitis and o<strong>the</strong>rs. Regardless of <strong>the</strong> etiology of hand/wrist pain, dental professionals should realize that <strong>the</strong>ir occupation is a perpetuating factor for <strong>the</strong> development of this pain. 12,16,32 Prevention is of great importance, and intervention strate- gies should become an integral habit in <strong>the</strong> operatory in <strong>the</strong> office and at home. References 1. Hamann C,Werner R, Franzblau A, et al. Prevalence of carpal tunnel syndrome and median mononeuropathy among dentists. J Am Dent Assoc. 2001;132:163-70. 2. Alexopoulos EC, Stathi I, Charizani F. Prevalence of musculoskeletal disorders in dentists. BMC Musculoskelet Disord. 2004;5:16. 3. Finsen L, Christensen H, Bakke M. Musculoskeletal disorders among dentists and variation in dental work. Applied Ergonomics. 1997;29(2):119-25. 4. Marshall ED, Duncombe LM, Robinson RQ, Kilbreath, SL. Musculoskeletal symptoms in New South Wales dentists. Aust Dent J. 1997;42(4):240-6. 5. Rucker LM, Sunell S. Ergonomic Risk Factors Associated with Clinical Dentistry. CDA J. 2002;30(2):139-48. 6. Lalumandier J, McPhee S. Prevalence and risk factors of hand problems and carpal tunnel syndrome among dental hygienists. J Dent Hyg. 2001;75:130-3. 7. Akesson I, Johnsson B, Rylander L, Moritz U, Skerfving S. Musculoskeletal disorders among female dental personnel—clinical examination and a 5-year follow-up study of symptoms. Int Arch Occup Environ Health. 1999;72:395-403. 8. Akesson I, Schutz A, Horstmann V, Skerfving S, Moritz U. Musculoskeletal symptoms among dental personnel—lack of association with mercury and selenium status, overweight and smoking. Swed Dental J. 2000;24:23-8. 9. Werner R, Hamann C, Franzblau A, Rodgers P. Prevalence of carpal tunnel syndrome and upper extremity tendinitis among dental hygienists. J Dent Hyg. 2002;76:126-32. 10. Anto C, Aradhya P. Clinical diagnosis of peripheral nerve compression in <strong>the</strong> upper extremity. Orthop Clin North Am. 1996;27:227-36. 11. Phalen G. The carpal-tunnel syndrome: seventeen years’ experience in diagnosis and treatment of six hundred fifty-four hands. J Bone Joint Surg Am. 1966;48:221-8. 12. Mackin EJ, Callahan AD, Osterman AL, Skirven TM, Schneider LH. Rehabilitation of <strong>the</strong> <strong>Hand</strong> and <strong>Upper</strong> Extremity, 4th ed. St. Louis, MO: Mosby; 2002:644- 67. 13. Karwowski W, Marras WS. The Occupational Ergonomics <strong>Hand</strong>book. Boca Raton, FL: CRC Press; 1999:775-7, 821-5 1643-4. 14. Rice VJ, Nindel B, Pentikis JS. Dental workers, musculoskeletal cumulative trauma, and carpal tunnel syndrome: who is at risk? A pilot study. Int J Occup Saf Ergon.1996;2(3):218-33. 15. Cailliet R. Neck and Arm Pain. 3rd ed. Philadelphia, PA: F.A. Davis; 1991:195-7, 212, 215-8. 16. Whyte-Ferguson L, Gerwin R. Clinical Mastery in www.ineedce.com 7
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