diagnosis, treatment & management of carpal tunnel syndrome curt hamann, m.d. february 2009 curt...

Diagnosis, Treatment Diagnosis, Treatment & Management of & Management of

Carpal Tunnel Carpal Tunnel Syndrome Syndrome

Diagnosis, Treatment Diagnosis, Treatment & Management of & Management of

Carpal Tunnel Carpal Tunnel Syndrome Syndrome

Curt Hamann, M.D.Curt Hamann, M.D.

February 2009February 2009

Curt Hamann, M.D.Curt Hamann, M.D.

February 2009February 2009

Loma Linda University

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hamann@smarthealth.com© 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.permission.

SURVEY1. The most common type of musculoskeletal disorder in dentistry is:A) carpal tunnel C) DeQuervain’s Disease B) tendinitis D) hand/arm vibration syndrome

2. Overall, male dentists may be at greater risk than female dentists for:A) carpal tunnel C) allergic contact dermatitisB) latex allergy D) lower back injury

1. The most common type of musculoskeletal disorder in dentistry is:A) carpal tunnel C) DeQuervain’s Disease B) tendinitis D) hand/arm vibration syndrome

2. Overall, male dentists may be at greater risk than female dentists for:A) carpal tunnel C) allergic contact dermatitisB) latex allergy D) lower back injury© 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written

permission.permission.

Course Objectives: Musculoskeletal Disorders

Characterize upper extremity musculoskeletal disorders (MSDs) in dental workers

Discuss effective ways to reduce symptoms and risk of MSDs development

Characterize upper extremity musculoskeletal disorders (MSDs) in dental workers

Discuss effective ways to reduce symptoms and risk of MSDs development

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Occupational Injuries and Illnesses, NIOSH

2004

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Dental Professionals Often Report Musculoskeletal

Symptoms• 46% -71% of dental students reported body pain: males in

the mid-lower back; females in neck and shoulder Rising et al., JADA 2005

• Dental hygienists report upper extremity pain

Johnson EG et al., J Dent Hyg 2003

• Dental hygiene students report more upper extremity numbness with longer use of ultrasonic instruments

Morse TF et al., J Dent Hyg 2003

• 75% of dental hygienists reported hand problems and 56% reported symptoms consistent with CTS Lalumandier & McPhee J Dent Hyg 2001

• 46% -71% of dental students reported body pain: males in the mid-lower back; females in neck and shoulder Rising et al., JADA 2005

• Dental hygienists report upper extremity pain

Johnson EG et al., J Dent Hyg 2003

• Dental hygiene students report more upper extremity numbness with longer use of ultrasonic instruments

Morse TF et al., J Dent Hyg 2003

• 75% of dental hygienists reported hand problems and 56% reported symptoms consistent with CTS Lalumandier & McPhee J Dent Hyg 2001© 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written

permission.permission.

What are Musculoskeletal Disorders (MSDs) ?

MSDs are also referred to as:MSDs are also referred to as: repetitive motion injury, repetitive strain injury, cumulative trauma disorder, over exertion injury

MSDs affect: MSDs affect: muscles, tendons, nerves, joints, spinal discs, ligaments, cartilage

MSDs develop over time; MSDs develop over time; not a single not a single event event

Symptoms range widely: Symptoms range widely: mild and periodic mild and periodic to severe and chronicto severe and chronic

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Common Symptoms of MSDs

• Pain

• Tenderness

• Numbness

• Blanching

• Tingling

• Burning

• Swelling

• Cramping

From Gray’s AnatomyFrom Gray’s Anatomy

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• Stiffness

• Limited motion

• Loss of function or strength

• Sensory loss

• Fatigue

• Spasms

• Muscle atrophy

Health Risk Factors for MSDs

• Increasing Age

• Gender (Female)

• Fibromyalgia

• Diabetes

• Autoimmune disorders

• Kidney disease

• Back problems

• Arthritis

• Menopause or pregnancy

• Hormone replacement

• Cervical radiculopathy

Gout Alcoholism Trauma Obesity Tremors Tumors or cysts Hyperthyroidism Hypothyroidism Psychosocial factors Smoking Low physical fitness

Gout Alcoholism Trauma Obesity Tremors Tumors or cysts Hyperthyroidism Hypothyroidism Psychosocial factors Smoking Low physical fitness

= Risk for Carpal Tunnel Syndrome

= Risk for Carpal Tunnel Syndrome

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Carpal Tunnel May be Harbinger of Type 2

Diabetes

•Up to 20% of diabetics have a compression neuropathy

•CTS can precede the diagnosis of diabetes by up to 10 years

•Check blood sugar!November 2006 DOCNEWS

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Work Related Risk Factors or MSDs

•Repetition and force: - poor

instrumentation/maintenance- overloaded patient schedules- poorly fitted gloves

•Awkward postures: - standing or sitting- hand positions- chair, patient position- operatory arrangement

•Contact Stress© 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.permission.

Are right angles wrong?

•Opening the hip angle can reduce back pain and improve access to the oral cavity

•Chairs with a tilting feature open the hip angle to 110°

• Saddle chairs open hip angle to 135°

•Minimizes stress to discs Dental Practice Report, October 2005

by Bethany Valachi. M.S., P.T., C.E.A.S.

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Vibration from Equipment is a Work Related Risk Factor for MSDs

Vibration from Equipment is a Work Related Risk Factor for MSDs

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No evidence of a relationship between:

• Blood/urinary Hg and musculoskeletal symptoms in dental personnel Akesson et al., 2000

• Amalgams and coordination, gait, strength, etc.; subclinical effect observed on vibrotactile sensation. Kingman et al., 2005

Inconclusive data:

• No relationship between blood Hg levels and neurobehavioral

effects Weil et al., JAMA 2005

• Some believe subtle effects associated with total Hg body burden Heyer et al, 2004; Echeverria et al., 1998

Hgo Exposure (Amalgam) A Potential Risk Factor in Dentistry?

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• Biking

• Bowling

• Exercise

• Golf

• Video games

Racquet sports Playing musical

instruments Weight-lifting Gardening Needle work Computer Carpentry Arts/crafts

Racquet sports Playing musical

instruments Weight-lifting Gardening Needle work Computer Carpentry Arts/crafts

Activity Related Risk Factors for MSDs

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• Symptom HistorySymptom History

• Physical Examination Physical Examination

• Palpatory AssessmentPalpatory Assessment

• X-RayX-Ray

• MRIMRI

• Electromyography Electromyography

• Ultrasound Ultrasound

• Nerve ConductionNerve Conduction (electrodiagnostic test for CTS) (electrodiagnostic test for CTS)

Diagnosis of MSDs Can Require:

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Neck and ShoulderNeck and Shoulder Rotator Cuff Tear or Rotator Cuff Tear or

TendinitisTendinitis Cervical SpondylosisCervical Spondylosis Myofascial Pain Syndromes Myofascial Pain Syndromes

(Tension Neck, Myalgias)(Tension Neck, Myalgias) Thoracic Outlet SyndromeThoracic Outlet Syndrome

Arm & ElbowArm & Elbow• Epicondylitis Epicondylitis

(tennis or golf elbow)(tennis or golf elbow)

• Cubital tunnel syndromeCubital tunnel syndrome

• Radial tunnel syndromeRadial tunnel syndrome

Neck and ShoulderNeck and Shoulder Rotator Cuff Tear or Rotator Cuff Tear or

TendinitisTendinitis Cervical SpondylosisCervical Spondylosis Myofascial Pain Syndromes Myofascial Pain Syndromes

(Tension Neck, Myalgias)(Tension Neck, Myalgias) Thoracic Outlet SyndromeThoracic Outlet Syndrome

Arm & ElbowArm & Elbow• Epicondylitis Epicondylitis

(tennis or golf elbow)(tennis or golf elbow)

• Cubital tunnel syndromeCubital tunnel syndrome

• Radial tunnel syndromeRadial tunnel syndrome

From

Gra

y’s

Anato

my

Musculoskeletal Disorders (MSDs) of the Upper

Extremities

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Musculoskeletal Disorders Musculoskeletal Disorders (MSDs) (MSDs)

of the Handof the Hand

Musculoskeletal Disorders Musculoskeletal Disorders (MSDs) (MSDs)

of the Handof the Hand Raynaud’s Phenomenon Guyon’s Canal Syndrome De Quervain’s Disease Trigger Finger White Finger Syndrome Hypothenar Hammer

Syndrome Hand/Arm Vibration Syndrome Cubital Tunnel Syndrome Carpal Tunnel Syndrome

Raynaud’s Phenomenon Guyon’s Canal Syndrome De Quervain’s Disease Trigger Finger White Finger Syndrome Hypothenar Hammer

Syndrome Hand/Arm Vibration Syndrome Cubital Tunnel Syndrome Carpal Tunnel Syndrome

Carpal tunnel

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Muscle Atropy

Median Nerve

COMPRESSIONCOMPRESSION

What is Carpal Tunnel Syndrome (CTS)?What is Carpal Tunnel Syndrome (CTS)?What is Carpal Tunnel Syndrome (CTS)?What is Carpal Tunnel Syndrome (CTS)?

Thenar MusclesThenar MusclesThenar MusclesThenar Muscles

Carpal Tunnel

Pain, Tingling, Numbness

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ADA Screened Dentists

(n=1,079)

ADHA Screened Dental Hygienists

(n=305)

Demographics 84% M; ~ 50 yrs 99% F; ~ 44 yrs

Self-reported hand

symptoms 28% 39%

CTS Diagnosis*(0.8 msec)

2.9% 3.0%

* Diagnosis requires impaired median nerve function and pain, numbness or tingling in the area affected by the median nerve * Diagnosis requires impaired median nerve function and pain, numbness or tingling in the area affected by the median nerve

The occurrence of CTS in dental workers is similar to the general

population (which ranges from 2.1%-2.9%)

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*Latko et al (1999) for industrial workers

But the prevalence of upper extremity tendinitis in dental

hygienists may be higher, giving rise to significant pain

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Prevalence of:

Dental hygienists(n=305)

Industrial workers (from other studies)

shoulder tendinitis 13% 13%

elbow/forearm tendinitis

6% 11%

wrist/hand/finger tendinitis

7% 6%

Physical therapy Rest, massage Exercises Muscle

electrostimulation

Splints/braces Vitamins Steroids Botulinum toxin Surgery

Possible MSDs Treatments

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• Can be difficult to obtain an accurate diagnosis due to multiple classification systems for MSDs (Van Eerd et al J Clin Epidemiol 2003)

• Limited data is available on the success of many interventions for MSDs.

• Increased coursework/education of dental workers about preventing MSDs and biomechanics is badly needed (Beach & DeBiase J Dent Educ 1998; and Thornton LJ et al., Appl Ergon 2004)

Challenges Remain in Evaluating MSDs in

Dentistry

Challenges Remain in Evaluating MSDs in

Dentistry

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Remember to adjust the job to you; DON’T fit you to the task.

Photos or videos of yourself working can show potential postural stress:- leaning forward or hunching over- head/body leaning or bent aside- repeated motions or static positions

A.N. Guignon, RDH 2004

Remember to adjust the job to you; DON’T fit you to the task.

Photos or videos of yourself working can show potential postural stress:- leaning forward or hunching over- head/body leaning or bent aside- repeated motions or static positions

A.N. Guignon, RDH 2004

MSDs in Dentistry: Posture & Motion

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Shift your weight

Use erect postures

Stay flexible Keep arms &

shoulders low Vary intensity

& direction of movement

Shift your weight

Use erect postures

Stay flexible Keep arms &

shoulders low Vary intensity

& direction of movement

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MSDs in Dentistry: Posture & Motion

Adjust the job

to you:

Vary hand,

wrist and finger

positions

Avoid

excessive

pressure and

extreme angles

Adjust the job

to you:

Vary hand,

wrist and finger

positions

Avoid

excessive

pressure and

extreme angles

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MSDs in Dentistry: Posture & Motion

Remember - adjust the job to youRemember - adjust the job to you:: Manual and automated equipment Manual and automated equipment

should be properly:should be properly:- - proportioned and weightedproportioned and weighted for for

youyou- - cushionedcushioned and textured (grip) and textured (grip) - - sharpenedsharpened- - insulatedinsulated from vibration from vibration

Clothing, shoes, and personal Clothing, shoes, and personal protective equipmentprotective equipment should be non- should be non-restrictiverestrictive

Managing MSDs in Dentistry: Equipment

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Optimal Air Pressure

1. Electric

2. Fiberoptic Light Source

3. Appropriate cord length

4. Contra angle

5. Lightweight www.ada.org

Handpiece Considerations for Optimal Ergonomics

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Keep point of force applications close to the body to reduce reaction force applied at the tooth/instrument interface

Dimensions of Dental Hygiene, March 2006, p. 19

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• Handle designs of perio instruments affect muscle load and pinch force

• 10mm diameter (large) and 15 grams (light) required least amount of load and pinch force

JADA, Vol. 137, August 2006, pp.1123-1130

The effects of periodontal instrument handle design on hand muscle load and pinch

force

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Remember - adjust the job to you:

Keep cords from restrictingmovements

Keep materials and tools within easy reach

Take the time to correctly position patient and equipment

Managing MSDs in Dentistry: Equipment

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Use magnification lenses or cameras to improve field visualization and posture

Branson BG et al., J Dent Educ 2004; Hagge, MS J Prosthodont. 2003

Modify operatory layout if needed Adjust or change chairs: gender

differences in body biomechanics Select flooring and surfaces that

facilitate movement

MSDs in Dentistry: Equipment

MSDs in Dentistry: Equipment

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• Stretch body regularly, especially upper extremities

• Take breaks during daily activities

• Adjust work schedules and environments as needed

• Encourage fitness and flexibility programs

• Stretch body regularly, especially upper extremities

• Take breaks during daily activities

• Adjust work schedules and environments as needed

• Encourage fitness and flexibility programs

Managing MSDs in Dentistry: Exercise &

Flexibility

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XTensor

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Be proactive; support staff concerns

Educate staff about latex allergies and MSDs

Encourage prompt diagnosis and treatment

Be alert to potential symptoms and risk in staff and patients

Modify behaviors, work practices and product choices as needed NOW

Establish preventive programs NOW

Be proactive; support staff concerns

Educate staff about latex allergies and MSDs

Encourage prompt diagnosis and treatment

Be alert to potential symptoms and risk in staff and patients

Modify behaviors, work practices and product choices as needed NOW

Establish preventive programs NOW

Management of Occupational Allergies and MSDs in

Dentistry

Management of Occupational Allergies and MSDs in

Dentistry

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In the modern view pain is an enemy, a sinister invader that must be

expelled. And if Product X removes pain thirty seconds faster, all the

better. This approach has a crucial, dangerous flaw: once regarded as an

enemy, not a warning signal, pain loses its power to instruct. Silencing pain without considering its message

is like disconnecting a ringing fire alarm to avoid receiving bad news.

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The United States consumes thirty thousand tons of aspirin a year, averaging out to 250 pills per person. Newer and

better pain relievers are constantly introduced, and consumers gulp them down: one-third of all drugs sold are

agents that work on the central nervous system. Americans, who represent 5 percent of the world’s population,

consume 50 percent of its manufactured drugs. Yet what does this obsession gain? I see little evidence that Americans

feel better equipped to cope with pain and suffering. Addiction to drugs and alcohol, a primary means of escaping grim reality, has mushroomed. In the years I have lived here, more than one thousand pain centers have opened to help

people battle the enemy that will not surrender. The emergence of “chronic pain syndrome,” a phenomenon

rarely seen in non-Western countries or in medical literature from the past, should set off alarms for a culture committed

to painlessness.

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I write as a physician, not a moralist, but any physician working in modern

civilization cannot help noticing our cultural deafness to the wisdom of the

body. The path to health, for an individual or a society, must begin by taking pain into account. Instead, eat too fast and too much

and take a seltzer; we work too long and too hard and take a tranquilizer. The three best-selling drugs in the United States are

a hypertension drug, a medication for ulcers, and a tranquilizer. These pain-

mufflers are readily available because even the medical profession seems to look upon

pain as the illness rather than the symptom.© 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written

permission.permission.

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STOP

Questions andAnswers

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SURVEY1. The most common type of musculoskeletal disorder in dentistry is:A) carpal tunnel C) DeQuervain’s Disease B) tendinitis D) hand/arm vibration syndrome

2. Overall, male dentists may be at greater risk than female dentists for:A) carpal tunnel C) allergic contact dermatitisB) latex allergy D) lower back injury

1. The most common type of musculoskeletal disorder in dentistry is:A) carpal tunnel C) DeQuervain’s Disease B) tendinitis D) hand/arm vibration syndrome

2. Overall, male dentists may be at greater risk than female dentists for:A) carpal tunnel C) allergic contact dermatitisB) latex allergy D) lower back injury© 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written

permission.permission.