Rose Mary has been an occupational therapist since 1987. She has extensive experience treating conditions of the hands and arms.
Carpal Tunnel Syndrome (CTS)
Carpal Tunnel Syndrome (CTS) is a common occurrence during pregnancy, resulting in numbness and tingling in the fingers and sometimes causing pain in the wrist. In my experience as an occupational therapist, carpal tunnel syndrome associated with pregnancy is somewhat different than CTS when not associated with pregnancy. The presentation is slightly different; therefore, strategies are slightly different. The good news is that CTS of pregnancy can be treated relatively easily, and I will share my tips with you here.
What Is Carpal Tunnel, Anyway?
Carpal tunnel syndrome (CTS) usually results in numbness or tingling in the thumb, index finger, middle finger, and thumb-side half of the ring finger. CTS sometimes progresses and causes pain to the wrist radiating into the hand. Symptoms frequently wake clients at night, and occur while driving and doing desk work. Symptoms may also be associated with gripping and prolonged activities.
Intermittent sharp pain at the base of the thumb is a different problem, DeQuervain’s tenosynovitis, and is also common during pregnancy.
What Causes These Symptoms?
The muscles that bend and straighten the fingers are located in the forearm. If you turn your arm so that your palm is facing up, you will be looking at the flexor surface of the arm. The muscles in the forearm are the finger and wrist benders. The muscle bellies taper down to cords. The tendon cords for the finger and thumb benders cross the wrist and travel across the palm to the fingers and thumb.
There is a wide strap called the flexor retinaculum or transverse carpal ligament, located at the base of the hand. This ligament holds the flexor tendons flush against the wrist bones, so that they don’t bowstring when the muscles contract. The transverse carpal ligament forms the roof of the carpal tunnel, and the wrist bones form the floor. Through the tunnel pass 9 muscle tendons and their protective sheaths, and the median nerve.
The bones and ligament forming the boundaries of the carpal tunnel do not have any “give”. If the tendon sheaths become inflamed and swollen, or if the wrist becomes swollen in general, the tunnel may become tighter and the median nerve gets squeezed. Pressure on median nerve causes the symptoms of carpal tunnel.
But What Causes the Inflammation?
The popular thinking is that repetitive motions, such as factory work, scanning purchases, and typing cause inflammation and swelling of the tendon sheaths. This is completely over-rated. This mythological thinking is propagated despite plenty of reputable studies to the contrary.
There is a higher prevalence of carpal tunnel in conditions like diabetes, rheumatoid arthritis, thyroid disease, and pregnancy, than in the “normal” population. This is highly suggestive of a systemic process, possibly hormone driven, versus the common assumption of a biomechanical cause. Further complicating the picture is gross over-diagnosis, declaring almost any symptoms of the arms and hands to be carpal tunnel syndrome.
It's Not Always Carpal Tunnel!
As an Occupational Therapist for almost 25 years, I’ve had plenty of clients, pregnant and otherwise to be referred to me for carpal tunnel syndrome. Yet rarely do I agree that the client is actually suffering from carpal tunnel. Symptoms are often more consistent with vascular origin, rather than nerve.
In my professional opinion, “carpal tunnel” of pregnancy has a huge vascular component. As pregnancies progress, many women retain increasingly more fluid throughout the body including the wrists, resulting in pressure on the median nerves. Hormones likely play a role as well.
Another contributor to the “carpal tunnel” picture is compression of the nerve-vascular bundle in the upper chest. This is an important component in most clients, including pregnant women. A primary cause of the compression is posture and position, such as overhead position of the arms, or forward posture.
Examples of overhead posture compressing the neurovascular bundle is changing a light bulb and washing or styling the hair. When performing these tasks, the arms often feel heavy or tired, which are vascular symptoms. Sleeping with your arm over your head will also compress the nerve trunk and major blood vessels of the arms. Compression of the neurovascular bundle may cause not only a heavy sensation in the arms, but could cause any number of patterns of pain, numbness, or tingling in the arms or hands.
A video from my conference presentation for Texas Occupational Therapy Mountain Central Conference 2010
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Strategies for Relief
Monitor Your Posture
One of the simplest and most effective strategies for anyone, including pregnant women, for the relief of presumed carpal tunnel, is to improve your posture. The more forward your shoulders are, the more your chest muscles are in a shortened position. The muscles will then shorten and become tight with your arms in various positions. The tight muscles compress the large nerves and blood vessels in the upper chest region. This compression causes various arm and hand symptoms.
Try to line up your shoulders with your ear holes. Do this in as many activities throughout the day as possible. It’s a process. It doesn’t happen overnight. Line up your shoulders with your ear holes while working at a desk. Your elbows should be down by your sides. As you extend your elbows out from your body, your shoulders will follow, putting your chest muscles in a shortened position.
Line up your shoulders with your ear holes when walking, when sitting in a meeting when watching television, when reading a book, when cooking dinner, etc., etc., etc. You get the picture.
Sleep position is another crucial factor in pain, numbness, and tingling of the arms and hands. Most of us call ourselves side sleepers, when in fact we are right and left anterior oblique sleepers. This position is more akin to sleeping on your stomach than side sleeping, and compresses the neurovascular bundle in the upper chest too. We can then have pain consistent with any of the nerve distributions, including the median nerve. We can also have vascular symptoms, such as numbness in the hand, or hand and arm. Numbness in the fingers from vascular compression usually resolves quickly after repositioning the arm, whereas numbness from nerve compression tends to take a little longer. Clients often describe shaking or rubbing the hand to restore sensation.
Sleep flat on your back or stacked on your side. If you are stacked, your shoulders will not be forward, and an imaginary rod passing through both shoulders would be perpendicular to the floor.
Additionally, we also tend to sleep with our hands up by our faces. If you sleep with your wrist bent, or with your head on your hand, this causes compression not only in the upper chest, but at the bent elbow, and at the wrist. Wrist braces can help keep the wrist neutral. Reversed elbow pads or a sock with a soft ball (or another rolled up sock) at the elbow can prevent bending your arm enough to get your hand to your face.
Wrist braces are a staple in the relief of carpal tunnel symptoms and are very effective. While Occupational Therapy clinics can make custom fitted splints, there are plenty of good over-the-counter (OTC) or off-the-shelf wrist braces. Unfortunately, there’s also a lot of pure junk out there.
The purpose of the wrist brace is to minimize or eliminate wrist movement, so that inflammation will subside. While complete cast-like immobilization is not necessarily what we’re trying to accomplish, the brace should significantly limit, and nearly immobilize wrist movement. If the wrist brace allows you to do everything you did before, why would anything (like your symptoms) change?!
Selecting a Good Wrist Brace
A good wrist brace will have a flat metal stay on the palmer side of the arm. The brace should be made of heavy canvas material, two pieces of heavy fabric with padding between, or some other type of material of substantial thickness and weight. The brace should be well fitted to the wrist and base of the hand, supporting the wrist in a functional position of slight extension. Many sources specify that the wrist should be neutral, but I compromise for compliance. We need slight extension, because that is the natural position for writing, gripping your clothing, holding a fork, etc.
Another feature of a good wrist brace is that it should be 2/3 to 3/4 the length of the forearm. This is basic biomechanics. Splints that are ridiculously short cannot provide an adequate base of support to stabilize the wrist.
Brace Wear Schedule
How often should you wear the wrist braces? That depends on the frequency, duration, and intensity of your symptoms. Definitely sleep in the braces, not only because most clients have symptoms while sleeping, but also to give your wrists a rest. Most clients report that it only takes a few nights to get used to the splints, so why not give your wrists a total rest when you don’t need to use your hands.
If you work at a desk job, and you always have symptoms doing desk work, then wear your braces when working at your desk. Don’t make excuses- it is absolutely possible to wear wrist splints and type, mouse, and do other office tasks. If your symptoms are constant, then you should wear the braces constantly, at least starting out, until your symptoms start to subside.
Pregnant women love compression gloves! I discovered this about 10 years ago. I had evaluated a young pregnant airman. Later she was in my clinic checking supplies. I noticed she was wearing her off-the-shelf wrist braces that I had dispensed. What I really noticed was that she was wearing the braces laced far too tightly. I said to her, “Wow, you’ve got your splint straps pulled really tight.” She told me the pressure felt so good, and that she wished the braces were long enough to squeeze her fingers too.
Well, I had an epiphany of sorts. My Occupational Therapy clinic stocked compression gloves. I commonly recommended them for arthritis clients, and for clients with various injuries causing swelling. So I dispensed gloves to my pregnant client. I saw her a few times after that as she made her supply rounds. She loved the gloves and said “I live in them”. Indeed, they looked well worn. She wore them under her wrist braces, which were then laced more appropriately.
After this client, I always dispensed compression gloves to my pregnant clients referred for carpal tunnel. Many said they only needed to wear the wrist braces for a week or two, and thereafter managed their symptoms with just the gloves (and other strategies like contrast baths and posture changes).
Contrast baths are a mainstay of Occupational Therapy clinics because they are excellent for drawing out swelling, and they relieve achy arthritis pain. They are also highly recommended by many expert sources to relieve carpal tunnel symptoms. Contrast baths are very easy to do.
You want to have two sinks, or two dishpans. Fill one with warm water, like deliciously warm bath water. Fill the other with cold, but not frigid water. Soak your hands in the warm water for three minutes, then alternate to the cold water for one minute. Start with the warm water, do three cycles of warm and cold, then end with three minutes in the warm water.
The warm water dilates or opens up the blood vessels. The cold water constricts or shrinks the blood vessels. Using only warm water would increase swelling. Alternating the warm and cold water causes alternating dilation and constriction of the blood vessels, which acts like a pump to pull out swelling.
Some sources recommend one-minute cycles of warm and cold water, so the time is not critical, but the alternating warm and cold is. I recommend doing contrast baths three to five times a day, including “cheaters for real life”.
If you are out and about, and need some quick relief, all you need to do is find a ladies’ room with hot and cold running water. If you have access to two adjacent sinks, let the cold water run in one sink, and have warm running water in the second sink. Alternate placing your hands under the warm and cold water for 30 to 60 second cycles, for a total of three to five minutes.
Some clients modify their morning bathroom routine (washing their face, putting on makeup, doing their hair), and put their hands under alternating warm and cold water. Many clients modify kitchen clean-up to get in a few minutes of “running water” contrast baths. If contrast baths are not convenient, you can use an ice pack to your wrists and hands.
Surprising Findings by Researchers
Some of most common occupational categories for CTS: homemaker, unemployed, retired (Derebery, 1998).
CTS is associated with systemic diseases such as RA, collagen-vascular disorders, DM, thyroid disease, renal disease, pregnancy, obesity, alcoholism (Derebery, 1998).
- Derebery, V. J., (1998). Etiologies and prevalence of occupational upper extremity injuries. In M. L. Kasdan (Ed.), Occupational hand and upper extremity injury and diseases (pp. 49-58). Philadelphia: Hanley and Belfus.
Nathan & Keniston (1998) found a greater correlation for CTS with obesity, advanced age, small wrist dimensions and lack of exercise than with occupational factors
- Nathan , P. A., & Keniston, R. C. (1998). Carpal tunnel syndrome: Personal risk profile and role of intrinsic and behavioral factors. In M. L. Kasdan (Ed.), Occupational hand and upper extremity injury and diseases (pp. 129-140). Philadelphia: Hanley and Belfus.
Talk to Your Health Care Provider
This article is not intended to be a substitute for professional medical advice, diagnosis or treatment. Consult your doctor, PA, or nurse practitioner. Among other things, your health care provider can rule out medical conditions, including heart attack and stroke. Consider asking for an occupational therapy consult.
This content is accurate and true to the best of the author’s knowledge and does not substitute for diagnosis, prognosis, treatment, prescription, and/or dietary advice from a licensed health professional. Drugs, supplements, and natural remedies may have dangerous side effects. If pregnant or nursing, consult with a qualified provider on an individual basis. Seek immediate help if you are experiencing a medical emergency.
© 2018 rmcrayne
Rajesh Naik from Mangaluru on June 09, 2020:
Nice article with lot of information.
Thank you so much.