Today Cayman Net News starts a ten part series on Carpal Tunnel Syndrome written by Barbara Currie Dailey. This educational series will run daily for the next two weeks. This series helps to dispel some of the myths related to this condition and includes an interview with a leading Carpal Tunnel Syndrome specialist, Dr Alejandro Badia MD, FACS, who is based in Miami Florida. It is hoped that this series will be a benefit to the population of the Cayman Islands.
As a writer nothing makes me happier than the act of writing itself. Next comes reader feedback letting me know you enjoy my books or weekly Flavours of Cayman cooking columns or have an old family recipe to share.
On the other hand, nothing worries an aging self-employed scribe more than being sidelined or worse, disabled, by a nagging medical problem time or an Advil can’t fix. Pain we can’t explain frightens us, especially when we’re past 55. Time is slipping away too fast with so much left to do we tend to deny symptoms and hope they go away. That’s what I did when I began to lose the use of my right hand early this year.
Ignorance, in more ways than one, is why carpal tunnel syndrome crept up on me. Like many people today, I had the wrong idea of what causes this condition and who its victims were. If the myth that it’s caused by typing and other repetitive activities were true, swiping credit cards would have disabled Cayman’s population years ago.
Carpal tunnel syndrome develops gradually over time, making it easy for busy older people like me to dismiss its worsening symptoms as part of aging. By the time I decided to get help, “shaking my sleeping right hand awake” throughout the day had become a reflex reaction to frequent numbness and burning sensations. What I excused as a “sprained finger” had become so swollen and painful I couldn’t hold a pen without pain radiating throughout my hand.
Not only did I have carpal tunnel syndrome; I had also developed an extremely painful condition called trigger finger—a problem whose symptoms have the same underlying cause. By that time surgery was my only treatment option.
Few people knew, or believe me now just weeks later, because my recovery time was so short and the surgical scars barely noticeable.
Surprised? I certainly was. As readers know, I haven’t missed a column deadline this year. Considering that each week’s column is made fresh and requires not only hours of typing (some call it writing), but also recipe testing and my amusing food photography of edible props—that’s a startling testimonial to my treatment. I confess to needing a kitchen helper the first few weeks after surgery, when it was too soon for lifting cast iron skillets, grating coconut or cutting a breadfruit. My husband Jim is a very handy guy.
I decided to share my story because I believe readers will benefit from what I learned “better late than never” about this widely misunderstood condition. Knowing the truth about carpal tunnel syndrome can prevent it from becoming the painful truth if you act soon enough.
And there’s another reason: I’m angry. First, with myself, a writer whose intuition and investigative instincts are usually acute, for failing to fact-check my “information” on this subject and accepting carpal tunnel mythology as pathology. But I’m even angrier with those who profit from perpetrating those myths about carpal tunnel syndrome, taking advantage of a gullible public by peddling useless “cures” or medically worthless advice. These hucksters rob people of time, money and potentially, their health by steering them away from seeking an accurate diagnosis and medically sound treatment.
Have I struck a nerve? If so, I hope you’ll keep reading. (A separate series, “Dr Badia Explains the Truth About Carpal Tunnel Syndrome, which will commence in Friday’s Weekender edition, is based on recent interviews with Dr. Alejandro Badia, my doctor and an internationally renowned orthopedic surgeon and hand specialist at the Miami Hand Center in Miami, FL. He presents the facts about carpal tunnel syndrome and treatment options available.)
Misconceptions and Stubbornness Delayed Treatment I never suspected carpal tunnel syndrome. That numbness and pain in my right hand and weakness around the base of the thumb was just arthritis or one of the surprises of getting older. At least that’s what I told myself.
What finally got my attention and penetrated my high pain threshold began as a betrayal by my right index finger, that critical and under-appreciated tool of both writer and cook. Between New Year’s and Easter this year it got “peculiar:” stiff and swollen, finally morphing into a painful parody of a sausage. It made simple things terribly painful and interfered with everything I need or like to do. Buttons became a nemesis and kitchen tools, my enemy. I adapted my work routine with fumbling two-fingered typing and scribbling big letters when I tried to write longhand. Eventually, my signature looked like a forgery. My bank’s fraud unit even called once to verify a check’s authenticity.
Stubbornly, I ignored it —until one morning, while in the kitchen trying to prepare the props for my weekly cooking column. I couldn’t open a can of coconut milk—using a manual can opener triggered what felt like an electric jolt. Pain shot from my swollen finger down the palm of my hand, through the wrist and all the way to my brain. Then I discovered I couldn’t bend my index finger enough to press my digital camera’s shutter or control buttons without excruciating pain. That was the last straw.
Later, trying to hide my growing panic, I called two friends in South Miami’s agricultural community for help. When it comes to choosing doctors, I rely heavily on “second opinions” from friends with positive first- hand experiences. I recalled hearing about family and employees who had suffered from accidents within the past few years, among them a serious hand injury from a machete.
I said I had a “bad finger,” probably a dislocated joint or sprained tendon. Both friends suggested I call the Miami Hand Center and Dr. Alejandro Badia, M.D, an orthopedic surgeon specializing in hand and upper extremity injuries. The office was close to Baptist Hospital in Kendall.
Like many otherwise intelligent people, I also consulted Dr. Google for advice, even though I recognized the internet as The Wild West of medical quackery, where it’s always open season on common sense. There, self- help treatments and New Age “cures” ambush educated people who should know better.
But I was too worried to take detours and my search was specific. Right away I found links to Dr. Badia’s interactive website, www.drbadia.com, and The Miami Hand Center, www.miamihand.com . Both offered detailed information about his credentials, qualifications and the facilities at Miami Hand Center, where Dr. Badia was listed one of four orthopedic surgeons and one plastic surgeon specializing in surgery of the hand and upper limb, including shoulder.
I was relieved to discover both sites were free from spin, like suspicious patient testimonials from “Mary S.” and “Bob M.” and pharmaceutical pop up ads. Google also turned up Dr. Badia’s Ask the Expert column in the online edition of the Miami Herald. He provided concise answers to questions about hand and upper extremity problems submitted via e-mail by readers—without any underlying sales pitch or claim that “only Dr. Badia can make you feel better.” All of this inspired confidence.
Further information revealed that Dr. Badia is an internationally respected authority on carpal tunnel syndrome who lectures frequently worldwide, including at prestigious medical institutions like the Mayo Clinic in Rochester, MN. That was interesting, but really didn’t concern me.
However, with such strong qualifications and my friends’ recommendations, I was certain Dr. Badia could fix my finger. I called the number on the website and because I was an overseas patient (and probably sounded panicky) the receptionist was understanding and let me jump the queue with an appointment for the following week.
An Education at the Miami Hand Center THE Miami Hand Center waiting room was crowded with patients representing a wide variety of ages, occupations— and orthopedic medical problems. Many had suffered injuries that appeared to be very serious. The waiting area (and as I later saw, examining room too) was also free from displays of glossy brochures touting the latest pain and arthritis drugs or orthopedic devices. That kind of blatant pharmaceutical advertising in a captive and vulnerable marketplace like a doctor’s waiting room offends me and makes me suspicious. Its absence was a detail I noticed immediately and impressed me. But something else made a powerful first impression. The efficient flow of patients in and out of both the examining rooms and busy nearby busy pain management and physiotherapy department was reassuring to watch. As patients exited, their faces almost universally reflected relief rather than anxiety—many were even smiling—regardless of casts, splints or bandages. I was almost embarrassed by my sausage finger, which suddenly seemed minor compared to the problems around me. There were so many human interest stories here. We were a small multiethnic community united by a common bond: a need for comfort and healing.
Afriendly older Hispanic lady sitting next to me had a large gauze bandage on her right hand. Because of her age, I assumed it was a wrist fracture. As we “chatted” using a combination of Spanglish and gestures, I learned she was 79 and it wasn’t a fracture. I was surprised when she used the English words “carpal tunnel.” I doubted this genteel septuagenarian had ever touched a computer and I must have looked surprised. But she said she’d had the surgery the week before and was there to have the dressing removed. It was her second surgery –her left hand was “fixed” several months earlier and she was very happy. Now soon she would to be able to cook and sew again, but more important than that: “not be afraid to hold her newborn grandson.” “Some said I was too old to do this, ” she said, “but my time left is too precious to waste. How could I live and not hold my only grandbaby?” she said. Her words touched and humbled me and made me ashamed of my skeptical reaction, which she must have noticed. That older woman’s confidence in her own treatment and her doctor helped reassure me I’d made the right choice in coming here. The Diagnosis: Carpal Tunnel Syndrome and Trigger Finger?
Once in the examining area, I was first asked to provide a detailed medical history, but contrary to what I expected, no MRI or CAT scan was required. Instead, I had X-rays of my right hand, followed by a nerve conduction study, during which electrodes attached to my fingers and wrist measured the nerve response in my hand. Once these were completed, Dr. Badia came in for the physical exam and consultation. His friendly, direct approach and optimistic attitude immediately put me at ease. He examined both hands and asked me to perform a several wrist maneuvers, including one called a Phalens test. In this, the patient holds the wrists fully flexed for a minute—that one made my right hand go numb and I had to shake it awake after. Dr. Badia assured me the X-rays had ruled out a fracture, tumor or dislocation, which was good news. It wasn’t a sprained finger, or residual trauma from a serious car accident in March 2006—another little fiction I indulged in. So what was wrong? “Your index finger problem is a condition called stenosing tenosynovitis or “trigger finger.” The medical explanation is that it is essentially a tendonitis of the flexor tendon. Sometimes the membrane surrounding the tendon becomes so thickened it gets stuck within its tunnel and catches, or “triggers, causing the painful condition you’ve obviously had for awhile,” Dr. Badia explained.
“Have you been experiencing any numbness and tingling or pain in your right hand, especially at night or in the morning?” Dr. Badia asked, puzzled as he studied my nerve conduction study test results. I hadn’t mentioned anything about that on my medical history questionnaire. I must have looked like the classic middle-aged woman suffering from White Coat Syndrome that causes instant symptom amnesia and makes you suddenly feel “fine.” ” No, not really, I replied, oblivious to the obvious as I sat on the examining table still alternately shaking my right hand and massaging the lower palm to wake it up—a frequent routine of mine throughout the day anyway.
Dr. Badia watched this and I saw his raised eyebrows above that surgeon’s skeptical and omniscient look irradiating patient denial. “That’s surprising because your nerve conduction studies indicate substantial compression of the median nerve in the wrist leading to your right hand. The very fact that you have this kind of tendonitis in your index finger indicates a high likelihood of having carpal tunnel syndrome. Those same tendons pass through the carpal tunnel, the area of the wrist where the median nerve is located, causing additional compression of the nerve due to limited space,” he said. My high school anatomy was a little rusty and Dr. Badia rewarded my blank look with more information. “The symptoms of trigger finger and carpal tunnel syndrome have the same underlying cause: a thickening or swelling if you prefer, of the membrane, or sheath, surrounding the tendon. Essentially, this is related to metabolic factors. It is NOT caused by repetitive activities like typing or computer use, as many people mistakenly believe. Because those swollen flexor tendons take up more space, this causes the median nerve to become compressed—in other words, a “pinched nerve” in the wrist. In turn, that causes the symptoms commonly associated with carpal tunnel syndrome: numbness, tingling and pain in the hand. Nerve conduction study is a sophisticated and highly accurate test for diagnosing carpal tunnel syndrome because it reveals any compression of that nerve. Your tests were definitely positive—they showed you have carpal tunnel syndrome in your right hand and it’s pretty far advanced,” Dr. Badia explained.
Carpal tunnel syndrome? How could that happen? At 55, I was too old for that disease. I considered it a Generation X disorder of “techhies” and compulsive video gamers who spent too much time on the computer or control panel. It was an excuse to take sick leave or attract sympathetic attention by wearing an uncomfortable looking splint. Although I do spend a lot of time on the computer, I have many other interests too, from cooking and gardening to photography and watersports. I have never touched a Nintendo or Playstation 2. And since I’m self-employed, I certainly don’t want time off from work.
There must be some mistake. Had Dr. Badia confused this condition with arthritis? My mother had frequent numbness and pain in her thumb muscle and fingers for years, beginning when she was in her 50’s. She blamed it on aging and arthritis and ran her hand under hot water in the morning and persevered. I learned to do the same, brushing off any suggestions of carpal tunnel syndrome. But arthritis, Dr. Badia explained, is a completely different painful medical problem, involving degeneration of the articular cartilage, not nerve compression. In reality, my poor mom probably suffered quietly from CTS for many years.
It was only then that I realized I’d been deluding myself, ignoring day and nighttime numbness and frequent hand pain for longer than I could remember. I attributed it “sleeping in a bad position”, “a pinched nerve from all those car accidents,” the humid tropics or not enough coffee. Whenever my hand went to sleep or became painful while driving or typing, I just shook it awake or did my little massage routine. This had been going on for years. There’s an old Caymanian saying that describes how I felt just then: Floor swallow me!” It means you feel so foolish you’d like to disappear. My hand woke up —and so did I. So exactly what is carpal tunnel syndrome— and how had I missed this creeping affliction in my own body? In part three of the series Barbara Dailey helps to demystify some come of the comman misconcetions about Carpal Tunnel Syndrome.
Demystifying Carpal Tunnel Syndrome Dr. Badia understood my reaction, which mirrored the widespread public confusion about carpal tunnel syndrome he encounters all the time. He patiently explained the facts. “Carpal tunnel syndrome (CTS) is a common but often misunderstood medical condition, even within the medical community itself. We understand what causes the symptoms, but researchers still don’t understand the pathology. That is, we don’t yet know what actually causes that thickening of the tenosynovium, or membrane surrounding the tendon, that creates pressure on the median nerve. That remains a medical mystery and medical researchers are working to discover the cause. “However, we do know it’s not caused by spending too much time on the computer or by so- called “repetitive stress injuries” which in fact, are usually a form of tendonitis,” he explained. “Certain repetitive activities that require exaggerated wrist positions for prolonged periods, like typing or playing a musical instrument— can aggravate symptoms after the onset of carpal tunnel syndrome—but they do not cause CTS.” “The wrist is the most complex joint in the human body. Carpal tunnel syndrome is a compression, not an infection or inflammation, of the median nerve located in the wrist, which controls sensation in the thumb and index through ring fingers. That nerve sits inside a complex “tunnel” made up of eight carpal (wrist) bones that form the floor and walls of the tunnel, and held together by strong ligaments. The roof of this tunnel is made up of the transverse carpal ligament,” Dr. Badia said, adding: “The nine tendons that bend or flex the fingers also run from the forearm through the carpal tunnel. When these tendons become inflamed, often for reasons unknown, the membrane or sheath surrounding them thickens, putting pressure on the median nerve. The nerve itself is not damaged, but when it is compressed, this causes the symptoms of carpal tunnel syndrome. These can include: numbness and tingling in the thumb and fingers; a burning sensation in the middle and index fingers; hand and wrist pain, sometimes resembling a sharp electric jolt. The symptoms are often worse at night and can interfere with sleep. If left untreated for a long time, they can get much worse, as I think you now know.” Carpal tunnel syndrome affects both men and women and occurs in a wide variety of occupations— from office workers to surgeons and musicians. It develops in socialites as well as housewives and professional women, However, CTS is most common in middle-aged women, especially perimenopausal and post menopausal. Women in their third trimester of pregnancy are also frequent victims, but the condition usually disappears within a month after childbirth. Medical studies suggest there is a complex connection between CTS and certain hormone levels whose fluctuations cause fluid retention. In fact, menopause is prime time for the condition worsening. CTS often develops in people with chronic metabolic conditions like diabetes, rheumatoid arthritis, thyroid disease or gout. Dr. Badia emphasized that CTS is not a circulatory system problem, often mistaken for one because of the numbness frequently associated with it. Dr. Badia stressed that CTS symptoms develop gradually. Trigger finger is linked to carpal tunnel syndrome as are other several related disorders—but can occur in patients without CTS and vice versa. Although carpal tunnel syndrome cannot yet be prevented, it can be treated effectively in its early stages. “The most effective treatment for mild symptoms is a night splint, which keeps the wrist in a neutral position during sleep. Most people bend their wrists when they dream and this puts pressure on the nerve, and a splint will help them sleep better. A small amount of medical data suggests high doses of Vitamin B6 may be helpful, acting as a physiological diuretic to decrease the swelling of the tendon sheaths. Acorticosteroid injection within the carpal tunnel can also be an effective treatment. For patients whose symptoms don’t respond to these conservative treatments and those with a significantly positive nerve conductive study (meaning tests show compression of the median nerve) a minor surgical procedure is necessary to relieve symptoms,” Dr. Badia explained. I was in for another surprise: I was one of those people who needed that surgical procedure. I Needed a Surgical Procedure: An Unexpected Diagnosis “I can make your finger better,” he said, taking my hand and pointing to the base of the finger (right along my life line.) “I simply make a small incision there in the palm at the base of finger ……” was all I heard before my brain fogged. When I came back from outer space a few seconds later, Dr. Badia was saying.… “I would also take care of the carpal tunnel problem at the same time with a second procedure called endoscopic carpal tunnel release. Both are painless outpatient procedures and done under local anesthesia—and take less than 30 minutes. You will need someone to drive you home after.” Temporarily stunned by this unexpected diagnosis, I had to ask Dr. Badia to repeat everything. “If you had come in for an evaluation much sooner, conservative treatment might have helped, including a corticosteroid injection within the carpal tunnel. But I’m afraid it’s a little late because your nerve conduction studies were so positive. Right now, that trigger finger won’t go away on its own,” he advised. That double whammy coupled with my own ignorance of this subject left me numb. I had heard disturbing stories about “dangerous and debilitating complications” from carpal tunnel surgery, second hand tales relayed by people who “knew someone with permanent wrist nerve damage” and other hearsay horrors. What’s worse, I’d let myself be influenced by a friend several years younger than I (and I now realize, an unhappy lady of leisure) who had carpal tunnel surgery several years ago and turned it into a new hobby. She complained for months about pain and discomfort, wearing a bulky black brace like an orthopedic Purple Heart. Her chronic whining made me deaf to this subject and any anything involving my wrist and small knives. What really worried me was that my wrist is so small. My hyperactive writer’s imagination came up with a sleepless 3 a.m. script filled with gory special effects on the operating table. They would sever an artery and I would bleed to death. The scalpel would slip and slice off my hand completely. I’d miss the deadline for my next column! Dr. Badia calmed my anxiety by explaining the two surgical procedures. The trigger finger release required only a small incision in the palm at the base of the index finger. “The other, called endoscopic carpal tunnel release, uses highly sophisticated fiber-optic technology and also requires only tiny incision, in the wrist. Both procedures are painless and the scars will be almost invisible within weeks. I treat hundreds of cases of CTS every year and have successfully performed more than 3000 carpal tunnel releases, just like the one I recommend for you, with NO complications.” Dr. Badia explained and then shared two incredible stories. “Last month I performed carpal tunnel release on a 101 year old woman. I had performed that procedure on her other hand when she was 98 and she was so relieved that she finally returned to have the other side done. Then her 80 year old daughter decided on surgery too. “I also did bilateral carpal tunnel release on a pioneering heart surgeon from Florida’s Gulf Coast. I operated on both hand simultaneously and he was able to perform valve replacement surgery only 8 days later. That story is posted on my website. We have many busy patients from out of town who will travel a good distance for this sophisticated endoscopic procedure that requires only minimal recovery time. “Most patients experience immediate relief from the symptoms of numbness, tingling and pain. The finger will take longer to heal, probably a few months, but you’ll feel relief from the worst symptoms quickly. Of course, a lot depends on your attitude. I can arrange to schedule the procedure next week. Perhaps even tomorrow if you are going to be in town for a short period. I see many out of town and overseas patients like you, who come in for 3 or 4 days to have this particularly easy surgical procedure,” Dr. Badia said. By now I had enough confidence in this doctor to feel I didn’t need a second opinion. I made an appointment for surgery the following week. During the next few days, I refused to listen to Second Opinions from individuals convinced I’d made the wrong decision. Some “helpful” people sent me “CTS shock sheets,” web page printouts warning of “the risks of dangerous and unnecessary carpal tunnel surgery.” They suggested alternative therapies ranging from chiropractic adjustments to electromagnetic gloves and other devices resembling instruments of medieval torture. I saved them all to laugh at later. Dr. Badia had already helped me overcome any fears and cured my ignorant misconceptions. In part four of the series Barbara Dailey talks about the surgical procedure and the road to a quick and speedy recovery. Page 8 CAYMAN NET NEWS • Issue 1438 Wednesday, 25 July 2007 Today Cayman Net News continues the ten part series on Carpal Tunnel Syndrome written by Barbara Currie Dailey. This educational series will run daily until Friday 3 August. This series helps to dispel some of the myths related to this condition and includes an interview with a leading Carpal Tunnel Syndrome specialist, Dr Alejandro Badia MD, FACS, who is based in Miami Florida. It is hoped that this series will be a benefit to the population of the Cayman Islands In part three of the series Barbara Dailey helps to demystify some of the common misconceptions about Carpal Tunnel Syndrome. How I Finally Learned Fact from Fable Diagram of the wrist showing the location and structure of the carpal tunnel and median nerve. Diagram of the wrist showing the location and structure of the carpal tunnel and median nerve.
In and Out (Quickly)—of the Operating Room I have a phobia about anesthesia that’s been my boogeyman for over 25 years. Thanks to one cocky doctor and his cavalier attitude I’d been scared of “going under” most of my adult life. I dreaded the preop meeting with the Miami Hand Center staff anesthesiologist the night before surgery but was relieved to discover that Dr. Angel Saavedra deserved his first name. He explained exactly how the local anesthesia and mild sedative he would use would affect me and answered any questions. I left feeling comforted and safe. The caring attitude and actions of the Miami Hand Center medical staff in the pre-op waiting area the next morning further reassured me. Endoscopic carpal tunnel release and trigger finger release are outpatient procedures performed under local anesthesia (and a mild sedative to calm patient anxiety) in the Miami Hand Center’s ambulatory surgical facility. Both procedures took less than 30 minutes. I was discharged immediately after and walked out with only a “light dressing,” a bulky but lightweight gauze bandage, far more intimidating than the small incisions it protected. There was no wrist cast or splint required. My thumb and fingers were completely free and I could use them for light activities. My discharge instructions ordered me to keep the bandage dry and my hand elevated above the heart level as much as possible for two days and perform “grabbing fistfuls of air” (finger extension/fist- making exercises) at least five times each waking hour throughout the day until the dressing was removed five days later. This was to promote circulation and range of motion and speed healing. I had to avoid any lifting, pushing or grabbing however. Once the local anesthetic wore off several hours later, I was surprised by the amount of feeling I already had in my fingers. By the next morning, it was as if someone had flipped an “on” switch in my hand. I had declined a prescription for painkillers and needed only an Advil in the morning and night for the first few days. The promise of painless surgery proved true. A patient representative called the next morning to check on me and answer any questions. She told me that by the third day after surgery, I could drive (automatic, but not a stick shift) but only if I was very careful and comfortable doing so. I could also use the computer for short periods but again –only if I felt OK doing it. Other light activities were fine, but nothing that put pressure on the hand or wrist while the bandage was on. That was great news! I was uneasy with the idea of driving with a bandaged hand —but I did return to the keyboard and met that next article deadline. In the following days, I realized that numbness and tingling I had, but had ignored so long, was gone. It was a painful admission for an educated person: I didn’t realize how badly I hurt —until I didn’t hurt anymore. When the dressing was removed five days later, I had another surprise—the incision scars were as small as Dr. Badia described. Worrying what was beneath that huge gauze bandage had needlessly concerned me. More good news: the stitches on both incisions would dissolve on their own—I didn’t need to worry about having them removed. I was told to keep the incision areas dry after showering or swimming for the first week while they healed, but I could resume light activities— like lifting a coffee cup but not a gallon water jug. And I was advised to keep sessions on the keyboard brief and avoid anything else that would put pressure on the palm, index finger or wrist or keep the wrist flexed too long, for the first few weeks. That included activities like vacuuming, chopping vegetables, using a manual can opener or trying to open a jar for the first time. I could cope with those restrictions, and by the end of a month, I could do almost everything in my normal routine, but more slowly and deliberately. Most patients don’t need physiotherapy after carpal tunnel surgery. However, I wanted to better understand both conditions, as well as hand and wrist physiology. I also wanted to learn anything, such as recommended activity modification, that could speed healing. I opted for two, hour-long sessions with a hand therapist at Miami Hand Center. The information and treatments I received were invaluable and I would recommend it to anyone with this problem. Here I am back in action after an unbelievably short time. While recovery time from carpal tunnel release differs among patients and depends a great deal on attitude, mine was incredibly quick. In fact, in appearance it’s hard to believe I had surgical procedures at all: the incision scars looks like nothing more than mosquito bites. During the first few weeks, I learned to do quite a few things left-handed for the first time in my life, an interesting middle age accomplishment. But now I can once again use the computer, sign my name legibly, even slowly peel and slice mangos and breadfruit. I can’t do pushups yet, and it’s going to be a few months before I’m ready to use a machete or reel in a yellowfin tuna. But conch season is months away, so there’s no need to worry about pounding anything right now. My index finger is much better, although still a little painful and stiff in the morning but so are other parts of me. Dr. Badia assures me this is normal after such a short time and is pleased with my progress. Apparently mine was a pretty advanced case and may take several months to heal completely but I know those symptoms will completely resolve over time. On the bright side, that procedure already restored 90% of my index finger function, up from almost nothing. I could live happily ever after with that improvement. I’ve had to change the way I do certain things and have gotten better at paying attention to physical reminders to focus, slow down and not overdo it right now. I take frequent breaks from the keyboard to stretch and do exercises, and try to avoid gripping things so aggressively (like the steering wheel) or using too much force with a knife when cutting or chopping food. My palm is a still a little tender at times and I have occasional twinges in my wrist if I lift something too heavy. I treat these as cues to avoid activities and awkward positions that put too much strain or stress on those areas. But these are nothing compared to the twinges of chagrin I feel from being so stubborn about seeking help in the first place. Postscript: And the Moral of This Story Is….. Don’t procrastinate. If you have symptoms of carpal tunnel syndrome, see a medical doctor who is a hand specialist. In addition to the Miami Hand Center, there are hand specialists throughout the USA, UK and many other foreign countries who can provide an accurate diagnosis and treatment if necessary. And please don’t waste your time or money shopping online for advice; reading New Age selfhelp books or experimenting with medically unproven therapies. Unfortunately we live in a time when the media and drug manufacturers seem to be a conspiracy, ready to label every ache, aggravation or physical quirk of aging as a new syndrome or addiction, with a new pill to cure it. Every day brings a new drug we’re urged “to ask our doctor about,” if we survive listening to the list of possible side effects. No wonder we feel lost and suspicious –it’s hard to separate fact from fiction. Even people with solid common sense can be tempted to try “alternative” treatments if they fear carpal tunnel syndrome. Those “therapies” may keep us out of a medical doctor’s office but offer only temporary–and often expensive— relief. They can’t relieve compression of the median nerve and won’t prevent symptoms from becoming worse. But they can reduce the swelling in your wallet. For example, the cost of a thorough evaluation at Miami Hand Center by an experienced hand specialist, including exam, X-rays and nerve conduction studies, cost only slightly more than three, hourlong therapeutic Shiatsu and acupressure massages. While I enjoy massage and believe in its benefits, my sessions never provided more than brief relief from discomfort I later learned were worsening symptoms of long-ignored CTS. While carpal tunnel syndrome isn’t a life threatening condition—it can pose a very real threat to your quality of life if left untreated, by interfering with or even forcing you to give up favorite activities. Don’t let that happen. Treatments are at your fingertips and provide a reassuring “light at the end of the tunnel.” For the remainder of the series, attention is turned to an interview with Dr Alejandro Badia, where talks about carpal tunnel syndrome, its misconceptions and who is at risk among other topics.
Interview with Dr Alejandro Badia, MD, F.A.C.S. Dr. Alejandro Badia is one of four internationally renowned orthopedic surgeons and one plastic surgeon specializing in surgery of the hand and upper limb, including shoulder at the Miami Hand Center in Miami, FL. He is also currently Chief of Hand Surgery at Baptist Hospital in Miami. Founded in 1991, The Miami Hand Center facilities include a state of the art outpatient surgical facility specializing in minimally invasive endoscopic and arthroscopic procedures. Dr. Badia graduated from Cornell University in 1985 with a Bachelor of Science degree in Physiology. He received his Doctor of Medicine degree from New York University in 1989 where he subsequently completed his internship in general surgery and residency in orthopedic surgery. He completed a fellowship in hand and upper extremity disorders at Allegheny General Hospital in Pittsburg, PA. He was awarded a traveling fellowship in hand surgery in Europe through the AO Trauma Association. He frequently lectures at medical institutions and universities throughout the US and overseas, including the renowned Mayo Clinic in Rochester, MN. An internationally respected authority on carpal tunnel syndrome, Dr, Badia authored the chapter “Median Nerve Compression Secondary to Fractures of the Distal Radius (Wrist)” in the comprehensive textbook “Carpal Tunnel Syndrome” edited by Luchetti and Amadeo. He has written numerous scientific articles related to carpal tunnel syndrome, as well as arthritis of the thumb basal joint; wrist arthroscopy and management of sports injuries of the wrist, elbow and shoulder. Dr. Badia provided the following information during several interviews with local author and columnist Barbara Currie Dailey, a recent patient whose account of her diagnosis and treatment of carpal tunnel syndrome, and a related condition called trigger finger, appeared Monday to Thursday this week in Cayman Net News and can be accessed through the archive section of www.caymannetnews.com. BD: Can you provide a simple explanation of Carpal Tunnel Syndrome? DB: “The key to understanding Carpal Tunnel Syndrome is to think of it as a pinched nerve which occurs in the wrist and causes symptoms such as numbness or tingling in the fingers and pain and weakness in the hand. However, there are many other painful conditions of the hand and wrist. For that reason, it’s important for anyone with those symptoms to be evaluated by a hand specialist to determine a proper diagnosis. “The good news is that Carpal Tunnel Syndrome (CTS) is easily treated, especially when diagnosed in the early stages. BD: Why is there so much confusion about Carpal Tunnel Syndrome today? DB: “I hold the news media responsible for a lot of this. Ever since the term “carpal tunnel syndrome” was coined by Dr. George Phalen back in the 1950’s the public has been confused by inaccurate reports that led to speculation about its cause and treatment. “In spite of medical evidence to the contrary, the media have repeatedly branded this condition an occupational disease, or “repetitive stress injury,” because of workers linking pain and numbness in their hands to repetitive activities such as typing or assembly line work. It is NOT a “repetitive stress injury;” it is not an injury at all. And this condition is not “caused by using a computer.” “Carpal tunnel syndrome became the subject of frequently sensationalized “medical news” reports during the last decade, coinciding with the rapid growth of computer use in the workplace and at home. “Right away, people discovered ways to capitalize on and profit from the medically unproven “news” that carpal tunnel syndrome was a workrelated “injury” caused by too much typing, prolonged use of a computer, or duties causing “repetitive stress.” “Furthermore, that misleading publicity spawned a multi million dollar industry devoted to “alternative” treatment and cures” many of which are medically worthless in preventing a condition that has nothing to do with a particular activity or occupation. “Regardless of medically proven facts, including published research findings easily obtained by any reporter, the media continued to recycle the same misleading, if not completely false information about CTS. Media outlets can be notoriously onesided in covering the medical field, rushing to scoop a story before confirming the facts. And they are slow to admit, much less correct, their errors by presenting the truth. BD: I understand you recently spoke with a producer at CBS network’s 60 Minutes about this subject? DB: “Yes, I did because it’s time the media told the truth about carpal tunnel syndrome and corrected common public misconceptions they helped create. Since 60 Minutes is good at investigating controversial subjects—and CTS has been one for too many years— I hoped CBS could be part of the solution. By presenting the facts to millions of viewers the program could help debunk the prevailing myth that anyone who works on a computer or uses their hands for other work-related tasks that require repetitive movements is at risk of developing carpal tunnel syndrome. This is a complete fallacy. “Not only has this erroneous belief interfered in the workplace, it has also prevented many people who don’t fall into these categories from seeking proper diagnosis and treatment. “But there’s another important issue. It was my hope that 60 Minutes would expose the billion dollar cost to society that this pervasive misinformation about CTS has caused. While it is important that the public understand that this is an easily treatable condition and NOT caused by a particular job, it is even more important for our society to realize the economic impact such false information has created. “Blaming this condition on frequent computer use or repetitive workplace activities is a misconception that costs companies millions of dollars each year in lost productivity from employee sick leave and workman’s compensation claims for a falsely labeled “occupational disease” whose diagnosis and treatment are simple and effective today. Unless treatment requires a surgical procedure, there is really no reason for most people to miss work at all. And with today’s sophisticated surgical technology, the average office worker, for example, can return to work in a few days. “Furthermore, in America’s litigious society employers and computer manufacturers have also become easy targets for lawsuits based on the erroneous claim that carpal tunnel syndrome is a “repetitive stress injury.” As I said before, medical research has proven this to be completely false. “We’ve also seen the development of “ergonomic” design computer peripherals. This caused people to waste money replacing equipment, while manufacturers made hefty profits. While a wrist rest makes sense, most of those products are medically worthless in preventing CTS symptoms from becoming worse —contrary to their claims. You see how quickly we returned to the traditional design of keyboards, for example. “In addition, there is a tremendous amount of quackery prevalent today, especially on the internet. Google “carpal tunnel syndrome” and you turn up a disturbing array of “alternative therapies,” gadgets, creams and other medically unproven “cures” that are costly and worthless —and prey on people’s ignorance. I’ve seen patients in my office who were afraid of treatment because of information they’d read online. Consequently, they delayed proper medical evaluation until their condition was extremely painful or even debilitating. “In spite of all these points, especially the economic waste, they weren’t interested in the story and that baffles me. I really believe that if their staff followed up with even a little investigative research, they would quickly realize how important this issue is.” In part 6 of the series Dr Alejandro Badia examines what causes Carpal Tunnel Syndrome and looks at some of the symptoms.
The Truth about Carpal Tunnel Syndrome – An interview with DrAlejandro Badia continued. BD: What causes Carpal Tunnel Syndrome? DB: “We don’t really know yet. Carpal tunnel syndrome (CTS) is a common but frequently misunderstood medical condition whose cause remains puzzling even within the scientific community. We can easily diagnose CTS and effectively treat its symptoms, but we don’t understand the pathology, meaning we are not sure exactly what causes it or how to prevent it. We do know that there is a strong metabolic component and for this reason, we see CTS in certain defined patient populations. “However, we do know that frequent use of the computer and typing DO NOT cause CTS, nor is there any medical evidence that repetitive thumb and finger movements cause this disorder. That includes text messaging on cell phones; using video gaming control panels or wireless devices like Blackberrys. I never see CTS in young male gaming fanatics or computer “geeks”, or in teenage girls who spends hours every day text messaging friends. If these activities were even remotely connected to CTS, my examining room would be full of these patient groups! “However, after the onset of CTS symptoms, repetitive activities that flex the wrist can aggravate those symptoms. Common sense says that modifying your work routine and avoiding or resting from such activities will help relieve symptoms—so will paying attention to good posture at the desk and taking care of your overall health. BD: Please explain Carpal Tunnel Syndrome in detail. DB: “Carpal Tunnel Syndrome (CTS) is not a circulatory system disorder, another common misconception because of the numbness that is one of the common symptoms of associated with this disorder, especially at night. “Carpal tunnel syndrome simply means that there is a compression of the median nerve at the wrist, not in the spine, which controls sensation in the hand and fingers. This nerve sits inside an area in the wrist called the carpal tunnel whose floor and walls consist of bones known as carpal bones. The roof of this tunnel is called the transverse carpal ligament. “Along with the median nerve, there are nine tendons running from the forearm through the canal that control flexing of the fingers and thumb. When these tendons become inflamed, often for reasons unknown, the membrane or sheath surrounding them thickens, taking up more space, crowding and putting pressure on the median nerve. That compression of the media nerve disrupts sensation and produces the symptoms of CTS. It is NOT an infection or inflammation of the nerve—the nerve itself is not diseased or damaged. This is a “space problem,” not a primary nerve disorder. BD: What are those symptoms? DB: “The first symptoms commonly reported by CTS sufferers are numbness and tingling in the hand which often first appear at night or early morning. Further along, patients may also have pain or a burning sensation especially the middle and index fingers. Sometimes patients describe this as resembling a mild electric shock. The symptoms are often worse at night and can eventually interfere with sleep. Patients may awaken when the hand goes numb and often hang their arm over the side of the bed to try relieving the symptoms. “Others experience pain and weakness in the hand, particularly in the bulky (thenar) muscle of the thumb. Like any medical condition, if left untreated, symptoms can get much worse. If allowed to progress untreated for many years, CTS could lead to atrophy of the muscles in the base of the thumb and permanent disability. In many cases, CTS is associated with other painful conditions, such as trigger finger or wrist tendonitis (DeQuervain’s) since the symptoms have the same underlying cause. Osteoarthritis of the thumb (basal joint arthritis) is often seen as a related condition as well.
The Truth about Carpal Tunnel Syndrome – An interview with DrAlejandro Badia continued. BD: Who is at risk for developing CTS? DB: “That’s a very good question and the source of tremendous confusion. First of all, CTS affects only about 5 in every 100 people in the United States. It is important to distinguish between actual cases and those with symptoms that may not be caused by CTS. This requires proper medical evaluation by a trained physician, preferably a hand specialist. “I’ll repeat it because it’s very important: the common misconception is that anyone who uses their hands for repetitive tasks like typing or computer use is at risk of developing CTS. This is not true. “As I said earlier, my colleagues don’t really understand the cause and pathology of CTS. We have only identified what causes the symptoms. Researchers, including doctors at the Mayo Clinic in Rochester, MN, are working hard to solve this medical mystery. A great deal of research is aimed at understanding the cell changes in the tendon sheath (tenosynovium) and what factors affect them, causing the thickening that leads to nerve compression— -and thus, the symptoms of CTS. “However, we have identified chronic medical conditions that predispose people to CTS. They include diabetes, rheumatoid arthritis, and gout and thyroid disease. Medical studies also indicate a complex connection between CTS and levels of certain hormones whose fluctuations cause fluid retention in the wrist area, aggravating the condition. This theory is reinforced by the fact that CTS is most common in women over 40, especially those who are perimenopausal or post-menopausal. Furthermore, CTS frequently occurs in pregnant women during the third trimester, but almost always disappears within a month after childbirth. “However, in many patients, CTS is idiopathic, meaning without any identifiable cause. “CTS doesn’t discriminate with regard to gender, ethnic origin, social status or occupation. It affects both men and women, regardless of race, across a wide range of occupations and age groups. I have treated construction workers, surgeons and professional musicians, socialites and housewives, office workers and chefs. While extremely rare in children, CTS can affect any age group but is most common in middle-age women. BD: How is Carpal Tunnel Syndrome diagnosed? DB: “First of all, no MRI, CT scan or other neurological test is required to diagnose this condition— this is a common misconception. Nor is CTS related to the spine and diagnosis does not require spinal x-rays. Carpal tunnel syndrome, by definition, is a compressed, or “pinched,” nerve at the wrist, not in the neck. That is a different condition called cervical radiculopathy and affects the median nerve roots, not the median nerve in the carpal tunnel at the wrist. “When a new patient comes in for an evaluation, there are several steps, beginning with taking a detailed medical history, which I hope the patient answers in a thorough and complete manner, followed by a physical examination. That includes simple routine tests involving hand and flexed wrist positions such as the Phalens test, which reproduce CTS symptoms in affected patients. If I suspect underlying problems, we take X-rays to rule out any bone or joint abnormality. Certain wrist problems are related to CTS as well and recognized by a hand specialist. “A simple and painless test called a nerve conduction study is a very effective diagnostic tool for CTS and performed right in our office. We connect electrodes to a patient’s wrist and fingertips. This measures the velocity and the latency of the nerve impulse across the median nerve at the wrist. The results tell the physician very accurately if the patient has a compression of the median nerve at the wrist, and how badly the nerve is compressed. When we say the tests are “positive,” we mean they reveal substantial compression. “We always hope to catch CTS in its early stages, when symptoms are still mild and often respond to conservative treatment. I want to emphasize again that this condition develops gradually and can be easily treated if diagnosed in the early stages. “However, if left untreated for years, it can lead to a loss of hand strength and dexterity; nerve and muscle damage, even partial disability.
The Truth about Carpal Tunnel Syndrome – An interview with DrAlejandro Badia continued. BD: Please describe the treatment options for CTS: DB: “The treatment for Carpal Tunnel Syndrome in its early stages is often directed at decreasing the inflammation of the tendons. The most common treatment without the use of drugs or injections is a “cock up” night splint which keeps the wrist in a neutral position during sleep, to prevent the normal bent position which often occurs during dreaming which puts pressure on the nerve. This helps a CTS sufferer sleep better. Symptoms often worsen at night because the position of the hand is at the same level of the heart while lying down and fluid accumulates in the soft tissues within the canal. Patients do NOT wear a splint 24 hours a day —-this is another fallacy and can cause other physical problems. We DO encourage them to change their routine in the future and rest from repetitive activities. “Other options to treat mild symptoms include the use of non-steroid anti inflammatory drugs (NSAIDS) like Ibuprofen or Advil. “There is a small amount of medical data that suggests high doses of Vitamin B6 may be helpful, acting as a physiological diuretic to decrease the swelling of the tendon sheaths. This shouldn’t be confused with other diuretics, such as those taken by heart patients. “An injection of corticosteroids such as cortisone within the carpal tunnel itself can relieve pain quickly by reducing tendon swelling. This “frees up space” to allow more room for the median nerve in the carpal tunnel and frequently, that resolves the problem. However, this is a limited treatment option, and I recommend no more than two injections, about 6 months apart. “For patients whose symptoms don’t respond to these conservative treatments and those with a significantly positive nerve conductive study I recommend a minor surgical procedure called endoscopic carpal tunnel release to relieve the pressure on the nerve. This is a painless and very effective treatment. BD: Wrist surgery frightens many people because of rumors, especially on the internet, about dangerous complications and permanent nerve damage. Please explain what’s involved with the surgical procedure you perform on CTS patients. DB: “That’s another very important point and I’m happy for the opportunity to respond to such common and completely unfounded concerns. “Surgical treatment for CTS is often as misunderstood as CTS itself—by both the public and many physicians. Unfortunately, this has led to misconceptions about the outcome from these procedures, causing some people to fear nerve damage or even complete loss of function in their hand if they have surgery. These are unfounded rumors, I assure you, and unfortunately, the internet is full of them. I urge people not to trust CTS information posted on commercial websites. Most are trying to promote worthless products or treatments. They use scare tactics condemning proven medical procedures as their “marketing strategy.” “The truth is that today’s endoscopic surgery is extremely successful. Contrary to another misconception, it is also minimally invasive and painless thanks to sophisticated modern endoscopic technique. Recovery time is fast and healing rapid. “In fact, I prefer to use “minor surgical procedure” when I discuss carpal tunnel release, and “surgery” to discuss far more involved cases like joint replacements and limb reattachment. I want people to understand there are significant differences and here’s why. “The most recent breakthrough in surgical treatment of Carpal Tunnel Syndrome, and the one commonly used in our practice at the Miami Hand Center, is called endoscopic carpal tunnel release. This is an outpatient procedure is performed under local, not general, anesthesia in combination with a mild sedative to relax the patient. First, a tourniquet is placed on the upper arm to prevent bleeding and make it easy for the surgeon to obtain an unobstructed view of the carpal tunnel. “The technique involves making a tiny incision of less than one centimeter in the crease of the wrist (palmar crease) and inserting a tiny endoscopic camera. This endoscopic device is called the Agee and is connected to a monitor. This sophisticated and extremely precise technology allows the surgeon to actually see the inside of the hand and make a division of the transverse carpal ligament, releasing the pressure on the median nerve, without a large, open incision. The ligament heals during the next few months in a more elongated shape. We certainly don’t “cut the median nerve” as some rumors suggest. “This is not laser surgery, but fiber- optic technology that allows the surgeon to operate “from the inside out.” As a result, tender tissue is not damaged and there is minimal pain, if any, after surgery. The entire procedure lasts about 30 minutes and the patient walks out after. “The advantages of endoscopic release are minimal scarring and much faster recovery, allowing most patients to return to work and resume other normal activities on a limited basis quickly. That depends, of course, on what the patient’s job and other daily activities involve. “I’d like to add that there is no age limit for endoscopic surgical treatment of CTS. Successful procedures have been performed on many people in their 80s and older. My recent patients included a 101- year old woman from Miami, whose positive results encouraged her 80 year old daughter to seek relief and have carpal tunnel surgery as well. “Most patients do not need physiotherapy after carpal tunnel release, but it is available at the Miami Hand Center for anyone who wants to take advantage of the knowledge and care our staff of hand therapists offers. It can help reassure patients their recovery is progressing and answer any questions or concerns
The Truth about Carpal Tunnel Syndrome – An interview with DrAlejandro Badia continued. BD: What is the recovery time from endoscopic carpal tunnel release and what can patients expect immediately after the procedure? DB: “I like to be conservative and so my answer is an average of about four weeks. Depending on their job and personal life, it takes most people about that long to resume their normal routine. However, many decide to return to work within only a few days, before the dressing is removed. This depends on the demands of their job and requires caution and moderation along with changes in behavior—like taking frequent breaks from repetitive activities, and avoiding aggressive gripping or lifting heavy objects. Let me give a brief “average” post-op timeline. “At the conclusion of the surgical procedure, the incisions and entire hand are protected by what we call a “light dressing,” meaning a bulky, padded but lightweight gauze bandage that protects the surgical wound but leaves the fingers and thumb free. It is not a cast or splint. The patient is discharged, in fact walks out, immediately following the procedure. We require patients to have someone drive them home since they are still feeling the effects of the sedative and local anesthetic. “They receive an instruction sheet advising them to keep the bandage dry until removed 4-5 days later, and the hand elevated above heart level as much as possible for the first two days and not to sleep on their side or arm if this is their normal sleeping position. In addition, they’re given a simple but important exercise: extend their fingers, then try to make a fist five times every hour when awake. They should also avoid any lifting, gripping or pushing that could stress the wrist—in other words, rest and “baby” your hand immediately following surgery and the first few days after. “The day after the procedure, a patient care representative from our office calls to talk with the patient, answer questions and make sure there are no concerns or complications—and that the patient read and is following the post op instructions. “In addition, patients from or staying in the Miami area are discharged with a confirmed post op appointment, usually 5 days later. That’s when we remove the dressing and the surgeon checks the incision and answers any remaining questions. The stitches will dissolve on their own in the next 7 – 10 days after that. “Many patients come from out of town, including traveling from overseas, specifically for this simple procedure and schedule the follow up appointment to remove the dressing with their doctor back home. I can easily communicate with them via phone or email and explain what to expect and address any concerns. I can also communicate with a hand therapist in their area and answer any questions through them if physical therapy is recommended or desired. “Some patients decide to return to work before the dressing is removed. Since the fingers and thumb are free, many are able to resume light office work but are cautioned to keep typing or sessions on the keyboard brief and avoid anything else that would put pressure on the palm, index finger or wrist or keep the wrist flexed too long immediately after the procedure and for the first few weeks. They must also avoid any lifting, pushing or gripping. “By the third or fourth day after the procedure, many patients can drive (an automatic shift, not a standard or stick shift) if they are extra careful, with the warning to avoid gripping the steering wheel too firmly. Driving should only be attempted only if the patient feels relaxed and comfortable doing so while still wearing the bandage. “After the dressing is removed and once the hand examined by the surgeon and found to be healing normally, the patient can shower and swim, but advised to keep the incision scar dry in between those activities for about a week longer. They can resume light activities, like limited housework and office work, including light typing and writing longhand. However, any activity using the hand, especially ones that put pressure on or require flexing the wrist repeatedly or for long periods should be avoided. Patients should guided by comfort and common sense. “I also firmly believe that a patient’s attitude affects his recovery. “I performed bilateral carpal tunnel surgery (both hands simultaneously) on a pioneering Florida Gulf coast heart surgeon some years ago—-and he returned to the operating room eight days later. That was an exceptional case, but it proves the power of motivation. I have also had patients who went horseback riding, skeet shooting and did other strenuous activities within a week after surgery, but I don’t recommend this. “Give yourself time to heal.