Diagnosis, Treatment & Management of Carpal Tunnel Syndrome

1. Loma Linda University Diagnosis, Treatment & Management of Carpal Tunnel Syndrome Curt Hamann, M.D. February 2009 © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

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

3. SURVEY 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 permission.

4. Course Objectives: Musculoskeletal Disorders • Characterize upper extremity musculoskeletal disorders (MSDs) in dental workers • Discuss effective ways to reduce symptoms and risk of MSDs development © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

5. Occupational Injuries and Illnesses, NIOSH 2004 © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

6. Dental Professionals Often Report Musculoskeletal Symptoms • 46% -71% of dental students reported body pain: males in the mid-lower back; females in neck and shoulderRising et al., JADA2005 • 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 CTSLalumandier & McPhee J Dent Hyg 2001 © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

7. What are Musculoskeletal Disorders (MSDs) ? • MSDs are also referred to as:repetitive motion injury, repetitive strain injury, cumulative trauma disorder, over exertion injury • MSDs affect: muscles, tendons, nerves, joints, spinal discs, ligaments, cartilage • MSDs develop over time; not a single event • Symptoms range widely: mild and periodic to severe and chronic © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

8. Common Symptoms of MSDs • Pain • Tenderness • Numbness • Blanching • Tingling • Burning • Swelling • Cramping • Stiffness • Limited motion • Loss of function or strength • Sensory loss • Fatigue • Spasms • Muscle atrophy From Gray’s Anatomy © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

9. = Risk for Carpal Tunnel Syndrome Health Risk Factors for MSDs • Gout • Alcoholism • Trauma • Obesity • Tremors • Tumors or cysts • Hyperthyroidism • Hypothyroidism • Psychosocial factors • Smoking • Low physical fitness • Increasing Age • Gender (Female) • Fibromyalgia • Diabetes • Autoimmune disorders • Kidney disease • Back problems • Arthritis • Menopause or pregnancy • Hormone replacement • Cervical radiculopathy © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

10. 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 © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

11. 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 permission.

12. 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. © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

13. Vibration from Equipment is a Work Related Risk Factor for MSDs © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

14. Hgo Exposure (Amalgam) A Potential Risk Factor in Dentistry? 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 © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

15. Activity Related Risk Factors for MSDs • Racquet sports • Playing musical instruments • Weight-lifting • Gardening • Needle work • Computer • Carpentry • Arts/crafts • Biking • Bowling • Exercise • Golf • Video games © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

16. Diagnosis of MSDs Can Require: • Symptom History • Physical Examination • Palpatory Assessment • X-Ray • MRI • Electromyography • Ultrasound • Nerve Conduction (electrodiagnostic test for CTS) © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

17. Musculoskeletal Disorders (MSDs) of the Upper Extremities • Neck and Shoulder • Rotator Cuff Tear or Tendinitis • Cervical Spondylosis • Myofascial Pain Syndromes (Tension Neck, Myalgias) • Thoracic Outlet Syndrome • Arm & Elbow • Epicondylitis (tennis or golf elbow) • Cubital tunnel syndrome • Radial tunnel syndrome From Gray’s Anatomy © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

18. Musculoskeletal Disorders (MSDs) of 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 Carpal tunnel © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

19. What is Carpal Tunnel Syndrome (CTS)? Muscle Atropy COMPRESSION Median Nerve Carpal Tunnel Thenar Muscles Pain, Tingling, Numbness © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

20. The occurrence of CTS in dental workers is similar to the general population (which ranges from 2.1%-2.9%) * Diagnosis requires impaired median nerve function and pain, numbness or tingling in the area affected by the median nerve © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

21. But the prevalence of upper extremity tendinitis in dental hygienists may be higher, giving rise to significant pain *Latko et al (1999) for industrial workers © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

22. Possible MSDs Treatments • Physical therapy • Rest, massage • Exercises • Muscle electrostimulation • Splints/braces • Vitamins • Steroids • Botulinum toxin • Surgery © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

23. Challenges Remain in Evaluating MSDs in Dentistry • 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 ofmany 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) © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

24. MSDs in Dentistry: Posture & Motion • 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 positionsA.N. Guignon, RDH 2004 © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

25. MSDs in Dentistry: Posture & Motion • Shift your weight • Use erect postures • Stay flexible • Keep arms & shoulders low • Vary intensity & direction of movement © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

26. MSDs in Dentistry: Posture & Motion • Adjust the job to you: • Vary hand, wrist and finger positions • Avoid excessive pressure and extreme angles © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

27. Managing MSDs in Dentistry: Equipment Remember - adjust the job to you: • Manual and automated equipment should be properly: - proportioned and weighted for you - cushioned and textured (grip) - sharpened - insulated from vibration • Clothing, shoes, and personal protective equipment should be non-restrictive © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

28. Handpiece Considerations for Optimal Ergonomics Optimal Air Pressure 1. Electric 2. Fiberoptic Light Source 3. Appropriate cord length 4. Contra angle 5. Lightweight www.ada.org © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

29. 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 © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

30. The effects of periodontal instrument handle design on hand muscle load and pinch force • 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 © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

31. Managing MSDs in Dentistry: Equipment 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 © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

32. MSDs in Dentistry: Equipment • Use magnification lenses or camerasto improve field visualization and postureBranson 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 © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

33. Managing MSDs in Dentistry: Exercise & Flexibility • Stretch body regularly, especially upper extremities • Take breaks during daily activities • Adjust work schedules and environments as needed • Encourage fitness and flexibility programs © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

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

35. Management of Occupational Allergies and MSDs in Dentistry • Be proactive; support staff concerns • Educatestaff about latex allergies and MSDs • Encourage prompt diagnosis and treatment • Be alert to potential symptoms and riskin staff and patients • Modify behaviors, work practices and product choices as needed NOW • Establish preventive programsNOW © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

36. 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. © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

37. 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. © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

38. 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 permission.

39. © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

40. Questions andAnswers STOP © 2003: SmartPractice- All rights reserved. No part of this program may be reproduced without written permission.

41. SURVEY 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 permission.