Alternative Ways to Treat Carpal Tunnel Syndrome
People with DM manifest carpal tunnel syndrome as well as Dupuytren syndrome more often (contracture of the palmar fascia, Figure 20.2). This contracture is indeed present in up to 63 percent of diabetics. The third and fourth fingers are involved more frequently (the small finger is not involved as in classic types of the disease). Furthermore, there are often sclerotic nodules on the heels and on the dorsal surfaces of the central interphalangeal joints (Garrod's nodules).
Examples are carpal tunnel syndrome, intercostal neuropathies, and lumbosacral plexopathies. These focal peripheral nerve lesions regenerate more slowly in diabetics than nondiabetics (124,125) and regeneration from them might be incapable of restoring function in many patients. If clinical therapy to arrest polyneuropathy is developed, attention will shift toward understanding how diabetic nerves with failed regeneration might be resurrected.
There have been no prospective, population-based studies of diabetic amyotrophy and mononeuropathies in subjects with diabetes. However, some prevalence figures for these types of neuropathy can be derived from a few cross-sectional studies. In a cross-sectional survey based in Rochester, Minnesota, asymptomatic carpal tunnel syndrome (CTS) was found in 22 of those with type 1 diabetes and 29 of those with type 2 diabetes, whereas the corresponding prevalence for symptomatic cases was 11 and 6 , respectively (40). Ulnar and femoral cutaneous entrapment was found in 2 of type 1 diabetes and 1 of type 2 diabetes subjects. Cranial mononeuropathy and trun-cal radiculopathy were not observed in the Rochester population, whereas proximal asymmetric polyneuropathy was identified in 1 of type 1 diabetes and type 2 diabetes subjects (40). No incidence data were available for any of these types of neuropathy.
Dupuytren's contracture (Figure 151) has a quoted prevalence varying between 20 and 63 in DM. Furthermore, in patients presenting with Dupuytren's contracture, a high prevalence of diabetes is found. It is more commonly found in elderly patients with a long duration of diabetes and may have an association with carpal tunnel syndrome.
L Carpal tunnel syndrome produces reduced sensation in the fingers and weakness touching the thumb to the fifth finger. The median nerve is trapped at the wrist. l Tarsal tunnel syndrome produces loss of sensation on both sides of the foot and wasting of the muscles of the foot resulting in decreased toe movement. It is like the carpal tunnel syndrome in the foot and results from trapping of the tibial nerve between two of the small foot bones.
Carpal tunnel syndrome, a type of focal neuropathy, occurs about three times more often in people with diabetes than in the general population and more often in women than in men. It occurs when the median nerve of the forearm is squeezed in its passageway, or tunnel, by the carpal bones of the wrists. It can cause tingling, burning, and numbness and can make you drop things you are holding without even realizing it. Suspect carpal tunnel syndrome if you have tingling in your hands or fingers that goes away when your arms are relaxed down at your sides. Carpal tunnel syndrome is often treated with splints, medication, or surgery to remove the pressure on the nerve.
Although discussed in detail in Chapter 22, a brief description of those associated with painful symptomatology is provided here (7,8). Those cranial mononeuropathies affecting the nerves supplying the external ocular muscles typically present with sudden onset of diplopia and an ipsilateral headache often described as a dull pain coming from behind the eye. Similarly, many of the focal limb neuropathies including entrapment neuropathies (7) might present with painful symptoms in the area supplied by the individual nerve. The tarsal tunnel syndrome, which is analogous to the carpal tunnel syndrome in the upper limbs, may present with localized foot pain, which should be distinguished from the pain of the diffuse sensorimotor neuropathy.
Several important observations have emerged from these studies that are of relevance to the understanding of localized, or focal diabetic neuropathies. It is clear that focal compressive types of nerve injury, such as ulnar neuropathy at the elbow or carpal tunnel syndrome, are unlikely to be ischemic in origin it is unlikely that a single compressive lesion would disrupt the rich nerve vascular supply. Direct investigations of blood flow at sites of nerve crush or transection have not identified ischemia (53,54). Instead, blood
Neuropathy may have pain or impaired sensation in the feet and hands, slow digestion, carpal tunnel syndrome, or impaired cardiovascular responses (17). Patients with diabetes are twice as likely to develop carpal tunnel syndrome as a result of edema or accumulation of fluid within the carpal tunnel area. Diffuse clinical neuropathies can exist distally or proximally. Distal neuropathy usually presents after acute stressful phenomenon, but can also be insidious in onset. Distal neuropathy can involve either motor or sensory nerves, and small and or large fibers. To evaluate a patient for entrapment neuropathies, Tinel's sign can not only be used for carpal tunnel syndrome but can also be used for median, plantar, ulnar, peroneal, fibular, and ulnar notch neuropathies. On occasion, in particularly difficult cases, nerve biopsy may be helpful in excluding other causes of neuropathy, and special arginine staining can be used to diagnose dying-back neuropathy (9).
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