It’s common for patients to come see you if they are experiencing escalating nerve pain in their wrist and hand. This pain can interfere with daily tasks and may become a barrier to their job. When a nurse practitioner treats a patient and they’re describing nerve pain in a hand, one of the first issues for you is to determine whether it’s carpal tunnel.

Here are some directives from orthopedic specialists you may find useful in your treatment sessions.

What Are Some Symptoms to Keep on Your Radar?

Your patients view you as a partner in their healthcare, so they are relying on your expertise to treat their pain. When they share discomfort, here are some symptoms to know.

“The most common complaint in patients who have carpal tunnel is they feel their whole hand goes numb or have numbness and tingling in the fingers,” said Bradley D. Wiekrykas, MD, an orthopedic surgeon at Temple Health and assistant professor of orthopedic surgery and sports medicine at Lewis Katz School of Medicine at Temple University in Philadelphia. “This may occur during the day with activities, be constant, or be worse at night.” 

Wiekrykas also outlined that anatomically, medical professionals know that patients with carpal tunnel should only have symptoms in the thumb, index, long, and sometimes ring finger, but he said patients often have a hard time distinguishing. “Sometimes all fingers are involved or only a few. The small finger should be spared of symptoms,” he said.

Wiekrykas suggests these questions to ask a patient regarding their symptoms: 

• How long have they had symptoms?
• Do they have symptoms at night that wake them up?
• Do they feel they have to shake out their hand?
• Are symptoms getting worse?
• Are there constant symptoms or intermittent?
• Have they had prior treatments?
• Do they drop objects due to their symptoms?
• Do they have symptoms in their contralateral hand?
• Are there medical comorbidities such as diabetes?
• Do symptoms feel more on the thumb side of their hand or the small finger side of their hand, hand dominance, their occupation or hobbies?

Use Everyday Benchmarks to Illustrate Symptoms

Other activities related to carpal tunnel are increased numbness when holding the steering wheel, holding the phone, or applying make-up, said Roy G. Kulick, MD, director of Hand and Upper Extremity Surgery at Montefiore Einstein in Bronx, New York. “I refer to these as the activities of elevation in which the hand is raised above the heart and this brings out the symptoms of carpal tunnel,” he said.

Short-Term Strategies to Suggest

Typically, especially if they are having worse symptoms at night or symptoms that wake the patient up at night, a removable wrist brace should be provided or prescribed to the patient to be worn at night, said Wiekrykas.

“This prevents the wrist from flexing during the night which increases pressure on the median nerve at the wrist and causes symptoms of carpal tunnel and nighttime awakenings,” he said.

Patients may also elect to receive a corticosteroid injection into the carpal tunnel at the wrist to reduce inflammation and reduce pressure and compression on the median nerve, Wiekrykas also said.

“For very mild carpal tunnel or if symptoms have been present for only a few weeks or months, this may provide significant relief for patients,” he said.

For patients with long-term symptoms or severe nerve compression, long term relief from an injection and or brace is less likely, he said. And an injection may also be offered for patients who are adamant about not having surgery or too sick for surgery. However, evidence would suggest, and the American Academy of Orthopaedic Surgery Clinical Practice Guidelines for carpal tunnel syndrome says that strong evidence exists that steroid injections do not provide long term improvement for carpal tunnel syndrome.

Should You Immediately Suggest Physical Therapy? 

Physical therapy, or more appropriate occupational hand therapy is typically not a first line treatment for carpal tunnel syndrome, said Wiekrykas. Nerve gliding exercises may help, however there is no strong evidence to suggest that will improve or reduce or resolve symptoms, he said.

If patients have associated finger stiffness and difficulty with finger flexion or making a fist, he noted that therapy can be beneficial to help with range of motion.

Should You Discuss Surgery as an Option?

If the patient’s symptoms persist, Kulick said he orders an electromyography test.

“I tell the patient it’s ‘like an x-ray of the nerve.’ This will give objective evidence of the nerve compression and is very reassuring to the patient that something is present, causing the problem. If the results of the nerve test are modest then a cortisone injection may be helpful for the symptoms,” Kulick said. “If, however, the nerve test indicates more significant compression, then surgery may be needed.”

Any surgery, regardless of the kind or type, can be scary for any patient, said Wiekrykas at Temple Health.

“Fortunately, surgery for carpal tunnel has a very low complication rate and is very beneficial in improving patient’s symptoms and quality of life with a relatively short recovery,” he noted. “Especially for patients with persistent symptoms, patients who have failed bracing or steroid injections, patients with moderate-to-severe carpal tunnel, surgery has been shown to be the only definitive long term solution.”

Should You Refer Them to a Specialist?

Wiekrykas advised that if you have a patient that you suspect has carpal tunnel syndrome, you may begin treatment with a brace and/or steroid injection, order additional testing such as electrodiagnostic studies or an ultrasound evaluation of the median nerve size at the wrist and refer to a specialist.

“Electrodiagnostic studies are helpful in diagnosis and determining severity of the carpal tunnel syndrome. If patients are hesitant or nervous about obtaining electrodiagnostic studies, ultrasound evaluation to measure the size of the median nerve at the wrist has also been shown to be helpful in the diagnosis and severity of carpal tunnel syndrome,” he said.

What Else Could Be Causing the Problems?

Kulick said other things may cause the symptoms of carpal tunnel such as a pinched nerve in the neck.

“The EMG can tell the difference between the carpal tunnel syndrome and the neck issue. An injury such as a wrist fracture and conditions such as rheumatoid arthritis or lupus can cause carpal tunnel syndrome but these are definitely carpal tunnel syndrome from a specific cause,” Kulick said.

And there are many very common conditions in the hand that the nurse practitioner will come across.

“Not just carpal tunnel but tendinitis conditions such as trigger finger or de Quervain’s tendinitis at the wrist. If the nurse practitioner is comfortable, these can be treated with a local cortisone injection,” Kulick continued. “Other common conditions include ganglion cyst and small tumors about the hand which should always be referred to the specialist.”

Wiekrykas and Kulick reported no disclosures.