Carpal Tunnel Syndrome doesn’t have to mean the end of a nail career, but if you suffer from tingling, numb, or aching hands, adjust your working technique and see a doctor.
Doing nails may make tens of thousands of hands look beautiful, but it may not make you feel very good.
Any long-term, repetitive motion task, such as typing, checking items at the grocery store, and doing nails, can lead to carpal tunnel syndrome ( CTS), a condition marked by tingling, numb, and aching hands and fingers.
Repeated hand and wrist motions make the protective membranes around the wrist tendon thicken. This thickening causes the median nerve, which controls both sensations in the skin and motor reactions in the muscles, to be squeezed against bone and ligament (see figure). The nerve entrapment can also be caused by injury, disease, or hormone-induced fluid retention. CTS is more common in women than men, partly because a woman’s carpal tunnel area is smaller.
In 1990, the American Academy of Orthopaedic Surgeons estimated that cumulative trauma disorders such as CTS cost $27 billion a year in medical bills and lost work days. In that same year, the National Institute of Occupational Safety and Health estimated that five million Americans were afflicted with a cumulative trauma disorder (CTD) and expected the numbers to keep rising. In 1988, CTDs were the most frequently reported on-the-job ailment.
CTS usually begins with numbness in the hand and the pins-and-needles sensation common after an area has “fallen asleep.” These feelings often go away, especially in the early stages of the condition, but you should see a doctor before the symptoms worsen.
If CTS is allowed to progress, thumb muscles weaken, grip strength is reduced, and the hand pain may radiate to the forearm or shoulder. To stop CTS, you may need to change the way you do things. You can reduce your risk of CTS simply by paying more attention to your hand movements, posture, and by taking frequent breaks. Keep your wrists straight while you work, since holding them at an angle increases pressure on the nerve. If you find you can’t work without bending your wrists, your table may be too high or too low. You also shouldn’t have to reach out across the table to hold your client’s hand. Sit up straight with both feet flat on the floor, rather than crossing your legs or wrapping your feet around the chair’s legs.
When you need to grip an object, use your entire hand and all your fingers. This distributes the pressure more evenly and requires less force. Finally, refine your technique to reduce the number of repetitive motions you use, and give your hands a few minutes’ break every half hour or so.
VISIT YOUR DOCTOR
Even if your symptoms seem minor, see a doctor because only he can perform diagnostic tests and ascertain how serious your condition is. Seeking advice and treatment early on can prevent potentially permanent damage.
Most of the diagnostic tests a doctor needs to perform are simple and relatively painless. He may test the range of motion in your wrists and take X-rays. The doctor may also evaluate the numbness and tingling sensations in your hands and fingers by testing how fast your nerve sends signals to your muscles and the strength of those electrical impulses. This test is called an electromyography (EMG) and involves sticking needles into different muscles and sending spurts of electricity to them to gauge their reactions. “If the reaction is delayed, I suspect that a nerve is pinched,” explains Tsuneo Hirabayashi, M.D., an orthopaedic surgeon in Torrance, Calif. “If the symptoms have been present for a long time, the muscles may have atrophied, and their response may be slower than normal.”
Vicki Peters, NAILS Magazine Shows general manager, had CTS in both hands. A nail technician for 10 years, Peters frequently put in 10 hour days at the salon. After maintaining this frenetic pace for four years, she began experiencing typical CTS symptoms, particularly the numbness. It became difficult to sleep. She saw her doctor for the EMG test, which she says was the most painful part of the experience.
Depending on the severity of your condition, the doctor may prescribe medication, heat treatments, rest, and/or a splint to immobilize the wrist. If your case is more severe, or if these measures don’t lead to improvement, you may need surgery to reduce the pressure on the nerve. However, unless a person’s muscles have already begun to atrophy, Hirabayashi likes to wait at least three to four months to see if conventional treatment helps before resorting to surgery.
Peters was given a brace for each hand to keep the wrists straight and to eliminate pressure on the median nerve. She put them on the moment she got in her car to leave work and kept them on through as many activities as possible. There were some chores she had trouble doing with the braces on, but she always wore them while she relaxed, watched television, and slept. Wearing the braces at night prevented her from curling her wrists for long periods of time---and from potentially putting weight on them while they were bent---which increases pressure on the nerve.
While conventional treatment helped, Peters decided to have surgery on her left wrist based on her test results and the continued trouble she had doing nails. Although right-handed, the grip Peters used to hold her client’s hand with her left hand caused her left side to be in worse shape.
Cindy Stryk, owner of Cindy’s Sculptured Nails in Austin, Texas, has been a nail technician since 1975. What had been mild CTS symptoms worsened from fluid retention after Stryk had two pregnancies 16 months apart. In 1980 she returned to her business fulltime and started putiing in 12-hour days, six days a week. Between her work as a nail technician and the stresses of lugging around two young children and the accompanying diaper bags, the CTS continued to worsen.
Like Peters, Stryk had more problems with her left hand than her right. “The faster you work, the harder you have to hold your client’s hand,” she says. “Your carpal tunnel is directly related to the amount of work you do. When mine was bad, I couldn’t tell how tight I was gripping.
“You can’t tell yourself to relax when you don’t know that you’re gripping too tight. I had clients tell me I was holding their hand too tight---I had the “iron claw.’”
Because she didn’t want surgery and she was afraid of being talked into it, Stryk avoided going to a doctor until the pain was so bad it kept her up at night. “You reach a point where you can’t sleep because your hands fall asleep or kill you with pain,” she says.
After visiting the doctor, Stryk held out for a year before having surgery on her left wrist in 1983. She first tried medication and cortisone injections. She also wore wrist braces. “If nothing else, they help you train yourself to keep your wrists in the neutral position,” Stryk says. Her doctor also recommended vitamin B6, which helps the body eliminate fluid, taking pressure off the nerve. The vitamins helped, especially her right wrist, but Stryk finally realized that surgery was her only alternative.
“I had been on anti inflammatories for another problem, which is probably the only reason my wrist lasted as long as it did,” says Stryk. “But I was losing too much strength in my left wrist. When you can’t lift a glass of water, your wrist isn’t much use to you.”
THE SURGICAL PROCEDURE
Surgery to repair damage from CTS is not to be feared. It often is done on an outpatient basis, which means you won’t spend a single night in the hospital. The most common surgical technique requires a two-inch vertical incision in the palm, although there are several different palm incisions a doctor will use, depending on the surgical technique he favors.
“I asked a lot of questions before the procedure, so I knew where the incision was going to be,” Peters says. “But other people I know were surprised after they came out of surgery to find that their hand, not their wrist, was what got cut into.”
After making the incision, the doctor cuts the ligament over the carpal tunnel area to ease the pressure against the median nerve. If the area in the nerve that is responsible for motor function has been damaged, the patient won’t be able to recover the lost strength in that hand, another reason why prompt medical attention is necessary.
However, Hirabayashi says that carpal tunnel surgery is 99% successful. “There will always be some weakness in the affected hand because the ligament is cut and not repaired during the surgery. The ligament functions like a pulley on a rope, and the slight shortening of the muscle caused by the divided ligament reduces the effect of the muscle contracting. But not all people notice a problem with their grip strength. Sometimes it just depends on how they hold things.”
There is a new procedure advocated by some physicians, which is similar to the arthroscopic procedures common in knee and shoulder surgeries. With the endoscopic method, a tiny incision is made and an implement with a scope is inserted. Doctors look through the scope, position the cutting blade under the ligament, and pull a trigger to move the blade.
Hirabayashi, however, is leery of the new method. He believes that recovery time isn’t as short or pain-free as patients are led to believe. “The incision isn’t what really hurts the patient, so it doesn’t matter if you cut the skin two inches or a millimetre,” says Hirabayashi. “It’s the ligament that hurts, and you cut that in both procedures.” He adds that with the endoscopic method it’s too easy to cut the nerve accidentally, which is why the president of the Hand Society, a medical association, criticizes the new technique.
`Peters had asked about having her procedure done under local anesthesia, since she knew that general anesthesia carries a small risk. Many other procedures, such as arthroscopy in the knee, are commonly done under local anesthesia. However, her doctor, Norman Zemel, M.D., advised against it, saying that under local anesthesia she would be more uncomfortable.
Hirabayashi also doesn’t recommend doing the procedure under local anesthesia. “With knee and shoulder arthroscopy, there is more room to maneuver and less chance of accidentally cutting something. In the wrist, it’s not as difficult to accidentally hit the nerve, and that’s very painful for the patient. Local anesthesia only works for the incision.”
Peters’ recovery from surgery was uneventful. She was a little groggy from the anesthesia on the day of the surgery, but the incision hurt less than she expected. Aside from the problems of trying to do daily tasks with her hand and forearm bandaged up, she says that life proceeded as normal.\
Peters was back in the office the day after her procedure, though now she says she should have waited another day. “It’s the anesthesia that knocks you out,” she explains. “But I felt fine when I woke up, and I felt like I was wasting time at home. I wanted to get back to work and start recuperating.”
Generally, the stitches are removed after 10 days. After Peters’ were removed, she was given stretches and exercises to improve her range of motion. Other doctors may want you to see a therapist while recovering, depending on their specific program, your work schedule, and your motivation to complete therapy on your own.
Stryk spent six weeks with her wrist in a cast, then another six weeks in a brace as she returned to work and slowly built up her hours. “They tell you when you go in for surgery that if you don’t change your habits, the carpal tunnel will come back,” Stryk explains. “So I went back real slow.”
A year after surgery, Peters is grateful that the numbness is gone. She still has days when she comes home from the salon and both her wrists ache. When this happens, she puts on her braces and even wears them to bed. She usually keeps her braces with her so she can wear them anytime the symptoms flare up. Stryk also relies on her brace for painful episodes.
Peters says that she hasn’t gotten complete strength back in her wrist, and that it is still sore when she puts weight on it and during cold weather. “It doesn’t feel 100%, but my expectations were a little too high,” says Peters. “It’s been a definite improvement, back to 90% to 95% of normal.”
Peters says that the strength in her left hand is almost completely normal, and that the range of motion improved about 30%. She is considering surgery on her right hand as well, though, she says, “If I could get my right hand not to fail asleep, I wouldn’t do it. But eventually it will get worse and I probably will. It’s an easy procedure to go through and recover from.”
Hirabayashi says that Peters’ lingering problems are common. Though most patients have no signs of numbness or pain following surgery, the site of the surgery can be sensitive and even slightly painful. “We cut a ligament during surgery that we don’t repair,” he explains. “Scar tissue forms around the area and that is what hurts. It’s hard to say if it ever goes away completely.”
Stryk works hard to keep her wrists in a neutral position as she works, to adjust her work table avoid straining her arms, and to allow more time between clients so that she can rest. For example, she used to do a set in an hour and a fill in 45 minutes, whereas now she takes two hours for a set and 1 ½ hours for a fill. Though these changes means her work capacity has decreased more than one third, Stryk says her health is more important.
The changes Stryk has made to her routine is perhaps saving her from surgery on her right wrist. She swears that the work-style changes have made her left wrist recovery a success. “My right wrist is now at a workable level,” she explains. “At this point, I’m not planning on having surgery on it. It’s expensive--- about $5,000 for the surgery---and most technicians don’t have insurance, so that’s definitely a major consideration.
“I have periodic numbness in my right hand, but not the pain I had in my left. I can do almost everything with my right hand, like lift heavy pans. Most of the time it doesn’t cause me any problems. However, if it got as bad as my left wrist was, I wouldn’t hesitate for a minute to have the surgery.”
Both Peters and Stryk say they would recommend the surgery to anyone who is suffering from CTS, especially if other remedies brought no relief. “The longer you wait, the greater the risk you have of damaging the wrist permanently,” says Stryk. “It won’t get better unless you quit your job completely and permanently. And CTS can affect everyday tasks as well. I was hesitant too, but I’m now 100% better than I was.”