Carpal Tunnel Syndrome
Contents (click on link):
1.- Carpal Tunnel Syndrome - What Can You Do For It?
2.- Do I Have to Have Surgery For Carpal Tunnel Syndrome?
3.- Carpal Tunnel Syndrome (CTS) – What Does Research Show?
4.- Carpal Tunnel Syndrome – Chiropractic vs. Medical Treatment
5.- Carpal Tunnel: Results of a Clinical trial of Two Treatments
1.- Carpal Tunnel Syndrome - What Can You Do For It?
Carpal tunnel syndrome or, CTS, is a common condition that drives many patients to chiropractic clinics asking, “…what can chiropractic do for CTS?” As an overview, the following is a list of what you might expect when you visit a Doctor of Chiropractic for a condition like CTS:
- A thorough history is VITALLY important as your doctor can ask about job related stressors, hobby related causes (such as carpentry or playing musical instruments), telephone work, or factory work – especially if it’s fast and repetitive. Your doctor will also need to learn about your “co-morbidities” or, other conditions that can directly or indirectly cause CTS such as diabetes, thyroid disease, certain types of arthritis, certain medication side effects, and others.
- A Physical Exam to determine the area(s) of nerve compression degree of severity. This may include ordering special tests such as EMG/NCV, if necessary.
- Treatment can include manipulation, soft tissue release, PT modalities (eg., electric stim., ultrasound).
- Home Therapies are the main topic for this Health Update. What can YOU do for CTS?
Here are some of the things that you, the CTS sufferer can self-manage:
A Carpal tunnel splint is primarily worn at night, keeping your wrist in a neutral or straight position. This position places the least amount of stretch on the nerves and muscle tendons that travel through the carpal tunnel at the wrist.
Exercises (Dose: 5-10 second holds, 5-10 repetitions, multiple times / day) such as: A. The “Bear claw” (keep the big knuckles of the hand straight but bend the 2 smaller joints of the fingers and thumb and alternate with opening wide the hand) B. Tight Fist / open hand (fully open – spread and extend the fingers and then make a fist, with the hand). C. The upside down palm on wall wrist and forearm stretch (stand facing a wall; with the elbow straight, place the palm of your hand on the wall, fingers pointing down towards the floor. Try to bend the wrist to 90 degrees keeping the palm flat on the wall. Feel the stretch in the forearm – hold for 5-10 seconds. Reach across with the other hand and gently pull back on the thumb for an added stretch! D. Wrist range of motion (dorsiflexion/palmar flexion) – Place forearm on a table with wrist off the edge, palm down. Bend hand downward as far as possible, then upward. Repeat 5 or 10 times. E. Wrist range of motion (pronation/supination) – Place forearm and whole hand on table-- elbow bent 90°, palm flat on tabletop. Rotate the wrist and forearm so the back of hand is now flat on tabletop. Repeat 5 or 10 times. F. Neck Stretch. Sit or stand with head facing forward. Side bend as far to the right as possible (approximate the right ear to right shoulder) and hold for 5 seconds. Reach over with the right hand to the left side of the head and gently pull further to the right to increase the stretch. Reverse instructions for the other side. Repeat 3 to 5 times. Consider other neck exercises if needed. G. Shoulder shrug and rotation. Stand with arms at the sides. Shrug the shoulders up toward the ears, then squeeze the shoulder blades back, then downwards and then roll them forward. Do the whole rotation slowly and reverse the direction. Repeat 3 to 5 times. If you cannot comfortably do the whole rotation, just shrug the shoulders up and down. H. Pectoral stretch. Stand in a doorway (or a corner of a room). Rest your forearms, including your elbows, on the doorframe, keeping your shoulders at a 90-degree angle. Lean forward until a stretch is felt in the chest muscles. Do not arch your back. Hold 20 seconds; repeat 5 times.
Job modifications are also VERY important but unfortunately, a topic for another time! In short, rotate job tasks (if possible), take mini-breaks, and use tools with handles that fit easily into the hands. Have a job station analysis completed if the above are not enough.
Carpal Tunnel Syndrome?
“For the last few months, I’ve been waking up at night with numbness and tingling in my hand. Lately, I’ve been waking up more often, 3-4 times a night and I’m having a hard time falling back to sleep. When I drive, my hands fall asleep within a few minutes and I have to shake my hand and fingers to wake them up. This has gotten to the point where I have to do something but I really don’t want surgery. What are my non-surgical options?”
CTS or, carpal tunnel syndrome is a condition where a nerve (called the median nerve) that travels down from the neck into the arm and through the wrist becomes pinched and inflamed. Common symptoms include numbness, tingling, dexterity problems (such as difficulty buttoning shirts), and opening jars due to weakness in grip and pinch strength. Sleep interruptions and loss of many daily activities, including work, occur because of CTS.
There are many non-surgical approaches to the treatment of CTS that should be utilized before surgery is considered, according to the American Academy of Neurology. In one study, 40% of neurologist polled recommended non-surgical care due to the potential side effects of surgery, some of which being severe, resulting in lengthy work loss post-surgically. A partial list of non-surgical care options include:
- Rest – Giving the inflamed CTS time to heal is therapeutic but not always an option.
- Activity/job modifications – Avoiding certain activities or modifying them by taking breaks during the work day, slowing down the pace of the job, altering the position of the job task, such as propping up a part so that the wrists do not have to bend to the extremes, or when necessary, complete avoidance of the job task.
- Wrist Splint – This is a brace that maintains the wrist in a neutral position so it cannot easily bend. When the wrist flexes or extends, the pressure inside the carpal tunnel (on the palm side of the wrist) increases significantly, placing additional pressure on the already pinched median nerve. Wrist splints are especially useful at night.
- Nerve Gliding Exercises – These are exercises that stretch the wrist joint and muscle tendons (as well as the median nerve inside the carpal tunnel), with the objective of breaking adhesions that limit the normal glide or movement of the nerve in the forearm and wrist.
- Manual therapy techniques – These include manipulation of the arm including the forearm, wrist, and hand and sometimes the neck and shoulder, when needed. The objective is to improve the range of motion of the joints and soft tissues that may be participating in the process of median nerve pinching.
- Anti-inflammatory medication / nutrients – Medications include aspirin, ibuprofen, naproxen and similar prescription drugs. Nutritional options including herbs (such as MSM, Wobenzyme, ginger, turmeric, boswellia), digestive enzymes, and Vitamin B6 may also help. Ice is also anti-inflammatory and direct, on-the-skin ice massage is quite effective.There are also homeopathic remedies. You should ask Dr. Press for a recommendation.
So often we hear, “…well if it’s so good, show me the proof!” Chiropractic case management of CTS has been well established for many years. And yet, we still hear skepticism from patients, MD’s, insurers, employers, and others about the benefits of chiropractic management of CTS. If we can, “show them the data” regarding the effectiveness of chiropractic for CTS patients, we will finally be able to help more people with this potentially disabling condition.
So, let’s take a look at the evidence that supports the benefits of chiropractic for CTS:
1) Davis PT, Hulbert JR, Kassak KM, et al. “Comparative efficacy of conservative medical and chiropractic treatments for carpal tunnel syndrome: a randomized clinical trial”
J Manipulative Physiol Ther. 21.5 (June 1997): 317-326.
The most important finding reported in this 91 patient study was that chiropractic treatment was equally effective in reducing CTS symptoms as medical treatment. The chiropractic care included ultrasound, nighttime wrist supports and manipulation of the wrist, arm and spine. Medical care included ibuprofen (800 mg, 3x/day for 1 wk, 800 mg, 2x’day for 1 wk, & 800 mg as needed for 7 wks) plus a night wrist splint. Both groups did equally well but given the side-effect potential of ibuprofen on the stomach, liver, and kidneys, a strong argument for the non-drug, chiropractic approach can be made.
2) Bonebrake AR, Fernandez JE, Marley RJ et al. “A treatment for carpal tunnel syndrome: evaluation of objective and subjective measures” J Manipulative Physiol Ther. 13.9 (Nov-Dec 1990): 507-520
CTS sufferers (n=38) received chiropractic spinal manipulation and extremity adjusting. Also, soft tissue therapy, dietary modifications or supplements (B6) and daily exercises were prescribed. After treatment, results showed improvement in all strength and range of motion measures. Also, a significant reduction in pain and distress ratings was reported.
3) Mariano KA, McDougle MA, Tanksley GW “Double crush syndrome: chiropractic care of an entrapment neuropathy” J Manipulative Physiol Ther. 14.4 (May 1991):262-5
In 1973, Upton and McComas first proposed the presence of the "double crush syndrome." Their hypothesis was that when a nerve is pinched anywhere along its route, it makes the rest of the nerve more sensitive to otherwise “normal” stimulation. A case report of a man with both cervical radiculopathy and carpal tunnel syndrome, i.e., "double crush syndrome" was presented. Chiropractic management consisted of chiropractic manipulative therapy as well as ultrasound, electrical nerve stimulation, traction and a wrist splint. The experimental basis, clinical evidence, etiology, symptomatology and findings of this condition are discussed. The Double Crush Syndrome helps explain why cervical/neck manipulation helps many CTS patients.
There are many patients who suffer from Carpal Tunnel Syndrome (CTS). In fact, CTS is one of the most common work related injuries. In spite of multiple studies that show the benefits of chiropractic treatment with patients suffering from CTS, many medical doctors are unaware of the studies and still tell their patients that chiropractic treatment is either ineffective, or may actually harm them. This unsupported ill advice can easily result in the patient not even considering chiropractic care as a potential effective form of treatment. This can be especially damaging to a patient who cannot tolerate anti-inflammatory medications such as Ibuprofen, Aleve, or aspirin. In fact, side effects secondary to stomach pain (gastritis and/or ulcer) can be quite common, especially at the recommended dose of 2400 mg / day. Moreover, if poor tolerance to these medications exists and a unsatisfying response to conservative medical treatment occurs, the “next step” offered to the patient may be surgery. Surgery that may have been avoidable had chiropractic treatment been considered on an equal par to non-surgical medical care.
There are several studies available that will enlighten those who simply are not aware of the effectiveness of chiropractic care in the treatment of CTS. In 1998, a 91 patient group was divided in half and treated for 9 weeks by either a non-surgical medical approach or by a chiropractic treatment approach. The medical approach included the use of 800 mg of Ibuprofen, 3x/day for 1 week, 2x/day for 1 week, and 800mg as needed to a maximum of 2400 mg/day dose for 7 weeks, as well as the use of a nighttime wrist splint. The chiropractic group utilized manipulation of the bony joints and soft tissues of the spine and upper extremity for 3x/week for 2 weeks, 2x/week for 3 weeks, and 1x/week for 4 weeks, in addition to ultrasound over the carpal tunnel and a wrist splint at night. It was reported that BOTH the medical and the chiropractic patient groups did equally well stating, “significant improvement in perceived comfort and function, nerve conduction and finger sensation.”
In 2007, two different chiropractic approaches were compared and found to both be equally effective in improving nerve conduction, wrist strength, and wrist motion as well as patient satisfaction and daily activity function. These improvements were maintained for 3 months in both groups equally as well. Another study reported significant improvements in strength, range of motion, and pain after chiropractic treatment was given to 25 patients diagnosed with CTS. The majority of the patients reported continued improvements for 6 months or more. There are other studies but I think the point is obvious – chiropractic treatment helps patients with CTS.
The type of treatment that one may receive when being treated by a chiropractor includes manipulation of the bony joints of the neck and upper extremity. The objective of this is to improve the mobility of the joints and loosen the muscles through which the nerves pass, particularly, the median nerve that runs through the carpal tunnel and innervates the 2nd to 4th fingers. There are several exercises of both stretching and strengthening types that strive for similar goals. Physical therapy modalities such as low-level laser therapy have reported beneficial results. Other modalities such as ultrasound, interferential current (IFC), ice massage/cupping over the tunnel, and others may also be utilized. Nighttime wrist splints or braces also help to keep the wrist straight so that prolonged bending of the wrist at night is not possible. There may be other treatment approaches that your chiropractic physician may suggest on an individual case basis.
A comprehensive examination by a Doctor of Chiropractic can determine if your carpal tunnel symptoms are likely to respond to care. He or she can also advise on at-home stretching exercises that can be done to help recovery. In some cases, hidden spinal and neck problems can influence carpal tunnel symptoms, and be the key to treating the cause vs. the symptom.
Carpal tunnel syndrome occurs when the median nerve, which starts at the neck and runs from the forearm into the hand, becomes compressed or squeezed at the wrist. In some cases there may also be compression at the spine.
The median nerve controls sensations to the palm side of the thumb and fingers (but not the little finger), as well as impulses to some small muscles in the hand that allow the thumb and fingers to move.
A recent study in the Journal of Manipulative and Physiological Therapeutics compared two different conservative treatments for patients with mild to moderate carpal tunnel symptoms. One treatment was the Graston technique, which uses an instrument to rub the forearm, wrist and hand areas to breakdown scar tissue and adhesions. In the other treatment a chiropractor applied deep pressure by hand to the same areas. These treatments are thought to release tight muscles and myofascial restrictions.
The patients got the treatments twice each week for four weeks followed by one treatment a week for two additional weeks. The patients also did at-home stretching exercises. They did not use common conservative treatments such as wrist splints and anti-inflammatory medications.
After both interventions, there were objective improvements to nerve conduction latencies (nerve function), wrist strength, and wrist motion. The patient symptoms of pain also improved, and both groups reported high satisfaction with the care they received.
Despite surgery being in widespread use in the US for carpal tunnel syndrome, it is important for conservative treatments to be tried prior to an invasive operation.
The surgical complication rates are low but when they do occur, can be devastating. In addition to direct surgery costs, one has to also consider disability payments (not working), and rehabilitation that may take several weeks. These costs can be substantial. For this reason, many medical doctors recommend conservative treatments first.
Of all the conservative options, manual therapy by a chiropractor is an excellent choice. It comes without the side effects associated with long-term use of medications.
(Most article content courtesy of Dr. B. Altadonna)