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Carpal Tunnel Syndrome Diagnosis

8 Jul

Despite being the most common entrapment neuropathy (pinched nerve) in the extremities, a gold-standard test for diagnosing carpal tunnel syndrome (CTS) has yet to be established. In part, this is due to how the symptoms develop from patient to patient, as well as the presence of other conditions that can result in a similar collection of symptoms. So when a patient presents with suspected CTS, how does their doctor of chiropractic determine if it’s CTS or something else?

The most useful starting point is a review of the patient’s history, which can reveal factors that point to the possibility of carpal tunnel syndrome, such as a job that requires forceful gripping of heavy tools. On the other hand, if a patient has a history of neck pain or whiplash, then it would make sense to evaluate the neck as a possible source of median nerve entrapment or the history may point to potential contributing factors, such as hormonal issues, that may require co-management with another healthcare professional.

Patients may also complete a CTS-specific questionnaire to collect data on the symptoms they’re experiencing, the location of the symptoms, and the intensity of the symptoms (typically on a 0-10 scale where 0=no pain and 10=excruciating pain).

The subsequent examination will follow the course of the median nerve to determine if there is pressure on multiple sites. At this point, a doctor of chiropractic may have a fairly strong suspicion on what is causing the patient’s symptoms, and he or she can formulate a treatment recommendation.

However, if the case is complicated, the patient may be referred for more advanced testing—like electrodiagnostic testing—to confirm the diagnosis. Because these tests can be unpleasant and painful to the patient and there is up to a 34% possibility for a false positive, it may sometimes be more useful to inform a diagnosis rather than as the initial means to make a diagnosis.  This was confirmed by a 2018 study that concluded that electrodiagnostic testing is not a reliable screening method for determining the severity of CTS.

During the course of care, patients may also be asked to complete short assessments, such as the Boston CTS Questionnaire (BCTSQ) that includes eleven questions (scored 1-5 for “normal” to “very severe”) for symptoms and eight questions for function (scored 1-5 for “no difficulty” to “cannot perform the activity at all due to hand and wrist symptoms”). Not only does this information help track a patient’s progress to determine if the treatment plan needs modification but it can be used to prove “medical necessity” to the patient’s insurance company.

This information should not be substituted for medical or chiropractic advice. Any and all healthcare concerns, decisions, and actions must be done through the advice and counsel of a healthcare professional who is familiar with your updated medical history.

The Hip-Foot Connection

15 Jun

When examining a patient for hip pain and other musculoskeletal conditions, doctors of chiropractic will expand their focus beyond the area of chief complaint to identify issues elsewhere in the body that may be underlying or contributing factors. This is especially true with the hip because anything that affects normal locomotion can lead to compensatory changes and abnormal motion in the hip joint, which can easily result in inflammation or wear and tear that causes pain. Such is the case with issues in the foot, like plantar fasciitis.

Plantar fasciitis is one of the most common causes of heel pain and is characterized by inflammation of the thick band of tissue (plantar fascia) located on the bottom of the foot that connects the heel bone (calcaneus) to the toes. Individuals with the condition may experience a stabbing pain that often occurs with initial weightbearing, especially in the morning. The intense initial pain usually improves after a few steps; however, it can also worsen following prolonged standing or intense activity.

The function of the medial longitudinal arch of the foot is to absorb shock and to add “spring” to each step. In the mid-stance phase of gait, the arch flattens out, stretching the plantar fascia (the “string”) and if stress and tension exceeds the tissue’s threshold or becomes too great, micro-tears inflame the fascia and cause pain when initiating weightbearing. This leads to pain and can affect normal gait, which can ultimately lead to issues up the kinetic chain, such as hip pain.

Risk factors for PF include advancing age, stressful exercise (running, ballet dancing, aerobic dance), altered arches in the feet (such as flat feet as well as a high arch), obesity, and occupations that require an individual to be on their feet all day, especially on hard surfaces.

Following diagnosis, which may include a review of the patient history and an examination, a conservative treatment approach in a chiropractic setting may include manual therapies (longitudinal and cross fiber friction massage); Graston technique (using spoon-like tools to stimulate blood flow and break up adhesions); stretching exercises (calf stretches off a step or using TheraBand to bend the foot and ankle upwards and extend the toes); prescription foot orthotics with pronation correction (lateral heel wedge); modalities (laser, ultrasound, extracorporeal shock wave therapy); and dorsiflexion night splinting. Patients may also be encouraged to reduce their intake of processed foods—which can increase inflammation in the body—and eat a more anti-inflammatory diet, like the Mediterranean diet, to aid in the healing process.

Because prolonged standing and stressful exercise can worsen the condition, patients may be advised to reduce the time they spend on their feet and switch to less impactful forms of exercise during recovery. The good news is that conservative treatment approaches, such as chiropractic care, are often successful in helping PF patients manage their condition.

This information should not be substituted for medical or chiropractic advice. Any and all healthcare concerns, decisions, and actions must be done through the advice and counsel of a healthcare professional who is familiar with your updated medical history.

Alpha-Lipoic Acid Supplementation for Carpal Tunnel Syndrome

10 Jun

When it comes to the conservative management of a condition like carpal tunnel syndrome, care will usually focus on reducing inflammation along the course of the carpal tunnel and improving mobility of the median nerve as it travels from the neck and into the hand. This treatment approach may also include the use of nutritional supplements, of which alpha-lipoic acid (ALA) is starting to show promise.

Alpha-lipoic acid (ALA) is an antioxidant that naturally occurs in the body and can also be found in organ meats, spinach, broccoli, and potatoes. However, it’s often consumed as a supplement in order to get enough into the body to have an observable effect. Though research is ongoing, two benefits of ALA that are important for potential carpal tunnel treatment are its ability to reduce inflammation and to protect nerves from damage.

In a 2020 study involving 134 patients on a surgical waiting list with mild-to-moderate CTS, researchers observed that taking a 600mg ALA supplement once a day for 60 days reduced both daytime and nighttime hand and wrist pain, with 14% of participants in the ALA group canceling their surgery. The authors of this study add that previous studies that combined ALA with either curcumin or gamma-linolenic acid provided similar benefits to participants.

A 2018 study that included 31 CTS patients reported that ALA, N-acetyl-L-carnitine, turmeric, vitamins B, E, and C formulated for peripheral neuropathy (taken twice a day for one month) led to similar improvements in pain, symptom severity, and function as extremely-low frequency electromagnetic fields (ELFEF) therapy, but the benefits persisted in the supplement group for another two months while the ELFEF participants reverted to their baseline pain and function levels.

A systematic review conducted in 2020 concluded that ALA is safe, even in groups normally observed to be at risk like smokers, cardiovascular disease patients, diabetics, pregnant women, children/adolescents, and individuals with neurological disorders, rheumatic disorders, and severe renal disease.

While further research is certainly warranted on the benefits of a supplement like ALA for the CTS patient, it is certainly showing promise, and a patient may consider it as part of a multimodal approach that can include manual therapies, specific exercises, nocturnal splinting, heat/ice, and an anti-inflammatory diet.

This information should not be substituted for medical or chiropractic advice. Any and all healthcare concerns, decisions, and actions must be done through the advice and counsel of a healthcare professional who is familiar with your updated medical history.

Reducing Carpal Tunnel Syndrome in the Office

13 May

Carpal tunnel syndrome (CTS) is a condition that occurs when the median nerve is compressed or restricted as it passes through the wrist. Because repetitive wrist and hand motions can inflame the tissues in the wrist and place pressure on the median nerve, workers in jobs that require such movements—such as those seated at a computer workstation all day—tend to have an elevated risk for the condition. That said, what can be done to minimize the risk?

A January 2021 study looked specifically at 1,000 office workers under age 50 from 30 workplaces in China. Participants completed a questionnaire that included information on demographics, work type, related physical and psychosocial factors, and wrist and hand symptoms using a body chart and a rating of the intensity of symptoms, nocturnal symptoms, and aggravating activities. Then, participants were clinically evaluated, and CTS was confirmed using standard testing protocols.

The authors reported that 22% of participants had wrist symptoms and 15% had hand symptoms, with 9.6% meeting the clinical criteria for CTS. Further analysis identified the following risk factors for CTS among office computer users: smoking, working with hand/wrist pain, prolonged computer use time, and working without breaks.

Mandatory breaks spread throughout the workday may be an effective strategy for reducing the risk for CTS among office workers. There is also strong research supporting the health benefits of integrating exercise with meditation during such breaks.

Meditation has been found to reduce stress and anxiety, as well as reduce chronic neck pain—another common complaint in the office environment. Incorporating physical activity during a short break will not only help lower the risk for CTS, but it may also reduce the risk for chronic ailments like cardiovascular disease and diabetes that are associated with high levels of sedentary behavior.

While it may not be possible to eliminate one’s risk for CTS, if hand and wrist symptoms are present, it’s important to seek care sooner rather than later because earlier intervention improves the odds for a satisfactory result. Doctors of chiropractic are trained to examine the whole person and look for all contributing factors in a patient’s chief complaint. With suspected CTS, it’s not uncommon to find additional areas along the course of the median nerve (the neck, shoulder, elbow, forearm) that need to be addressed to resolve the patient’s pain, numbness, tingling, and weakness symptoms.

This information should not be substituted for medical or chiropractic advice. Any and all healthcare concerns, decisions, and actions must be done through the advice and counsel of a healthcare professional who is familiar with your updated medical history.

Home Exercises for Carpal Tunnel Syndrome

6 Apr

Carpal tunnel syndrome (CTS) is the most common peripheral neuropathy affecting approximately 3% of the general adult population. Individuals with jobs or hobbies that involve fast, repetitive movements and forceful gripping with little-to-no rest may be at increased risk for CTS, as are those with metabolic/hormonal conditions that can lead to increased swelling/pressure/inflammation in the wrist. In most instances, treatment guidelines recommend utilizing conservative treatment approaches, like chiropractic care, before consulting with a surgeon. In addition to workstation modifications, manual therapies, nutritional recommendations to reduce inflammation, nocturnal splinting, and co-management with other healthcare professionals, doctors of chiropractic will also advise patients to perform exercises at home to speed recovery and prevent recurrence.

Below is a description of four CTS-specific exercises recommended by the American Academy of Orthopedic Surgeons (AAOS).

Exercise 1: Wrist Extension Stretch. With the elbow straight (but not “locked”), bend the wrist back (as if saying “STOP”) and use the other hand to apply “over-pressure” to assist to a maximum tolerated stretch. Hold for fifteen seconds. Repeat five times for each wrist.

Exercise 2: Wrist Flexion Stretch. With a straight elbow (but not “locked”) and the palm facing down, bend the wrist downward until the fingers point toward the floor and use the other hand for to achieve the maximum tolerated stretch. Hold for fifteen seconds, repeat five times for each wrist.

Exercise 3: Median Nerve Glides. Make a fist (with the top of the hand facing upward) and then open the hand, but not the thumb, and bend the hand backward toward the forearm and extend the thumb backward. Rotate the palm up toward the ceiling, keeping the wrist/fingers/thumb extended. Grasp the thumb with the other hand and extend back (assist) to tolerance (but not too hard). Hold for three to seven seconds and repeat on the other hand.

Exercise 4: Tendon Glides Type One: Start with the hand pointed outward with the fingers straight out, palm facing down. Bend the fingers upward and then curl them downward into a fist. Tendon Glides Type Two: Start with the hand pointed outward with fingers straight out, palm facing down. Bend the fingers downward touching the end of the fingers to the base of the palm.

The AAOS recommends warming up the hands and wrists with heat for about 15 minutes before performing these exercises and using ice for 20 minutes to cool down afterward. If your symptoms to worsen, cease these exercises and consult with your doctor of chiropractic about modifications.  

This information should not be substituted for medical or chiropractic advice. Any and all healthcare concerns, decisions, and actions must be done through the advice and counsel of a healthcare professional who is familiar with your updated medical history.

Chiropractic Care for Carpal Tunnel Syndrome

16 Mar

While many people may consider carpal tunnel syndrome (CTS) to be the default cause of any pain, numbness, tingling, or weakness in the hand and/or wrist, the condition is more complex. In some cases, a patient with such symptoms may not have CTS at all. So when a patient comes into the office to be evaluated for CTS, how does their doctor of chiropractic determine if CTS is the culprit and how is the condition managed?

To begin, CTS occurs when the median nerve is compressed as it travels through the wrist, which can result in pain, numbness, tingling, and weakness in the thumb, index, middle, and the thumb side of the ring finger. Traditionally, investigators believed the compression of the median nerve itself was responsible for generating these symptoms, but recent studies suggest it may be reduced mobility of the median nerve that’s to blame or it may be a combination of both compression and loss of nerve mobility.

If the patient’s symptoms are localized to the thumb and the first three fingers, as described above, then the median nerve may be affected. However, if symptoms occur on the other side of the ring finger and the pinky, then a different nerve, the ulnar, may be entrapped.

The median nerve itself doesn’t just appear at the wrist. It arises from the neck, passes through the shoulder, and runs down the arm. Compression of the median nerve at any of these locations can result in CTS-like hand and wrist symptoms, even in the absence of symptoms further up the course of the nerve. Additionally, compression can occur in multiple locations, which is described as double- or multi-crush syndrome. This was first reported in 1973 by Upton and McComas, and since then, multiple studies have reported that when a nerve is compressed in more than one location, it becomes hypersensitized and is more susceptible to damage or injury.

When median nerve entrapment is suspected, a doctor of chiropractic will examine the entire length of the nerve to identify all possible issues that should be addressed. If the contributing factors are musculoskeletal in nature, then treatment may include manipulation, mobilization, soft tissue work, modalities, nocturnal splinting, workstation modifications, stretches, and at-home exercises to reduce pressure on and increase the mobility of the median nerve. Changes in hormone levels can also lead to swelling of tissues that surround the median nerve. In which case, co-management with the patient’s physician may be required to achieve an optimal outcome.

The good news is that the non-surgical, multi-modal approach used by doctors of chiropractic is highly effective in patients with CTS, especially if the patient seeks care early in the course of the disease when the symptoms are milder.

This information should not be substituted for medical or chiropractic advice. Any and all healthcare concerns, decisions, and actions must be done through the advice and counsel of a healthcare professional who is familiar with your updated medical history.