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Carpal Tunnel Syndrome – OVERVIEW (Part 2)

12 Mar

This discussion picks up from last month as we review the “nuts & bolts” of carpal tunnel syndrome (CTS). We left off at “CLINICAL PRESENTATION”…

CLINICAL PRESENTATION (continued): A weakness in grip and pinch strength usually follows an initial loss of sensation in the second to fourth palm-side fingers. The intensity of weakness is more dependent on the amount of pressure versus duration of time of numbness. In other words, if a high degree of pressure suddenly occurs inside the carpal tunnel (like a fracture with bleeding into the tunnel), the patient may feel weakness right away. But usually, CTS is a slow, smoldering condition and if weakness occurs, it comes on slowly and most patients cannot say for sure when their weakness symptoms started.

PHYSICAL EXAM: It is important to assess other possible areas for neurological compression, such as the neck, shoulder (thoracic outlet), elbow, and/or forearm. Also, it’s necessary to rule out “co-morbidities” or other conditions that contribute to CTS. The list is long but includes diabetes, hypothyroid, pregnancy/birth control pills/recent menopause, kidney disease, arthritis, Lyme disease, multiple sclerosis, and more. The physical exam may also include a sensory exam and a motor exam as well as specific orthopedic provocative tests that can reproduce CTS symptoms. Your doctor may also order an EMG/NCV (electromyography/nerve conduction velocity) but NONE of these tests are 100% sensitive and specific—that is, there are false-positives and negatives. Lab and blood tests can help tease out some of the other possible conditions (listed above). X-ray, MRI, CT scan, and ultrasound may help identify spurs, fracture, cysts, and other space occupying causes of CTS, but no one test is enough.

TREATMENT: Chiropractic offers manual therapies such as manipulation, mobilization, massage, and myofascial release of not just the wrist and hand but also the cervical spine, shoulder, elbow, and forearm regions, if the median nerve is impeded in places beyond the wrist. Doctors of chiropractic often utilize night splints and recommend rest, job modifications, and anti-inflammatory agents such as ginger, turmeric, bioflavonoid, and proteolytic enzymes. Because being overweight can increase one’s risk for CTS, lifestyle improvements aimed at cutting excess mass may be recommended as well. MDs may prescribe anti-inflammatory drugs and help manage co-morbidities such as diabetes, hormone replacement, hypothyroid, and the like. Often, a coordinated “team approach” of care providers works best. Surgery may be necessary in some cases but usually ONLY after all the above fails.

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.

Carpal Tunnel Syndrome – OVERVIEW (Part 1)

5 Feb

Carpal tunnel syndrome (CTS) represents a collection of signs and symptoms resulting from the compression or pinching of the median nerve as it passes through the carpal tunnel at the wrist. In this overview, you will see why CTS can be a challenging ailment to diagnose and treat.

SYMPTOMS: Numbness, tingling, and pain. Less commonly, burning and/or sharp pain in the index to the thumb-side half of the fourth finger, palm-side only. Loss of grip strength (such as unscrewing a jar) may occur but usually later in the course of the condition.

PATHOPHYSIOLOGY: Compression of the median nerve inside the bony carpal tunnel occurs when the pressure inside the tunnel increases, often due to overuse with subsequent swelling. There are multiple epidemiologic factors including genetic, medical, social, vocational, avocational, and demographic with a complex interplay between some or all these factors. However, definitive causative factors remain obscure and unclear in many cases.

EPIDEMIOLOGY: About one to three people per every 1,000 will develop CTS in a given year, and estimates show about 50 people per 1,000 currently live with CTS in the general population. However, the incidence may rise as high as 150 cases per 1,000 subjects per year, with prevalence rates greater than 500 cases per 1,000 subjects in certain high-risk groups. The incidence and prevalence is similar in developed countries like the United States, the United Kingdom, and the Netherlands, but CTS is almost unheard of in some developing countries. The female-to-male ratio for CTS is three-to-ten females to one male. Carpal tunnel syndrome seems to peak at age 45-60 years old with only 10% of CTS patients under the age of 31. The condition is not fatal, but if left untreated, severe cases can lead to complete, irreversible median nerve damage and a loss of much hand function.

CLINICAL PRESENTATION: A patient’s history is often more valuable than the physical examination when it comes to CTS. Patients may report the above-listed symptoms, which may worsen at night and interrupt sleep. Symptoms may also increase in intensity during activities like driving, crocheting, and painting. Frequently, CTS affects both hands, but it’s usually worse in the dominant hand. Patients may have difficulty “mapping” their symptoms well and may feel numbness, tingling, pain, and/or weakness in the whole arm and/or forearm. It’s often prudent to look for additional compression elsewhere in the course of the median nerve in the neck, shoulder, and/or elbow. Less commonly, the patient may experience whole hand hot/cold sensitivity with color changes and/or sweating, which may indicate autonomic nervous system involvement. The use of CTS questionnaires can help diagnose and track progress during care. This discussion will continue next month – stay tuned!

Carpal Tunnel Syndrome – More Than Just a Wrist Problem

8 Jan

Carpal tunnel syndrome (CTS) is a common condition that affects around 6-12% of the population and can result in significant pain and disability. The financial costs associated with CTS can be staggering – ranging from $45,000 to $89,000 per patient over a six-year period when productivity loses are taken into account.

Historically, doctors and researchers have described CTS as the result of compression of the median nerve as it travels through the bony carpal tunnel at the wrist. However, there is recent evidence that CTS is a more complex pain syndrome with multiple studies showing women with CTS exhibit widespread pressure pain hypersensitivity, thermal pain increases, and what’s called “enhanced wind-up in extra-median nerve territories.” In other words, the central nervous system seems to be involved, affecting the whole body, not just the wrist and hand.

Traditionally, the management of CTS has included conservative interventions primarily focused on relieving wrist and hand symptoms using splints, manual therapies, modalities (ultrasound, laser), and exercise—with surgery recommended if the patient fails to respond treatment. In looking at CTS as a product of the central nervous system (CNS), therapies that target desensitizing the nervous system may be more effective.

A 2017 randomized clinical trial compared manual therapy with surgery for improving BOTH pain and central sensitization (“nociceptive gain”) in CTS patients. Here, researchers randomly assigned 100 women to either a manual therapy group who received one session per week for three weeks including “desensitizing manoeuvres of the CNS” or a surgical intervention group (50 in each group). The research team evaluated pressure pain thresholds (PPT), thermal pain thresholds (hot or cold – HPT or CPT), and pain intensity at baseline, three, six, nine, and twelve month intervals following the intervention.

After one year, those in the manual therapy group experienced higher increases in PPT over the carpal tunnel at three, six, and nine months and greater decreases in pain intensity at three-months than those who underwent a surgical procedure. Otherwise, the outcome measurements were similar for both groups.

The significance of this study supports that a non-surgical, manual therapy approach (in which chiropractic specializes) is more effective in the short term and equally effective in the long term as surgery for BOTH pain and central sensitization (PPT only – not HPT/CPT for either group).

Treatment Option Comparison for Carpal Tunnel Syndrome

7 Dec

Carpal tunnel syndrome (CTS) results from the compression of the median nerve as it travels through the wrist. Classic symptoms associated with CTS include numbness, tingling, and weakness in the thumb, index, middle, and ring finger. In non-emergency situations, treatment guidelines recommend patients undergo conservative care before considering more invasive procedures, like surgery. This month’s article will look at the differences between standard medical care vs. chiropractic care to treat CTS.

In a case study series, researchers divided 91 patients with confirmed signs and symptoms of CTS into two groups: one receiving standard medical care utilizing ibuprofen and night splints; and one group receiving chiropractic care including manipulation of the upper extremity bony joints and soft tissues, as well as spinal manipulation. Researchers monitored improvement with self-reports, nerve conduction, and vibrometric sensation testing of the affected hand.

Both treatment groups experienced improvements in comfort, finger sensation, and nerve conduction; however, vibrometric sensation testing revealed greater improvements among members of the chiropractic treatment group (3.05 decibels vs. 1.37 decibels).

The authors of the study point out that chiropractic provides an alternative form of non-surgical care, and patients with CTS should be offered the option, especially for those who cannot take a non-steroidal anti-inflammatory drug (NSAID) due to intolerance like stomach irritation or liver-kidney issues. Personal preference is also important in the decision making process for CTS.

Other CTS treatment options often offered by doctors of chiropractic include work modifications, ice therapy, and nutritional options such as ginger, turmeric, boswellia, bromelain, fish oil, and others. There are also CTS-specific stretching exercises that can be done multiple times per day at home and work. The treatment plan for the CTS patient will often include several of these options in order to achieve a satisfying outcome.

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.

What Causes Carpal Tunnel Syndrome?

6 Nov

Carpal tunnel syndrome (CTS) is a condition that arises when the median nerve becomes compressed as it travels through the bony tunnel made up of the eight small carpal bones of the wrist. Its symptoms include pain, numbness, and tingling in the thumb, index, middle, and thumb-side half of the ring finger. If the pressure is great enough, weakness in grip and pinch strength can occur as well.

There are many conditions or factors that contribute to and/or cause CTS, which can complicate its diagnosis and treatment. Some of these include: diabetes, obesity, pregnancy, birth control pills, hypothyroid (low thyroid function), arthritis, smoking, alcohol abuse, poor nutrition, being female (due to wrist size and/or hormonal shifts), bony abnormalities (such as spurs, misalignment of the carpal bones, and tunnel shape), aging, and certain occupations (heavy manual labor, vibrating tools, high repetitive tasks, firm gripping requirements, food servers, dental hygienists).

Additionally, impingement of the median nerve as it passes through other structures in the body can contribute to a patient’s symptoms, so it’s important for a doctor of chiropractic to examine the entire course of the nerve—from the neck to the shoulder to the elbow and then to the wrist. In some cases, the median nerve may not be impeded as it passes through the carpal tunnel but rather, there is pressure on the nerve elsewhere that causes symptoms similar to CTS. In these instances, if treatment only focused on the wrist, the patient may not have a successful outcome.

Outside of an urgent condition, like a broken wrist that may require surgery to take the pressure off the median nerve, treatment guidelines recommend using conservative (non-surgical) approaches first. This can include addressing any activities that place pressure on the nerve (making changes to a workstation, for example) or conditions that may contribute to inflammation or swelling in the wrist.

Inflammation within the carpal tunnel can be reduced using both ice therapy, as well as by consuming turmeric, ginger, and other spices with anti-inflammatory properties.

To restore normal motion to the joints in which the median nerve may be compressed, doctors of chiropractic may utilize manual therapies such as manipulation and mobilization. Patients may also wear a wrist splint at night in order to avoid increased pressure caused by bending the wrist in an effort to find a comfortable sleeping position.


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.

Carpal Tunnel Syndrome and Body Type

5 Oct

Is there a relationship between carpal tunnel syndrome (CTS) and body mass index (BMI)? A 1994 study focused on 949 patients who presented with right arm numbness and tingling. In the study, the patients underwent electromyography and nerve conduction velocity (EMG/NCV)—the “gold standard” of tests to diagnose nerve injuries in conditions such as CTS.

Researchers then sub-divided the group by age (three groups: younger than 45; between 45 and 64; and 65 or older), body size (defined by BMI), and gender. Investigators compared those who were obese (BMI more than 29) to the other groups: slender – BMI less than 20; normal – BMI 20-The findings revealed that of the 261 patients diagnosed with CTS, only 16% were slender compared with 39% who were obese. This indicates that those with obese body types are 2.5 times more likely to develop CTS than slender individuals. Regarding gender, 43% of obese women had CTS compared to 32% of obese males, and 21% of slender women had CTS compared to 0% of slender males. The mean age for the CTS patients was higher at 48.1 years of age (vs. 44.7 years), with the peak occurrences in the 45-65 year old group (41%), followed by those 65 years or older (26%), with the rate in those younger than 45 years old group at  21%.

This study is consistent with previously identified risk factors for developing CTS: obesity, older age, and being female. But are there additional “body type” risk factors?

It turns out that other studies have found that people with square-shaped wrists, short/wider palms (with shorter third fingers), and those with poor upper back strength all have a higher risk for developing CTS.

We’ve looked at other well-known risk factors previously such as diabetes, arthritis, pregnancy, birth control pill use, occupation type, smoking, alcohol abuse, poor nutrition, high LDLs (“bad” cholesterol), and genetic factors. Doctors of chiropractic are trained to diagnose and treat CTS, and ALL studies recommend EARLY treatment, so DON’T WAIT!

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.