Pain Relief Chiropractic

Carpal Tunnel Syndrome (CTS) can present with a very mild, occasional numbness or tingling in the thumb, index, middle, and ring fingers and may never progress much beyond that point. But, for other patients, CTS is a painful, rapidly progressive problem that requires immediate attention. What makes it mild for some and bad for others? Let’s take a look!

The common denominator of CTS is median nerve compression at the wrist resulting in the tingling, burning, itching in the palm, thumb, and fingers (except the little finger). Symptoms can also include weakness in grip strength, as the median nerve innervates muscles that help you grip things with your hands. The compression may occur from the nerve becoming swollen, inflammation of the surrounding tendons, a cyst forming in the tunnel (ganglion cyst is most common), and/or a bony spur from arthritis poking into the tunnel. There are other causes or “contributors” of CTS that may make it more intense for some than others. Fluid retention or edema can increase the pressure in the carpal tunnel. This can be caused by pregnancy, taking birth control pills, or by hormone replacement therapy (estrogen for osteoporosis and/or hot flashes). Another type of edema (called myxedema) is associated with low thyroid function, and CTS can be caused or worsened in those with hypothyroidism. Obesity is another risk factor for developing CTS. The shape of the wrist may also predispose some to CTS and when combined with other contributing causes, CTS symptoms may become quite severe. Trauma or injuries to the upper limb, especially fractures at the wrist, can cause CTS almost immediately, and an improperly treated wrist fracture (such as a colles fracture) can result in long-term CTS. Arthritis is often accelerated when wrist fractures occur and this can result in a long-term problem that includes stiffness in the joint with loss of movement and pain in addition to CTS signs and symptoms.

Another cause of CTS is diabetes. For diabetics, their blood can be thicker and have a more difficult time traveling through the small blood vessels (called capillaries) resulting in numbness and tingling of the distal extremities: the hands and feet. Over time, neuropathy creates a hypersensitivity of the nerve, and this can result in carpal tunnel syndrome and/or can make it more difficult to manage. It has also been reported that the use of insulin, metformin, as well as sulphonylureas, and thyroxine are associated with increased CTS management challenges. Over-activity of the pituitary gland (the “master gland”) as it regulates the endocrine system is another contributor to CTS. Rheumatoid arthritis is a connective tissue disorder where antibodies inappropriately attack the lining of the joints creating swelling and pain. This can result in increased pressure on the median nerve in the carpal tunnel from both the inflamed joint as well as inflammation of the surrounding soft tissue. Combinations of these may also occur, which can make it challenging to determine which one(s) is the primary issue. Side effects to certain medications such as aromatase inhibitor drugs for breast cancer are also been well-published causes of CTS symptoms

The following activities have also been associated with an increased risk for CTS: vibrating hand tools, carrying heavy trays of food, working in a highly repetitive assembly-line type of job, milking cows, gardening, knitting, playing musical instruments, computer use, painting, meat and poultry processing, and carpentry.

Chiropractic offers a non-drug, non-surgical approach that is highly effective and therefore should be your FIRST STEP in the management of CTS!

We realize you have a choice in whom you consider for your health care provision and we sincerely appreciate your trust in choosing our service for those needs. If you, a friend, or family member requires care for Carpal Tunnel Syndrome, we would be honored to render our services.

Carpal Tunnel Syndrome (CTS) is a condition caused by compression of the median nerve as it travels through the carpal tunnel at the wrist, possibly resulting in numbness, tingling, and eventually weakness in the thumb and the index, middle, and ring fingers. “True” CTS occurs when the median nerve is pinched while it travels through the carpal tunnel; however, other conditions can mimic and/or contribute to CTS. Let’s take a look at seven possible causes of CTS…

• Swelling of the flexor tendons: This is probably the most common cause of carpal tunnel symptoms and is usually due to overuse of the hands associated with highly repetitive tasks like line work, computer typing, sewing, knitting, or playing a musical instrument. When fast repetitive gripping is required, especially if firm gripping is needed and/or the environment is cold, symptoms can occur more quickly. There is a sheath that wraps around the tendons traveling through the tunnel that is lubricated by synovial fluid. This normally keeps the tendon sliding freely inside the sheath. In the CTS patient, the tendon and/or the sheath tightens and creates swelling as extra synovial fluid is produced in an attempt to remedy the excess friction. This increases the pressure inside the sheath and causes more swelling and pain, and eventually conditions such as tendonitis and/or tenosynovitis. If left untreated, this can result in “trigger finger” (stenosing tenosynovitis) that can be more resistant to treatment. This enlarged, swollen tendon-sheath complex places pressure upon the median nerve and results in the classic symptoms of CTS.
• Misalignment of carpal bones: If one or more of the eight carpal bones become misaligned, it can cause the transverse carpal ligament (the floor of the tunnel) to tighten, narrowing the carpal tunnel and compressing it contents — including the median nerve!
• Direct compression of the tunnel: ANY occupation that requires the use of hand tools or any other objects that apply pressure directly to the carpal tunnel can cause CTS. Examples include hammers, screwdrivers, drills, pliers, jackhammers, a computer mouse, and more.
• Vibration: Any job or tool that requires firm gripping and vibration such as jackhammers, chain saws, hand buffers, or grinders can irritate the contents inside the carpal tunnel.
• Cold Temperatures: Cold vasoconstricts blood vessels and decreases blood flow to the area. When the cold exposure is prolonged, the lack of blood flow can keep needed oxygen from reaching the tissues that need it, possibly causing injury or contributing to an existing injury. Meatpacking or poultry plants are good examples of jobs requiring highly repetitive work in a cold environment.
• Arthritis: Old injuries (such as wrist fractures) or jobs that wear down the hyaline cartilage (smooth covering on joints) over time can result in spurs that can compress the nerve. Inflammatory arthritis, like rheumatoid, can also add pressure to the tunnel resulting in CTS.
• Multiple crush: More than one compression location on the median nerve can worsen CTS. This added compression can occur at the forearm, elbow, shoulder, and / or neck.

We realize you have a choice in whom you consider for your health care provision and we sincerely appreciate your trust in choosing our service for those needs.  If you, a friend, or family member requires care for Carpal Tunnel Syndrome, we would be honored to render our services.

Carpal Tunnel Syndrome (CTS) affects MANY individuals from all walks of life and in many occupations. Today’s discussion centers around CTS in musicians, and most importantly, what can be done about it.

It’s thought that CTS affects musicians because of their rapid, repetitive finger movements. The “formula” for CTS risk includes: Repetition + Speed + Force = CTS. This means highly repetitive movements at a fast pace using forceful movements significantly increase a person’s risk for developing CTS. If we add other risk factors of CTS including, but not limited to obesity, age over 50, female, the presence of diabetes, arthritis (especially rheumatoid), thyroid disease and others, then the risk increases dramatically. We can modify certain factors by losing weight, reducing practice time, changing the speed at which we practice (mixing it up between fast vs. slow tempos), taking mini-breaks from practicing, and more. However, we may not be able to change other factors like the presence of diabetes, arthritis, thyroid disease, and other hormonal imbalances. So the question arises, what can chiropractic do for CTS?

Chiropractic management focuses on the goal of treating what causes CTS – which frees up the nerve from being compressed. It is well established that compression of the median nerve ALONG ITS ENTIRE COURSE from the neck to the hand can create CTS or CTS-like complaints. Therefore, we determine the location(s) of compression by placing pressure over the points of common nerve entrapment, which include the wrist’s carpal tunnel, the forearm near the elbow (pronator tunnel), the inner upper arm near the elbow (Struther’s ligament), the shoulder and the arm pit area (behind the pectoralis minor muscle), as well as under the collar bone, and importantly, between the anterior and medial scalene muscles in the front/side of the neck (frequently missed). Chiropractic treatments may include manual release techniques such as Active Release Technique (ART), myofascial release (MFR), trigger point therapy (TPT), joint manipulation of the wrist, forearm, elbow, shoulder, neck and/or home self-applied treatment which includes activity modifications, using a night time splint, and exercises (which we teach you how to do). Nutritional considerations are also important (see last month’s Health Update)!

Treatment may also include exercises like the Carpal Stretch and the First Rib Stretch. The Carpal Stretch (median nerve flossing) involves standing sideways to a wall with your elbow straight, fingers pointing down with palm against the wall at shoulder height. Feel for the deep stretch in the forearm palm-side muscles. Follow this by bending your head sideways away from the wall. Using your opposite hand, gently pull your head over further sideways (no sharp pain allowed). Hold for up to 30 seconds and repeat two to three times or until you feel it loosen up. This can be repeated multiple times a day. If you don’t have a wall, do the same thing but with the arm extended forwards from the body (rather than sideways). Reach under your hand and gently pull your thumb back feeling for a similar deep stretch through the carpal tunnel (palm side wrist) and forearm. To perform the First Rib Stretch, place a towel over the shoulder close to the neck. Reach behind with the opposite hand and grasp the towel pulling downwards while the other hand grasps the front of the towel also pulling down. Drop your head sideways to the opposite side to increase the stretch. We can OFTEN help you avoid surgery so PLEASE try these exercises and our treatments BEFORE granting permission for surgery!

We realize you have a choice in whom you consider for your health care provision and we sincerely appreciate your trust in choosing our service for those needs. If you, a friend, or family member requires care for Carpal Tunnel Syndrome, we would be honored to render our services.

Carpal Tunnel Syndrome (CTS) management strategies were introduced last month, which we will conclude this month with Part 2. In part one, we cited three primary goals of CTS management that include the following: 1) Physical management strategies; 2) Chemical management strategies; and 3) Self-management strategies. All three goals include a component that we as doctors of chiropractic control AND (most important), a component that you the patient controls. We will continue this discussion this month with chemical management strategies.

2. Chemical management strategies: Here, MY JOB includes guiding you in methods to reduce swelling or inflammation. The first method involves the use of ice. Different cooling approaches include the use of ice cup/massage (applied directly on the skin until numb, which takes about five minutes) and/or ice packs (takes about 10-15 minutes). We can also offer assistance in choosing various anti-inflammatory herbs (such as ginger, tumeric, boswellia) and vitamins (such as vitamin B6 or pyridoxine; magnesium, fish oil / omega 3 fatty acids, vitamin D) with anti-inflammatory properties. Recently, probiotics have also been demonstrated to reduce inflammation! YOUR JOB is to follow these recommendations that you and I agree upon to help reduce the inflammatory effects of CTS. Other “chemical strategies” may include adding the primary care physician to “the team,” as prescriptions for various conditions such as diabetes, hypothyroidism, rheumatoid arthritis, and others may be appropriate in certain CTS cases.

3) Self-management strategies: Though we have already looked at “MY JOB” and “YOUR JOB” as it pertains to 1) Physical management and 2) Chemical management strategies, overlap exists between all three CTS management goals. In other words, as the name implies, “self-management strategies” includes the need for you to comply with the recommendations. For example, wearing the cock-up wrist splint primarily at night (when sleeping and less commonly at times during the day), following instructions regarding job modifications, nutritional strategies and, when applicable, pharmaceutical intervention are things you can do to alleviate symptoms. One of the MOST IMPORTANT self-help strategies is the training of carpal tunnel specific exercises, as well as exercise in general. Maintaining a proper weight (a BMI between 20-25) is also a goal that will help CTS, as obesity is a risk factor for this condition and a host of other conditions, including diabetes!

EXERCISE #1: Stand near a wall. Place your palm on the wall at shoulder height pointing the fingers down towards the floor, keeping the elbow straight. Reach across with the opposite hand and pull your thumb back as you stretch the palm-side forearm muscles. Hold 5-10 seconds until you feel the muscle “melt.” Repeat three times per side, five times a day. You can use the edge of a counter top rather than a wall, if you like.

EXERCISE #2: Bend the elbow 90 degrees. “Dig” your thumb DEEP into the palm-side forearm muscles close to the elbow. Slowly straighten the elbow and maintain the deep pressure into the muscle until the elbow is completely straight. REPEAT this multiple times moving your thumb one inch closer to your wrist from the last pressure point until you are one to two inches from the wrist (or, until you don’t feel much tenderness). You can vary the speed at which you straighten the elbow but generally, slower is better than fast movement, and the deeper the pressure, the better.

Repeat these two exercises on BOTH sides so you can feel the difference between the two, regardless if you have problems on both sides. Since the neck and shoulder can be involved, we will also show you how to stretch these areas, as keeping the whole “kinetic chain” stretched is very important for long-term benefits.

We realize you have a choice in whom you consider for your health care provision and we sincerely appreciate your trust in choosing our service for those needs. If you, a friend, or family member requires care for Carpal Tunnel Syndrome, we would be honored to render our services.

Carpal Tunnel Syndrome (CTS) can arise as a result of a number of different causes and as such, treatment is guided by the specific needs of the individual and tailored to each individual case. With that said, there are specific treatment strategies that chiropractors provide that address three primary goals: 1) Physical management strategies; 2) Chemical management strategies; and 3) Self-management strategies. All three goals include a component that we, the doctor, control AND a component that you, the patient, can control or manage. This combined effort or “team approach” ALWAYS works best, especially over the long-term. So, let’s break these three management strategies down along with the two components: my job (as your chiropractor) and your job (as my patient)!

1) Physical management strategies: This category addresses the mechanical nature of CTS. That is, compression of the median nerve at ALL of the possible sites, not JUST the wrist/carpal tunnel area. Since the median nerve arises initially from the neck or cervical spine, nerve root compression of C6-T1 (and a little of C5) can give rise to CTS signs and symptoms. As discussed last month, this area can be one of the “great imposters” of CTS and/or it may contribute as a co-conspirator and combine with CTS, which magnifies or increases the CTS signs and symptoms, the so-called “double-crush syndrome.” Other “mechanical” sites of compression can be reviewed in last month’s Health Update, but in brief, these may include the thoracic outlet (shoulder area), Struther’s ligament (just above the elbow), the pronator tunnel (just below the elbow), the anterior interosseous membrane (forearm), as well as at the carpal tunnel itself.

MY JOB (as your chiropractor) is to reduce the pressure on the nerve at any and/or ALL these locations (remember, each case is unique). This can be done by using manual therapies including (but not limited to) manipulation of joints in the neck, shoulder, arm, elbow, forearm, wrist, hand, and fingers. Mobilization of muscles and other soft tissues may include active release techniques, friction massage, trigger point therapy, stretching with and without resistance, traction, and more. Various modalities might be used to reduce muscle tightness, swelling, or inflammation.

A nighttime wrist splint keeps the wrist in a neutral position, as the carpal tunnel’s pressure goes up A LOT when the wrist is bent. Since you cannot control the position of your wrist while you sleep, the brace can REALLY HELP! A BIG part of my job includes teaching YOU about CTS so that you understand the underlying causes, thus allowing you to identify jobs, hobbies, or situations where you may be inadvertently harming yourself. If you can, PROMPTLY identify offending wrist positions and STOP the repetitive injurious movement and then MODIFY your approach to the task, whether it means taking “mini-breaks,” changing the work station set up, or some other approach. Along with this “teaching concept” is exercise training. It is also VERY IMPORTANT for you to properly perform the carpal tunnel stretches and other exercises (see Part 2 next month) on a regimented/regular basis.

YOUR JOB includes wearing the brace (don’t forget or procrastinate), most importantly at night. You can wear it during the day while driving or doing something where you are not “fighting” the brace. In some cases, the brace can bruise you if you are moving your wrist against it repetitively or too hard, and it can actually do more harm than good in those situations. Your job is also to identify ways to do your job and/or hobbies with less torque or twisting of your wrist.

Next month’s discussion will start chemical strategies (#2 on the list above), which includes several very effective and safe approaches in the CTS management process. We will then address #3, “Self-management strategies,” which will include various CTS-specific exercises.

Carpal Tunnel Syndrome (CTS) is caused by compression and subsequent irritation of the median nerve as it travels through the carpal tunnel and into the hand where it innervates the palm side of the second to fourth digits. As stated last month, the median nerve is sometimes referred to as, “…the eye of the hand” since we rely so heavily on activities of daily living (ADLs) that require its health and function. Some of these ADLs include buttoning a shirt, picking up small objects, tying a shoe or neck tie, writing, holding a book or coffee cup, gripping items such as a phone or steering wheel, opening jars, household chores, and carrying objects, especially with the finger tips.

When patients present with CTS signs and symptoms, one would think that the examination and treatment would be fairly straightforward and “routine.” The problem is, no two cases of CTS are identical because of all the possible mitigating factors, or the presence of OTHER issues that may be contributing or may be the REAL cause for CTS in that particular person. This may explain the reason surgical release of the transverse carpal ligament doesn’t always work!

The “Great Imposters” of CTS include both physical and chemical factors. Physical factors include (but are not limited to): 1) Cervical nerve root compression: Since the median nerve originates from the C6-T1 (and a little from C5) nerve roots exiting the spine, it only makes sense that a pinched nerve in the neck can mimic a pinched nerve at the wrist. The difference here is “usually” that the whole arm is involved, which is less likely in CTS only. Moving down from the neck, the next most common location for a mechanical pinch is at the 2) Thoracic outlet: Here, the nerve roots coming from C5 to T2, like merging lanes of a highway, come together to make the three main nerves that enter the arm and along with the blood vessels, this “neurovascular bundle” leaves the upper chest region and travels through the thoracic outlet to enter into the arm. The thoracic outlet can become narrowed if there is an extra rib, a shift in the collar bone or shoulder blade, from muscles that are too tight (especially the anterior scalene and/or pectoralis minor), or from anything that occupies space within the thoracic outlet. 3) Struther’s ligament: In a few of us (only about 2%), there is a ligament just above the elbow that can entrap the median (as well as the ulnar) nerve, creating a pinch and subsequent numbness below that point, mimicking CTS. 4) Pronator tunnel: The median nerve is more commonly entrapped by the pronator teres muscle just below the elbow, and treating this location can be highly rewarding when managing stubborn CTS cases. Less common is entrapment in the mid-forearm, though it’s possible by either the interosseous membrane that connects the ulna and radius or from fracture of the ulna and/or radius. The most distal point of median nerve compression is at the carpal tunnel. Entrapments can be singular or multiple and when more than one “tunnel” compresses the median nerve, the term double or multiple crush is utilized. Management MUST address ALL points of compression to obtain long-term satisfying results. Other “imposters” of CTS include a host of conditions including (but not limited to) thyroid disease, diabetes, arthritis, pregnancy, birth control pill use, obesity, and MANY others! Chiropractic makes the most sense when it comes to managing CTS from mechanical causes. If response is slow or not satisfying, we will order tests and/or consults to get to the bottom of what “imposters” may be contributing to your CTS symptoms!

We realize you have a choice in whom you consider for your health care provision and we sincerely appreciate your trust in choosing our service for those needs. If you, a friend, or family member requires care for Carpal Tunnel Syndrome, we would be honored to render our services.