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What Isn’t Carpal Tunnel Syndrome?

7 Jun

Numbness in the hand is a common problem that we’ve all had at one time or another, and unless it becomes frequent, we usually don’t worry too much about it. When it starts to wake us up at night, that SHOULD get our attention! Since carpal tunnel syndrome (CTS) is one of the most common causes of hand numbness, that must be it, right? Not necessarily!

CTS is caused by pinching of the median nerve as it travels through a sometimes too tight boney tunnel made up of the eight small carpal bones at the wrist. But there are two other nerves that arise in the neck and travel down the arm to the hand that may be the culprit, one of which is the ulnar nerve (the other is the radial nerve).

When the ulnar nerve is entrapped near the humorous, it creates a condition called cubital tunnel syndrome (CuTS). It’s during the examination that a doctor of chiropractic can determine if the culprit behind a patient’s hand symptoms is the median nerve, the ulnar nerve, or even both nerves.

Diagnosis can become tricky, as there are other causes of whole hand numbness such as diabetic neuropathy or an injury to a network of nerves closer to the neck called the brachial plexus. More commonly, cutting off the blood supply in the upper, inner arm will make the whole arm (not just the hand) numb and feel “dead” until it “wakes up,” which may take a few minutes for the blood to percolate back into the arm and hand.

CuTS can occur from repeatedly applying pressure to the pinky-side of the elbow, such as leaning on the elbow against a hard surface, keeping the elbow bent too long (such as talking on a cell phone), resting the arm or elbow on the sill of a car door with driving, and/or maintaining prolonged awkward positions, like playing a musical instrument such as a flute or violin. Baseball pitchers throwing too many sliders and curve balls are also at increased risk of developing CuTS.

Like with CTS, the longer you wait before seeking treatment for CuTS, the longer it may take to recover (or in some cases, full recovery may not be possible) so if you’re feeling numbness, tingling, or pain in one or both hands, please consult with a doctor of chiropractic right away!

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.
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Can Carpal Tunnel Syndrome Be Prevented?

7 May

Let’s say you’ve applied for a job that requires frequent gripping and handling of products and you heard that carpal tunnel syndrome (CTS) is a problem at this particular manufacturing plant. You really need the job, but you are leery of the possibilities of developing CTS. Is there anything you can do to PREVENT it?

Though there are no “guarantees” that CTS won’t occur despite our best efforts at prevention, here are some practical approaches that can make a big difference:

  1. LIGHTEN IT UP: CTS risk increases as a result of three things: Force + Speed + No Rest. First, try using less force or lighten up on your grip whenever possible. Though it’s hard to change habits, try gripping tools less tightly (use higher quality tools if they reduce the need to squeeze hard), don’t “pound” the keys of your keyboard, don’t squeeze your computer mouse, kitchen utensils, etc. and don’t strangle your golf club, tennis racquet, garden tools, or steering wheel. Use lighter-weight tools/utensils at home or work.
  2. TAKE BREAKS: Take 30-60 second stretch breaks every 15 minutes to allow the soft tissues in the hands and wrists to recover.
  3. STRETCH 1: Place your palm on the wall/desk pointing your fingers downward and stretch your wrist as far back as possible (elbow straight) until you feel the “pull” in the forearm muscles. HOLD for five to ten seconds and repeat on the other side. STRETCH 2: Make a fist for three seconds, then straighten out the big knuckle joints of the fingers (make a “bear claw”), followed by opening the hands and fanning out the fingers as far as possible. Hold each position for five to ten seconds and repeat as time allows.
  4. KEEP THE WRISTS NEUTRAL: When possible (driving a car, sleeping, etc.), keep your wrists straight/avoid bending. Use a wrist splint at times to help remind you (especially at night).
  5. CHANGE YOUR ROUTINE: Instead of staying at a risky task until you’re done, switch to a task that doesn’t require extreme gripping and force and/or switch between the left and right hand.
  6. CHECK YOUR POSTURE: Keep the chin tucked in (retracted) and head back. Avoid forward head posture and sit up “tall.” At a desk, keep knees, hips, elbows at 90°, and arch the lower back—in other words, don’t slouch!
  7. AVOID COLD HANDS: Try to avoid letting your hands and fingers get cold. Wear gloves (if possible), have a small space heater nearby, or rub your hands together. Even fingerless gloves can help a lot.
  8. ROTATE BETWEEN TASKS: Discuss rotating between job tasks with co-workers and your boss to avoid the same repetitive movements during your shift. This can really help in assembly line work.

SEEK HELP SOONER RATHER THAN LATER: Heed the early warning signs of CTS. Do NOT let CTS advance without seeing a chiropractor, as studies show that waiting too long reduces the success rate of treating CTS! Your doctor of chiropractic can teach you exercises, retrain your posture, suggest ergonomic (work) improvements, and treat your overused muscles and joints.

 

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.

CTS and Other Causes of Hand Numbness

12 Apr

Carpal tunnel syndrome (CTS) occurs when the median nerve is compressed at the wrist. However, there are other anatomical locations in which the median nerve can experience interference, and the median nerve is not the only nerve that ventures into the hand. So if you experience a symptom like hand numbness, CTS may not be the culprit…

After CTS, the next most common nerve pinch is the ulnar nerve at the inner elbow, which is technically called “cubital tunnel syndrome” (CuTS). This is often caused from over-use of the arm such as lifting and/or gripping with the palm up. The unique difference between CuTS and CTS is that the pinky and ring finger are affected but NOT the index, middle, and thumb-side ring finger, which are the median nerve-innervated fingers affected by CTS. Because over-use is also a common cause of CTS, these two conditions can co-exist, in which case all five fingers may be affected but not necessary all at the same time.

The shoulder is yet another fairly common location for a pinched nerve and is referred to as “thoracic outlet syndrome” (TOS). The most common nerve pinched here affects the fourth and fifth fingers, similar to CuTS; however, with TOS the upper arm is also affected, not just the elbow to the inner hand.

Another relatively common location for a pinched nerve affecting the arm is at the neck, often from a herniated disk and/or an arthritic spur where the nerve exits the spine. Depending on which nerve is compressed and the amount of compression, the numbness/tingling can affect different parts of the arm and/or hand.

Doctors of chiropractic are trained to differentiate between these various “syndromes” and to safely deliver treatment to the affected joints, muscles, and other soft tissues to reduce pain and restore proper motion so patients can return to their normal activities of daily living.

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 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).