Facts About Carpal Tunnel Syndrome and Sleep

            Have you ever woken up at night with numbness and tingling in your fingers and had to climb out of bed and shake your hands, flick your fingers, and/or rub your arms to “…wake them up?” Well, you’re not alone! In fact, this is one of the more common and often one of the FIRST symptoms of Carpal Tunnel Syndrome (CTS). So, WHY does this happen?

            The “carpal tunnel” is literally just a tunnel that MANY components of the body travel through on the way to the hand. The walls are made from eight small “carpal” bones and the “floor” of the tunnel is made by the transverse carpal ligament. These structures vary in size and shape and differ between males and females, which may be one reason CTS is more common among women than men. The contents of the tunnel include eight tendons that connect the muscles in the forearm to the index, third, ring, and pinky fingers. A ninth tendon that connects to the muscle that flexes the thumb also travels through the tunnel along with blood vessels. Perhaps most importantly, the median nerve that supplies sensation and strength to the palm side fingers (index, third and ring fingers) and the palm of the hand also travels through the carpal tunnel. The tendons to the fingers and thumb are “sheathed” and can swell due to the friction created by the tendon rapidly moving in the tight sheath. This is one reason why people who work in an occupation that requires fast, repetitive hand movements (such as assembly line work, carpentry, food preparation, for example) will often have problems with carpal tunnel syndrome.

            The pressure inside the wrist normally doubles when it is fully bent either forwards or backwards. However, because there is already greater pressure in the affected carpal tunnel of individuals with CTS (due to swollen tendons, for example), the pressure inside the carpal tunnel can increase much more when the wrist is bent. This added pressure can exacerbate the symptoms normally associated with CTS -- including numbness and tingling in the hands and fingers -- especially when the wrist is bent for a prolonged period of time, such as during sleep.

            Treatment associated with carpal tunnel syndrome includes the use of a night wrist cock-up splint, which keeps the wrist from flexing or extending during sleep and helps the swelling inside the carpal tunnel abate. Cock-up splints are not typically worn during the day, as they tend to interfere too much with normal activity and may actually worsen the condition depending on the length of time and the type of work the person is performing. Driving will often increase symptoms, and use of the cock-up splint can be effective during this time.

            Chiropractic management offers a unique form of treatment called manipulation and mobilization that is applied to the fingers, hand, wrist, forearm, and any other area where nerve compression might be present, which frequently includes the cervical spine/neck region. The shoulder and elbow may also require care.

            Anti-inflammatory measures including ice massage over the wrist and anti-inflammatory herbal preparations such as ginger, turmeric, and/or digestive enzymes taken between meals can help. Modifying the ergonomics of a CTS patient's workstation is a good idea in order to reduce the repetitive strain commonly associated with chronic carpal tunnel syndrome.

Carpal Tunnel Syndrome and Neck Pain – The Great Mystery!

            Carpal Tunnel Syndrome (CTS) develops when the median nerve is pinched at the palm-side of the wrist causing numbness in the index, third, and thumb-side half of the ring/fourth finger. Since the median nerve passes through the neck, it's possible that dysfunction in the neck can interfere with the median nerve, resulting in carpal tunnel syndrome-like symptoms. Sometimes the median nerve can be "pinched" in both the neck and the wrist in what's known as double crush syndrome.

            Though many patients benefit from both surgical and non-surgical CTS treatment approaches, it is not uncommon for the results to fall short of a total resolution of symptoms. In these unsuccessful cases, it's possible the median nerve is "pinched" at one or more locations other than the area the treatment focused on. In some cases, the hand symptoms and other signs of CTS can improve following treatment to relieve cervical dysfunction. The opposite can also be true with neck pain and related symptoms improving when the carpal tunnel is treated.

            The concept of “differential diagnosis” has to do with considering multiple possible causes that can create similar symptoms, and one by one, ruling “in” or “out” each diagnosis by performing various tests with the ultimate goal of coming away with one solid diagnosis. Of course, the problem with this is that there is often more than one diagnosis at play, and in such cases we must determine which one is primary vs. secondary.

            Taking our topic this month as an example, a chiropractor may often see cervical spine x-ray findings such as degenerative disk spaces, osteoarthritic spurring, or narrowing of the foramen that the spinal nerves pass through in route to the arm and hand. However, they may not be sure if these findings are “clinically important” or even contribute to a “cervical radiculopathy” or pinched nerve in the neck. It's possible to see these same x-ray findings in patients with no radiating arm symptoms whatsoever. Similarly, patients with radiating arm / hand complaints may have NONE of these findings! The same holds true with bulging and/or herniated disks in the neck because these may or may NOT cause any radiating symptoms. When a chiropractor is able to reproduce arm and hand symptoms during an examination of the neck that are similar to CTS, this increases the doctor's suspicion that at least a portion of the hand complaints may be attributed to nerve compression from the neck. When both neck and wrist findings co-exist, tests like EMG (electromyography) and NCV (nerve conduction velocity) can really help in some cases, but in other instances, the degree of nerve loss (the amount of damage) may not be enough to be accurately assessed with such diagnostic tools.

            The “bottom line” is that all health care practitioners start “conservative” and wait until all approaches have been exhausted prior to recommending surgery. As described in previous articles, there are MANY non-surgical approaches that chiropractors can provide and you owe it to yourself to try these conservative approaches first!

Carpal Tunnel Syndrome – WHAT YOU NEED TO KNOW!

            Carpal Tunnel Syndrome (CTS) develops from a nerve problem in the wrist (the median nerve) and is NOT a “muscle problem” like some people believe. That is not to say the median nerve cannot be trapped and pinched by muscles. When this occurs, the condition is labeled with a different name, depending on which muscle(s) are pinching the nerve or where the entrapment is located. Here are some more FACTS about CTS that you need to know:

            SYMPTOMS: CTS complaints include numbness, pain, tingling, and/or weakness of the hand (especially fingers two, three, and four), and while this can be constant, it usually comes and goes.

            ONSET: CTS usually comes on gradually. However, the length of time over which it progresses can be HIGHLY VARIABLE. It can take weeks, months, or even years before the patient consults with their chiropractor or family doctor.

            CAUSE: There are MANY reported causes of CTS, but it is not completely known how the process starts out or how it evolves for different people. Risk factors include age greater than 50, obesity, genetics (family history of CTS), gender (as it favors females over males), work type (highly-repetitive, hand-intensive work), pregnancy, birth control pill usage, thyroid disease, diabetes, rheumatoid arthritis, and more. In general, swelling is the culprit that results in pressure on the median nerve. This most commonly occurs from overuse of the hands and fingers. Playing musical instruments, sewing, crocheting, basket weaving, assembly/line work, meat processing work, typing/computer work, and waitressing are common over-use activities.

            CLINICAL COURSE: Early into the disorder, CTS is usually easily managed and reversible. However, if the amount of pressure on the nerve is too much, the symptoms can become permanent. Think of a wire and how wearing away the plastic coating will “short” the wire. There are multiple layers to our nerves and the wearing away of the outer layers over time can become a problem resulting in permanent numbness and/or weakness.

            BIGGEST MISTAKE: Don’t wait until your symptoms are terrible! If you feel periodic numbness and tingling and you find yourself shaking your hand and “flicking” your fingers in attempt to “wake them up,” NOW IS THE TIME TO COME VISIT YOUR CHIROPRACTOR before nerve damage occurs and the risk of permanency increases.

            HOW CHIROPRACTIC HELPS: Treatment guidelines for CTS recommend a non-surgical approach, and this is where chiropractic comes in! A wrist night splint is typically recommended since sleep interruption due to numbness is VERY common as we cannot control our wrist position when we sleep. Ice (not heat) is best as it reduces swelling (see #3 above). Rubbing an ice cube (or Dixie cup of ice) over the palm-side of the wrist works well. First, you will feel COLD followed by BURNING, then ACHING, and finally NUMBNESS (“C-BAN”). At this point STOP, as the next stage of cooling is frost bite! Do this three times a day or as directed. Your doctor of chiropractic will also talk to you about taking “mini-breaks” at home and/or at work and teach you exercises or stretches that can be performed during these breaks! A work station assessment is often very helpful as sometimes a simple change in work position or method can reduce wrist strain considerably. Your doctor of chiropractic may also perform manipulation to the small joints of the hand, wrist, elbow, shoulder, and neck as indicated in each specific case. He or she may also perform soft tissue release techniques to the muscles and soft tissues of the forearm, shoulder, and neck regions as needed. Surgery should be the LAST step in the treatment process, used only if all other non-surgical options have been tried without success.

The Challenges of Carpal Tunnel Syndrome

            Carpal Tunnel Syndrome (CTS) is one of the most common “peripheral neuropathies” patients have when they visit a chiropractor for the first time. Peripheral neuropathy (PN) is defined as “…damage or disease affecting nerves, which may impair sensation, movement, gland or organ function, or other aspects of health, depending on the type of nerve affected.” Let’s take a closer look!

            Common causes of PN include systemic conditions such as diabetes, vitamin deficiency, medication side effects (such as chemotherapy meds), traumatic injury, after radiation therapy, excessive alcohol intake, an autoimmune disease such as rheumatoid arthritis, and/or viral infection. PN can be linked to an individual's genetics that are present from birth. For others, it can be unknown which is then referred to as “idiopathic.”

            PN can affect one nerve (mononeuropathy) or multiple nerves (polyneuropathy) and can be acute (which means it comes on quickly) or chronic (which means it comes on gradually over time and progresses slowly). PN symptoms can include cramp/charley horse-like pain, muscle twitching, muscle atrophy or shrinkage, numbness, tingling, pins and needles, burning or cold feeling, and can also affect other tissues such as bone causing degeneration, skin changes, and hair and nail changes. PN can also affect a patient's balance and coordination which can increase an individual's chances of falling. If organs or glands are also impacted, PN can lead to poor bladder control, heart rate or blood pressure changes, and/or affect the sweat glands.

            Getting back to CTS specifically, one of the challenges of this condition is determining the cause/s. Here’s what we know about CTS: 1) it is more common in women than men; 2) it is more common in those who are overweight; 3) it is more common in those who work in highly repetitive environments; 4) it is more common over age 50; 5) it is often accompanied by other upper extremity “over-use” conditions like tendonitis in the hand, wrist, elbow, and/or shoulder and can also involve the neck (as CTS cases improve faster when treatment is also applied to the cervical spine); and 6) it commonly includes one or more of the conditions previously mentioned that can cause neuropathy such as diabetes and rheumatoid arthritis. Other conditions such as hypothyroid can also cause or worsen an existing case of CTS, in part due to “myxedema,” a type of swelling that occurs with this condition. Here, the additional swelling can add to the compression or pressure pushing on the median nerve in the carpal tunnel and either cause CTS or worsen an existing case.

           

            Because CTS can have more than one underlying cause, it's important that your doctor determine as many as possible in order to achieve the best treatment results. We’ve all heard of the cases that fail to respond to surgical intervention, which in many cases is because there were MULTIPLE CAUSES and only one was addressed with the surgical approach. Surgery has always been described as “the last resort” and indeed it’s appropriate in some cases. However, MANY CTS patients respond well to chiropractic management, which often includes (but is not limited to): 1) joint manipulation and mobilization of the hand, wrist, forearm, elbow, shoulder, and neck; 2) use of a night-time splint; 3) home/work exercises; 4) physical therapy modalities; 5) nutritional considerations; and 6) ergonomic modifications (work station assessment). If these approaches fail to achieve satisfying results, your doctor will refer you to a hand surgeon to determine which procedure might be best for you.

Carpal Tunnel Syndrome vs. Cubital Tunnel Syndrome

            Carpal Tunnel Syndrome (CTS) belongs to a group of disorders referred to as “cumulative trauma disorders,” or CTDs. The word “cumulative” refers to the cause being repetitive motion, usually fast and prolonged. Over time, the wear and tear on the upper extremities accumulates and symptoms begin to occur and possibly worsen. This can result in changes in movement intended to avoid further injury that then overstress another part of the arm, which can lead to a second injury. Like dominos, injury after injury can eventually result in multiple conditions between the neck and hand. Let’s take a look at two of the more common CTDs…

            Carpal Tunnel Syndrome (CTS) is the most well known of the CTDs because the thumb, index, third, and fourth ring finger comprise 90% of the hand’s function. This part of the hand is innervated by the median nerve that travels through the carpal tunnel at the wrist. When injured, it can make fine motor movements, like tying your shoe, difficult-to-impossible! Our grip strength is also greatly affected by a pinch of the median nerve, so dropping coffee cups, difficulty removing a gallon milk jug from the refrigerator, and the ability to lift and carry are all compromised. Some risk factors for CTS include: 1) Age over 50; 2) Female gender; 3) Obesity; 4) Working in a highly repetitive motion type of job (assembly line work, meat/poultry plants, typing); 5) The presence of other CTDs such as forearm, wrist, or hand tendonitis; and 6) Metabolic conditions such as thyroid disease (hypothyroidism), diabetes, rheumatoid arthritis, and more. Management strategies include: 1) Night use of a wrist splint (i.e., rest); 2) chiropractic manipulation of the small joints of the wrist and hand, and often, the elbow, shoulder, and neck; 3) Muscle and tendon myofascial release / mobilization techniques; 4) Management of any underlying metabolic condition (like hypothyroid disease and diabetes); and 5) Anti-inflammatory measures (ginger, turmeric, boswellia, bioflavinoids, vitamin B6, ice massage over the palm side of the wrist). NOTE: Recent studies have reported the use of NSAIDs -- non-steroidal anti-inflammatory drugs like Advil (ibuprofen), Aleve (Naproxen), and aspirin -- can interfere with and prolong the healing process. Chiropractic care may also include the use of modalities such as low level laser therapy, pulsed magnetic field, ultrasound, and/or electrical stimulation. Your doctor may order an EMG/NCV (electromyogram/nerve conduction velocity) if the case is not responding appropriately. Surgical intervention is the LAST RESORT but frequently, conservative chiropractic care yields satisfying results!

            Cubital Tunnel Syndrome (Ulnar Nerve Entrapment – UNE): This is similar to CTS but it involves the ulnar nerve being pinched at the inner elbow (near where the "funny" bone is located). The big difference here is that the numbness/tingling involves the pinky side of the fourth and fifth fingers (NOT the thumb, index, third, or thumb-side of the fourth finger). Remember, you can have BOTH CTS and ulnar nerve entrapment (UNE) at the same time, in which case all five fingers may be involved. Causes are similar as CTS, but a more recently identified cause is called “cell phone elbow” due to the prolonged elbow flexed/bent position while using a phone. An overnight splint keeping the elbow straight as well as a wrist splint can be very effective. Otherwise, the treatment is similar to that described for CTS and it is frequently easily managed with non-surgical chiropractic care!

Why Nighttime Pain with Carpal Tunnel Syndrome?

            Chiropractors are often asked, “Why does Carpal Tunnel Syndrome (CTS) bother me so much during the night?” Let’s take a look!

            The carpal tunnel is made up of eight small carpal bones that bridge the forearm to the hand. Without these eight little bones, the motion at the wrist would be very restricted and limited to bending a little bit up and a little bit down. Think of all the things you are able to do with a large range of motion at the wrist like tightening a small screw by hand, pulling on a wrench, using a hammer, working under the dash or inside the engine compartment of a car, threading a needle, sewing, knitting, crocheting, and even washing dishes. As you can see, we put our wrists in some pretty strange positions!

            Look at the palm-side of your wrist and wiggle your fingers. Do you see all that activity going on? Now, move your eyes slowly towards the elbow as you keep moving your fingers. It is pretty amazing how much movement occurs near the elbow just by moving the fingers! There are actually nine tendons that travel through the carpal tunnel, and these tendons connect your forearm muscles to the fingers. That’s why there is so much movement in the upper half of the forearm when moving your fingers, and in people with CTS, these muscles are usually overworked and super tight. This is why chiropractors work hard to loosen those muscles during treatment! These nine tendons are covered by a sheath, and friction between the tendon and the sheath is reduced by an oily substance called synovial fluid. When we repetitively and rapidly move our fingers, the friction that builds up produces heat, and if the oily synovial fluid can’t keep up, swelling occurs.

            Any situation where there is increased swelling in the body can also promote CTS. For example, during pregnancy, hormonal shifts can result in a generalized swelling similar to taking BCP’s (birth control pills). Hypothyroid results in edema or swelling referred to as “myxedema” that can cause or make CTS worse. Some of the inflammatory arthritis conditions such as rheumatoid, lupus, scleroderma, and more can also predispose one to developing CTS. Obesity by itself is a risk factor for similar reasons.

            So, why are we so susceptible to CTS symptoms at night? The main reason is that we RARELY sleep with our wrist in a straight or neutral position. We like to curl up in a fetal position and tuck our hands under our chin, bending the wrist to the full extent (90°). By doing so, the pressure inside the wrist “normally” doubles, but in the CTS patient, the pressure can increase by six times! This pinches the median nerve against the ligament that makes up the floor of the tunnel as it travels through the carpal tunnel, which then wakes us up and we find ourselves shaking and flicking our fingers to stop the numb, tingling, burning, pain that commonly occurs with CTS! This is why we prescribe a wrist brace for nighttime use and it REALLY helps! DON’T JUMP TO SURGERY FIRST – TRY CHIROPRACTIC FIRST!

The “Many Faces” of Carpal Tunnel Syndrome

            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!

Carpal Tunnel Syndrome: Onset and Symptoms

            Carpal Tunnel Syndrome (CTS) is a painful, often debilitating, progressive condition that occurs when a nerve in the wrist becomes compressed. Let’s take a closer look at what CTS is and what can be done for it!

            ONSET: Often, CTS starts with an infrequent, vague sort of numbness or tingling that prompts us to periodically shake our hand and flick our fingers. Most of the time, we initially don’t give this much thought, as it isn’t too irritating. As time passes -- and this can sometimes be days, weeks, or months -- the intensity, frequency, and duration gradually worsen. Sooner or later, it can get to the point of prompting a visit to a Chiropractor. The rate that CTS progresses is more dependent on the amount of pressure on the median nerve more so than the length of time the pressure is applied. In other words, CTS can develop immediately if the nerve becomes acutely pinched from things like a wrist fracture or other obvious trauma. In these cases, it is VERY IMPORTANT that the nerve is decompressed promptly to avoid permanent nerve damage. However, a gradual worsening of symptoms over time is far more common, but it is still BEST to come in sooner rather than later since the greater the degree of inflammation or swelling, the longer the recovery time.

            SYMPTOMS: The symptoms of CTS are quite unique and specific. It is not unusual for patients to say, “…I think I have carpal tunnel” when any complaint of the wrist or hand arises. CTS causes numbness, tingling, and/or pain specifically into the index, middle, and the thumb-side of the ring finger, as this is what the median nerve innervates, but not usually the thumb (unless the nerve is also compressed before the wrist). Numbness on the ring finger and pinky is usually the result of an ulnar nerve pinch, which frequently occurs at the inner elbow where the “funny bone” is located and/or at the shoulder (“thoracic outlet”), and/or the neck (from a pinched lower cervical nerve root). Combinations of these can result in a “double crush” or “multiple crush” injury and treatment must then focus on ALL the places where the nerve compression occurs. This is why you should consider obtaining CTS treatment sooner rather than later, because when you wait and let it go, the tendency is to start making changes in the way you use your arms and hands. This is an unconscious compensatory response that often leads to further problems higher up in the arm and/or neck.

            According to the National Institute of Neurological Disorders and Stroke, CTS is the MOST COMMON of the “entrapment neuropathies” where the body’s peripheral nerves become compressed or pinched. It is estimated that 5% of women and 3% of men have CTS, and studies estimate 3-6% of adults (most commonly between ages 45-64 years) in the general population suffer from CTS. Chiropractic offers a non-drug, non-surgical approach that is highly effective. This should be your FIRST STEP in treatment as surgery can often be avoided!

7 Possible Causes of Carpal Tunnel Syndrome

            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…

1.                   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.

2.                   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!

3.                   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.

4.                   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.

5.                   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.

6.                   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.

7.                   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. 

Carpal Tunnel Syndrome “Home Remedies”

                 Carpal Tunnel Syndrome (CTS) results in pain, numbness, tingling, grip strength weakness, interrupted sleep, and can interfere with work, social family, and recreational activities. Symptoms can radiate up the forearm and into the fingers making tasks that require intricate finger movements very difficult. Many of us know someone who has had carpal tunnel surgery, but what can be done in order to avoid surgery? Let’s find out!

                Exercise: The follow five exercises should be performed MANY times a day! The goals are to keep the tendons traveling through the carpal tunnel freely, promote better circulation, remove the pinch on the median nerve, and strengthen muscles. As a general warning, modify or STOP ANY exercise if you feel sharp pain or worsening of symptoms!

1. WRIST CIRCLES: Palms down, elbows bent 90 degrees, draw a circle with your third/long finger. Repeat five times, clockwise and counterclockwise. Increase the size of the circle with each repetition.
2. THUMB STRETCH: Place the palm of your hand on a wall (elbow straight) fingers pointing downward. Reach across and pull your thumb back and hold for five seconds and repeat three to five times.
3. 5-FINGER STRETCH/"BEAR CLAW"/FIST: a) Spread your fingers out of both hands as far as possible; b) Bend ONLY the fingers tips (not your big knuckle joints); c) Make a tight fist. HOLD each position for five seconds repeat three to five times.
4. WRIST CURLS (4 positions: Palm up, Thumb up, Palm down, Pinky up): Using either Thera-Band / Tubing or light hand weights, sit and rest your forearm on your thigh; position your hand palm up and lift the weight/stretch the tubing towards the ceiling. SLOWLY release the resistance on the tubing / lower the weight towards the floor. Repeat this three to five times in each of the four hand positions listed above. For the “pinky up” exercise, raise your arm from your side so you can position your hand so the pinky faces the ceiling. Feel free to support your wrist with your other hand. You can gradually increase the weight (max. 5 lbs./2.27 kg) / band resistance.
5. NECK STRETCHES: Bend your head sideways to the right and reach over with the right hand and pull gently while reaching down towards the ground with the left. Move your head and neck into various positions feeling for a good stretch in different tight neck muscles. Repeat this on the other side.

                Diet and Nutrition: This is very important, as you can reduce the inflammatory markers in your body quite well by doing some very simple things! First, stop eating grains, as they can cause inflammation! Supplement your diet with 4000 IU of fish oil / day and 5000IU of vitamin D3 per day (of course, talk with your Doctor first). Avoid sugar as much as possible. This will not only help reduce your swelling, but usually boosts your energy and helps with weigh loss – as obesity is a risk factor for CTS!

                Sleep: Since we cannot control the position of our wrist when sleeping, wearing a splint that holds your wrist straight at night is extremely helpful. We will help you with this!

                Driving: It's common for CTS symptoms to worsen while you hold the steering wheel. Position your hands at an 8 and 4 o’clock position on the wheel to keep the wrist straight. Wearing the splints when driving can help as well.

                Chiropractic Care: There are often multiple sites between the neck (where the median nerve starts) and wrist that needs to be kept loose to minimize nerve compression. These treatments are very effective for many people!

Carpal Tunnel Syndrome – What Can I Do to Help? (Part 2)

            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 and Musicians

            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 During Pregnancy

            While Carpal Tunnel Syndrome (CTS) is usually characterized as a repetitive stress injury, it can also be caused by pregnancy. In fact, CTS is a common complaint among pregnant women due to the increase in fluid build-up in the tissues, including the forearms and wrist. Edema is the technical term for fluid build-up, and it is hard to avoid during pregnancy. This swelling results in increased pressure on the median nerve that originates in the neck, travels through the shoulder, into the arm, through the wrist and innervates the thumb, index, third and half of the fourth finger. The “usual” initial symptoms include a “half-asleep“ sensation in the fingertips prompting the sufferer to shake and “flick” the fingers in attempt to “…wake them up.” These symptoms (with or without pregnancy) commonly occur at night, as many tend to sleep with wrists in bent positions. When we bend our wrist in any direction, the pressure inside the carpal tunnel will double.

            This can happen even more if there is edema or swelling present from the hormonal shift that occurs during pregnancy. This is why chiropractors will frequently fit CTS patients with a “cock up splint,” which is to be used primarily at night, as it often gets in the way during routine daytime activities. However, there may be times when the cock-up splint can be quite beneficial, such as when driving and holding onto the steering wheel. Grip strength may also be affected, making buttoning shirts and opening jars difficult. CTS may only affect your dominant hand, but it can affect both. It is less common that CTS only impacts the non-dominant hand. There is an increased likelihood of developing CTS if you had it previously and/or if other family members have had CTS. Also, if you’ve had problems with your neck, back, or shoulder, such as an old whiplash injury, slipped disk in the neck, or broken collar bone, you are also at greater risk of developing CTS. If you were obese before the pregnancy and/or put on too much weight during the pregnancy, this too will increase the risk.

            Besides the splint, other forms of care during pregnancy include: 1) EAT A BALANCED DIET. Include small amounts of lean protein (meat, poultry, eggs, beans) with each meal. Reduce the amount of salt, sugar, and fat you eat and drink PLENTY OF WATER! Eat at least five portions of fruit and veggies EVERY DAY! 2) VITAMIN B6. Pyridoxine or B6 has been reported to help CTS sufferers, and it is good for the nervous system. Foods rich in B6 include sunflower and sesame seeds, dark green vegetables (like broccoli), garlic, hazelnuts, lean meat, avocados, and fish (salmon and cod especially). Consider a B6 supplement, but DON’T exceed 150mg/day. 3) MATERNITY BRA. Be sure to wear a good fitting maternity bra with straps that don’t dig into your shoulders and neck. Wear it early on, as this can reduce the weight off your neck, ribcage, and shoulders and can help avoid compression of the median nerve. 4) Herbs such as chamomile tea, ginger, turmeric, and others that fight inflammation can be effective – we will guide you on the dose! 5) Wrist exercises, wrist manipulation/mobilization, traction, and muscle release work can ALL be VERY effective which we can provide for you.

            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 – What Can I Do to Help? (Part 1)

            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. 

            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 – What Is It?

            Carpal Tunnel Syndrome (CTS) basically occurs when pressure is applied to the median nerve as it travels through the wrist on the palm side resulting in numbness, tingling, pain, and later, weakness of the grip and pinch functions. But, the median nerve can be pinched at many other locations as it courses down from the neck to the hand, which is why we examine and treat the CTS patient from the neck down! The median nerve has been described as the “eye of the hand,” as it is one of the three major nerves formed from the brachial plexus-- that “highway” of nerves made up of the C5-T2 roots leaving the neck, merging together to eventually form the three main nerves of the arm. Because the median nerve function regulates pinch and grip strength, buttoning a shirt, writing a note, driving a car, and even sleeping are ALL affected by a median nerve pinch. But WHAT is CTS? Let’s take an “inside” look!

            We know that fast, repetitive motion-related jobs like meat or fish packing plants, assembly line work, sewing occupations, and the like can cause CTS over time. Look at the palm side of your wrist and wiggle your fingers. Do you see ALL THE MOVEMENT that is occurring just before the wrist in the forearm? That motion is coming from the tendons, which like shoe strings, attach the forearm muscles to the fingers. Notice ALL the movement in your forearm muscles closer to the elbow – that’s a lot of motion! There are nine tendons that are covered by a lubricating sheath that help the fast moving tendons reduce friction, thus decreasing the chances for heat build up, swelling (inflammation), and subsequent pain and loss of function. But, there is a limit or threshold that the tendons and sheaths can withstand before they just can’t keep up. These nine tendons and sheaths are quite tightly packed together as they leave the forearm and enter the carpal tunnel.

            The carpal tunnel is made up of eight small wrist bones called the “carpal bones,” and ANYTHING that makes that tunnel more narrow can effectively cause CTS. If we look at what happens INSIDE the tunnel in the CTS patient, the venous blood flow and nerve flow (called “axonal transport”) is blocked when the PRESSURE inside the tunnel occurs. We all know what it feels like when a blood pressure cuff is inflated on our arm – if it’s pumped up too high or left on too long, the arm REALLY HURTS! That’s because the blood can’t get past the inflated cuff and oxygen can’t get to our muscles and tissues past the cuff and IT CAUSES PAIN!

            To give you an appreciation of the pressure difference between the normal vs. CTS wrist, normally, the pressure ranges between 2 and 10 mmHg. We pump up a blood pressure cuff to about 150-200 mmHg when we take blood pressure, so this is NOT MUCH! This 2-10 mmHg pressure increases when we change the position of our fingers, wrist and forearm with wrist extension (bending the hand backwards), causing the greatest pressure increase. This is why we fit the CTS patient with a wrist “cock-up” splint to be worn at night since you can’t control your wrist position when you sleep and any bent position increases the pressure and can wake you up due to numbness, tingling, pain prompting you to shake and flick your hands and fingers until they, “…wake up.” When CTS is present, the pressure inside the tunnel goes up exponentially, meaning NOT 2 or 3 times, but 6, 12, 24 times what is normal and even higher! Now, if you add wrist bending (extension > flexion), the pressure REALLY gets high and it doesn’t take long for the nerve pinch and blood loss to wake us up. We’ve previously talked about other conditions that can make developing CTS more common or make it worse like hypothyroid, diabetes, arthritis, kidney disease, and more. AGAIN, this is because an increase is pressure results from these conditions (increased swelling = increased pressure = increased symptoms). As chiropractors, we will guide and manage your care through the healing process of CTS using a conservative, NON-SURGICAL treatment approach – TRY THIS FIRST!

            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.

The Many Faces of Carpal Tunnel Syndrome

            Carpal Tunnel Syndrome (CTS) was first reported in the late 1800’s and the first surgery was noted in 1933. In the beginning, CTS surgery was rarely performed, reportedly because the nerve pinch was present somewhere before the median nerve reached the wrist or carpal tunnel. In brief, possible compression sites include the cervical nerve roots (C5-7), the brachial plexus, thoracic outlet, above the elbow, in the proximal and/or mid forearm, and finally at the wrist / carpal tunnel.

            Estimating the frequency of CTS is challenging due to the fact that the pinch or entrapment may include more than one area before the wrist resulting in double and multiple crush syndromes. One European study reported the incidence of CTS at 5.8% in women and 0.6% in men while another reported 3.4% in the United States. Even the causation of CTS is all over the board. For example, the annual incidence of CTS in automobile workers ranges between 1-10%, while in a fish processing plant, it was reported to be as high as 73%! To make this even more challenging, the cause of CTS is commonly associated with other conditions such as diabetes and pregnancy. In diabetics, CTS ranges between 14% and 30% and those who are pregnant have a 2% incidence. Even harder to report is the incidence of median nerve pinching proximal to the wrist as this ranges between as little as 1% to as high as 75% for pronator tunnel syndrome in already symptomatic women. Gender is also a factor as women are reported to be four times more likely to develop CTS than men. If there is NO other condition associated with CTS, the term “idiopathic” is applied, and this reportedly occurs 43% of the time.

            Another issue making CTS a challenge to diagnose is the many risk factors associated with it, and sometimes studies are published that contradict one another about the possible risk factors. There are studies that report CTS is more likely to occur with conditions including: 1) Jobs or activities associated with wrist flexion or extension; 2) Hysterectomy without ovary removal; 3) Obesity; and 4) Varicosities in men. Some studies indicate risk criteria such as: 1) Use of birth control pills; 2) Age at menopause; 3) Diabetes; 4) Thyroid dysfunction; 5) Rheumatism; 6) Typing; and, 7) Pinch grasping. One study reported the highest incidence to occur in those with previous wrist fracture (Colles’ fracture), and common conditions included rheumatoid arthritis, hormonal agents or ovary removal, diabetes, and pregnancy. Another study reported obesity and hypothyroid as being risk factors, but not all studies support that theory. Certain medications have been reported to be associated with higher CTS risk including: 1) Insulin, 2) Sulfonylureas (diabetes meds); 3) Metformin; and 4) Thyroxin.

            As doctors of chiropractic, we perform a thorough history, examination, and offer MANY non-surgical, non-pharmaceutical ways of treating CTS. Some of these approaches include: 1) Joint and soft tissue manipulation of the neck, shoulder, elbow, forearm, wrist, and hand; 2) Wrist splinting, especially at night; 3) Vitamin B6 and anti-inflammatory nutrients; 4) Home exercises for the neck, arm and hand; 5) Work station / ergonomic evaluations; 6) Dietary counseling for various conditions listed previously; 7) Co-management with primary care, rheumatology, neurology, orthopedics, and others.

            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 and the Neck?

                Carpal Tunnel Syndrome (CTS) is a problem that occurs when the median nerve gets pinched as it passes through the tunnel at the wrist, resulting in numbness that includes the palm side of the hand, the thumb through digit three and the thumb-side half of the ring or fourth finger. So, how does the neck fit into the cause and/or the treatment of CTS? Let’s take a look!

                The neck is comprised of seven vertebrae and eight pairs of nerves that travel down the arms allowing us to feel sensations such as hot/cold, vibration, and sharp/dull. These nerves allow us to move our muscles and joints including the fingers, wrist, elbow and shoulder. These eight pairs of nerve roots, like a super highway of eight lanes of traffic, eventually merge into the ulnar, median, and radial nerves that extend down our arms. The median nerve is the primary nerve involved in carpal tunnel syndrome, so let’s take a look at the route that it takes as it leaves the cervical spine, or neck.

                Initially, when the eight nerve roots first exit the spine they interconnect forming the brachial plexus, and by the time the nerves reach the arm pit, they’ve “merged” into the three main nerves that extend the rest of the way down the arm. The median nerve can become trapped or pinched at a number of different places, most commonly at the wrist’s carpal tunnel followed by the pronator tunnel which is located at the elbow just past the crease on the palm side. It can also be pinched before the elbow by a ligament that exists in about 1% of us (Struther’s Ligament), but this is rare.

                If a fracture should occur anywhere along the route of the nerve, that too can cause a compression. The neck is a common location where the cause of the numbness can arise. The median nerve arises from three nerve roots that exit the neck (C5, C6, and C7); therefore, ANYTHING that places pressure at this location in the neck can result in similar symptoms as CTS.

                The term, “double crush” syndrome applies to the situation where compression (pinching) of a nerve occurs in more than one place. This was first discussed in 1973 and has since been a debated topic. When a nerve is compressed in more than one location, there is a physiological change in the way the nerve transmits a signal and a minor (sub-clinical) compression that would by itself not be symptom-producing becomes symptomatic if a second compression occurs elsewhere along the course of the nerve. Similarly, metabolic changes, such as diabetes, can also make minor CTS symptomatic. This is why it is ESSENTIAL that the entire course of the nerve be tested, not just at the wrist but also at the neck, shoulder, and arm. I’m sure you can see the importance of this, as surgical decompression at the wrist may NOT help in a case where a more significant pinch is present elsewhere. This has been estimated to occur between 30-75% of the time! A common site for double crush with CTS is at the cervical nerve root, and treatment of the compression site in the neck by a chiropractic adjustment can MAKE OR BREAK a successful outcome when treating CTS. The bottom line? Try chiropractic FIRST as you can’t reverse an unnecessary 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.

CTS “Facts”

            WHAT is Carpal Tunnel Syndrome (CTS)? CTS occurs when pressure is applied to the median nerve which travels from the neck, through the shoulder, upper arm, elbow, forearm, and through the carpal tunnel where the “pinch” is located. The median nerve innervates most of the palm of the hand, the thumb, the index finger, middle finger, and the thumb side of the ring finger. The carpal tunnel is made up of eight little bones in the wrist that form the arch and a ligament that forms the floor. There are nine muscle tendons, the median nerve, as well as blood vessels that travel through the tunnel.

           

            WHAT are the symptoms of CTS? The “classic” symptoms include burning, itching, tingling, and/or numbness of the second to fourth fingers with the need to shake or “flick” the fingers to “wake up the hand.” When present long enough, or when the pressure is hard enough on the nerve, weakness in the grip occurs and accidental dropping of tools, coffee cups, and so on can occur. Pressure on the nerve increases when the wrist is bent backwards or forwards, especially for long time frames and/or when the wrist is moving in a fast, repetitive manner with jobs like carpentry using vibrating tools, a screw driver, hand drill, a hammer, line production work, waitressing, and so on. Often, symptoms are first noticed at night, as we tend to sleep with our wrists bent and tucked under our chin or neck. Symptoms can also occur during the day, especially when driving or when performing repetitive work. Difficulties buttoning a shirt, making a fist, grasping small objects and/or performing manual tasks are common complaints of CTS.

            WHAT are some causes of CTS? CTS is most commonly caused by a combination of factors that result in swelling of the tendons that travel through the carpal tunnel. This includes over working the arm and hand in any of the jobs described above, but it is more likely to happen when conditions that create generalized swelling occur. Some of these conditions include trauma (like a sprained wrist), hypothyroidism, an over-active pituitary gland, during menstruation or pregnancy, menopause, rheumatoid arthritis, diabetes, mechanical wrist problems, repetitious work (work stress), or the repeated use of vibratory hand tools. It is also possible to develop a cyst (like a ganglion) or a fatty tumor within the tunnel. CTS is also more common with obesity, but sometimes, no logical cause can be identified!

           

            WHO is at risk of developing CTS? Women are three to four times more likely to develop CTS. This may be because of the hormonal aspects described above and/or the relative smaller wrist, which results in a smaller carpal tunnel. There's also an increased risk of CTS in people over the age of 50. Other at risk individuals include diabetics, people with hormonal imbalances (taking birth control pills, pregnancy, hypothyroid, etc.), and people who work on assembly lines.

           

            How is CTS diagnosed? EARLY diagnosis and treatment is KEY to a successful outcome! The physical exam includes assessing the structures of the neck and entire upper extremity, as the pinch is often in more than one place. A blood test for thyroid disease, diabetes, and rheumatoid arthritis is also practical. Other tests that may help us diagnose CTS can include and EMG (nerve test) and/or x-ray/MRI. Next month, we’ll discuss treatment and prevention!

            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: More “Fun Facts!”

                Did you know that Carpal Tunnel Syndrome (CTS) can affect anyone? None of us are immune to developing CTS as roughly 1 out of 20 of us will develop CTS in our lifetime! This month, let’s look at some of the risk factors for developing CTS.

1)       Race: Caucasians carry the greatest risk of developing CTS.

2)       Gender: Women are three times more likely than men to develop CTS. This may be because female wrists are smaller and shaped a little differently than male wrists, but hormonal differences are probably the most important reason for this variance.

3)       Pregnancy: Up to 62% of pregnant women develop CTS. This is thought to be due to the excess fluid retention that normally occurs during pregnancy and most likely stems from the elevation in hormone levels that NORMALLY occurs during pregnancy. The prevalence in the first, second, and third trimesters is 11%, 26%, and 63%, respectively, thus supporting the fact that the risk increases with the length of the pregnancy. Though CTS usually resolves after giving birth, symptoms can continue for as long as three years following delivery!

4)       Birth Control Pill (BCP): The use of BCPs increases CTS risk due to an increase in hormonal levels similar to the CTS risk increase during pregnancy.

5)       Occupational: Workers in highly repetitive, hand-intensive occupations (such as line work, sewing, finishing, meat processing, poultry or fish packing) have a higher rate of developing CTS.

6)       Injury to the wrist or hand: An obvious example is a wrist fracture from a slip and fall, sports injury, or blunt trauma like a car accident. When there is a direct pinch on the median nerve, nerve damage can occur quite quickly, and as a result, the onset of symptoms can be very fast. Less obvious injuries, which usually have significantly slower onsets, include repetitive motion injuries, often referred to as “cumulative trauma disorders” and include a group of conditions such as tendonitis, sprain/strain, bursitis, and other types of soft tissue injuries.

7)       Certain conditions: Nerve damaging conditions that can cause CTS include diabetes and alcoholism. Other conditions that can contribute and/or cause CTS include menopause, obesity, thyroid disorders, kidney failure, and more.

8)       Inflammatory conditions: These include several types of arthritis such as rheumatoid, lupus, and others. Osteoarthritis is technically NOT an “inflammatory” condition but it can cause CTS by compressing the median nerve via a bone spur formed within the carpal tunnel.

9)       Faulty work stations: A job site has A LOT to do with whether or not a person develops CTS. Though jobs that require fast, repetitive movements pose the greatest risk (see #5 above), other work-related factors that may be controllable can also significantly contribute to the development of CTS. Some of these include the shape of tools such as screwdriver handles shaped like a gun (pistol) which allow for better alignment of the wrist than a “normal” straight screwdriver handle. Another is a power tool that may have too much vibration or torques too hard at the end of a cycle. A handle that is too cold/hard (e.g., metal handle) or that may be too large for the worker’s hand is an additional factor to consider. Positioning the work so that the wrists can stay straight vs. bent can be VERY helpful. In fact, if some of these “ergonomic” factors are not fixed, CTS can be next to impossible to remedy. Also, poor posture in the back, neck, and the rest of the body can result in compensatory faulty postures elsewhere. Look in a mirror and poke your chin out towards the mirror. Now look at your shoulders. See how they roll forward and feel the strain in your upper back and neck? Keep your chin tucked in, NOT out. This can make a BIG difference in your posture!

                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.