Treating Carpal Tunnel Syndrome
Most common treatments recommended in the medical profession for carpal tunnel syndrome are wrist splints and surgery. When wrist splints are recommended they are usually worn for a period of time, especially at bedtime to help the patient from aggravating their pain or symptoms by limiting the movement of their wrists. They are helpful to some, but not intended to be curative. At best they should be expected to prevent aggravation by stressful posturing of the wrists while sleeping. Many carpal tunnel sufferers are recommended to surgery immediately. All of the risks for surgery in general have to be taken into account when choosing this path. The risks include all those associated with exposure to hospitals and surgical operatories which are well documented elsewhere as well as possible surgical failure. Those who have contraindication for surgery including long-standing circulatory compromise such as seen in late-stage diabetes are often not suitable candidates.
The use of pain and anti-inflammatory medications can provide temporary relief but rarely result in lasting corrections. Local steroid injections often give nice relief but again mostly on a temporary basis.
An additional difficulty with carpal tunnel management arises when there has been failure to recognize additional contributing conditions. From a neuromechanical point of view alone, there needs to be evaluation for thoracic outlet involvement as well as cervical spine involvement which can result in the so-called “double-crush” syndrome.
A novel diagnostic and treatment protocol has been developed and successfully utilized in the chiropractic profession that reduces compression on the median nerve at the carpal tunnel. These protocols are based primarily on manual adjustment methods applied to the structures of the wrist and hand. A particularly effective one of these protocols evaluates the strength of the opponens muscle of the affected extremity. The most common variation includes a standard muscle test evaluation of the opponens muscle in the forearm prone position as well as the forearm supine position maintaining careful constant positioning when moving from the supine to prone test positions to not allow any wrist postural changes such as lateral deflection of the wrist in an attempt to recruit adjacent musculature which would disguise a true weakness. If the opponens muscle is week in the forearm prone position but is normally strong in the forearm supine position then the only change that has been made is the rotation of the forearm structures, mainly the radius and the ulna and their fascial attachments. In this simple scenario, which is a common presentation, the assumption would have to be that something about a change that occurred during the course of the rotation of the forearm caused the weakening of the opponens muscle. Insofaras the opponens muscle is innervated exclusively by the median nerve and then whatever happened during the rotation of the forearm had to of impacted the median nerve in one position but not in the other position that tested strong. When the radius or the ulna has been predisposed through injury or overuse or other causes to be misaligned it is possible for that misalignment to be exaggerated in one of the test positions sufficiently to cause median nerve compression and opponens muscle weakness. When the opposite position is tested there is insufficient disturbance to the median nerve and hence the opponens muscle tests strong. This leads to a presumption of misalignment of either the radius or the ulna, although a misaligned carpal bone can sometimes found to be the culprit.
The confirmatory test to determine whether the above presumption is correct is to give a test challenge push by the examiner to either the ulna or the radius in a direction that would move that bone away from the central carpal tunnel. Experience has taught that almost invariably the misalignments of the radius or the ulna, in a typical outpatient setting, will be misalignment of internal rotation. One or both of these bones may be involved in internal misalignment compressing the median nerve. A test challenge push of the suspected radius or ulna is ordinarily sufficient to release sufficient median nerve compression such that an immediate retest of the opponens muscle which had been formerly weakened will now test normally strong. This serves as confirmation that it was actually that structural misalignment which was causing that median nerve compression and proves the capacity for normal functioning of the opponens muscle due to normalization of innervation as evidenced by the restored strength. This is typically a temporary result and intended for examination purposes only. In this examiners experience radius and ulna misalignments are typically found to account for approximately 85% the cases seen. Associated joint inflammation and myofascial disorder should also be attended to during a course of care for these types of carpal tunnel cases.
The actual correction of the major portion of lesion causing the carpal tunnel syndrome is a specific manual adjustment to the misaligned structure. It is often useful to use an electronic recoil adjusting instrument as additional aid in achieving the desired correction. Adjunctive physical therapy can be helpful in speeding up the healing process. The most preferred is often applications of interferential therapy to the involved wrists to assist in flushing inflammatory debris and relieving pain. When causalgia/burning are a presenting symptom, it can be useful to have the patient utilize a TENS (Transcutaneous Electrical Nerve Stimulation) unit at home.
Utilizing this clinical approach for a period of approximately 18 to 20 visits over approximately 3-4 months is usually a sufficient treatment regimen to achieve near-complete to complete resolution of the condition. Occupational insults to the condition as occurs in pressure-washer operators can result in longer treatment periods but with still excellent results. The very elderly and those with significant circulatory embarrassment (such as occurs in late diabetes with capillary bleeding directly onto the nerve), who would not be necessarily the best surgical candidates at all, can have the above prescribed procedures, carefully modified for their relative contraindications and typically achieve results of 40% – 60% improvement with few outright failures.
Home care for most patients includes simply wearing plain elastic wrist bands on and off during the day as tolerated and when doing strenuous activities. Only a very small number of people actually require cock-up splints usually for comfort during sleep in the initial stages of treatment only. Most often patients who may have been wearing splints for years are able to forego them at the very beginning of treatment. Additional home care might include the use of a B-Complex supplement with vitamin C as a way of covering the occasional situations where B-6 may actually have a direct role in the underlying condition.
An important part of clinical management of the carpal tunnel case is to be sure to educate the patient on avoidance of using the wrists as weight bearing joints as they are not designed for this purpose. The doctor should be keen to observe the patient arising out of a chair and noticing whether or not they use their wrists as assists in weight-bearing. They can be re-taught to launch themselves out of chairs in a healthier way propelling themselves up and out with their knees and hips primarily and using the hands as a special guidance/proprioceptor tools.
The above treatment scenario represents the basic and most common presentations seen in primary care practice. It is important to screen carpal tunnel sufferers for thoracic outlet involvement with Adson’s test, Roos’ test, and best of all with Applied Kinesiological challenge to the supraclavicular structures over the thoracic outlet itself. Additionally cervical foraminal compression testing, firm digital probing of lower cervical vertebrae in multiple directions to determine if radicular symptoms are elicited makes for a more complete examination. Forearm extensor musculature myofascial involvements are common co-morbid but easily treated conditions that will favor a more total recovery.
Greater consideration to conservative approaches for carpal tunnel syndrome may result in less surgical expense and risk, and more satisfying patient outcomes.