Carpal Tunnel Syndrome

Carpal Tunnel Syndrome

When hand pain strikes, it can be a difficult problem to deal with since we use our hands for so much; our work, our play. It can also be distressing psychologically to have a part of your body not working as it should. Realize this:

Carpal Tunnel Syndrome Is Very Common!!!

Carpal Tunnel Syndrome (CTS) is a very common problem and one of the leading causes of work related injuries. This is partially due to the advancement in technology and the dramatic increase in the pace of work performance (1). The carpal tunnel is a small space in the wrist made up of wrist bones (carpal bones) and a ligament on top, through which 9 tendons and the median nerve travel into the hand.

CTS is often times caused by prolonged use of our hands and wrists (repetitive stress). As a result, there is swelling of the forearm and wrist muscle tendons inside the carpal tunnel, forcing the median nerve upwards against the roof of the tunnel (the transverse carpal ligament), pinching it. Symptoms initially include numbness or tingling, followed later by weakness in the muscles innervated by the median nerve. This often results in grip and pinch strength loss, dropping of pens, difficulty buttoning a shirt, waking up at night with numbness in the 2nd, 3rd, and 4th fingers of the involved hand and driving induced numbness.

In addition to overuse, there are other causes or contributors to the onset and presence of CTS:

* Age. Our workforce is aging (2). Kaplan reported people over 50 years of age have a greater risk at failing conservative medical treatment (3).
* Gender. Women are 3 times more likely to suffer from CTS, with the peak incidence between 45 and 54 years old. (4)
* Other problems/conditions. Obesity, hypothyroidism, diabetes, rheumatoid arthritis, and lupus (5 Atcheson, et al). Forty percent of CTS patients were reported to have a metabolic, inflammatory, or degenerative condition that might have caused or at least contribute to the symptoms. Moreover, the authors point out that only 35 patients (11.8%) knew that they had any of these conditions.
* Nerve Compression. Nerve compression in the neck and/or arm above the wrist can also contribute to CTS (6).

Approximately 2/3rds of employees from industrialized countries use a computer on a daily basis and one of five spend at least 75% of their total work time behind a computer. Its no wonder so many suffer from neck, shoulder, arm pain, including carpal tunnel syndrome (CTS). There are many reasons for the presence of CTS in office workers who utilize a computer. The following is a partial list of causes:

* The computer screen is not positioned correctly in front of the worker forcing the neck to be rotated to the side or the head has to look up or down too far.
* The mouse and/or keyboard is placed on top of a counter, too high to operate without significant bending of the wrist, often against the sharp edge of the counter.
* The shape of the keyboard is flat, forcing the hands and wrists to pronate (roll inwards) too far. This places more pressure on the nerves in the forearms.
* The use of a mouse usually requires the entire arm to move, frequently running off the mouse pad requiring repositioning.
* Paper work data that needs to be entered in the computer is placed too far off to the side and sustained neck rotation is required during the data entering process.
* The chair and computer desk do not fit the persons height (either too high or too low) and/or the feet dont touch the floor.
* There is too much glare from windows or overhead lighting making it difficult to see the screen.
* In the aging worker, poor eye sight requires the use of magnifiers which can be quite distorting when the head is moved, even a small amount.
* There are often other medical conditions that the computer operator may have that increase the likelihood of developing CTS such as obesity, hormone replacement therapy, diabetes mellitus, hypothyroid, the use of birth control pills, and others.

Because the symptoms can slowly and gradually appear, most people wait a while, sometimes years, before they seek treatment for CTS. It is important to recognize the initial signs and properly manage the condition AS EARLY AS POSSIBLE to avoid a potentially disabling CTS condition. Early treatment may be minimal and only require learning proper exercises or making minor activity modifications.

Hand pain can be a difficult thing to diagnose since there are many causes of hand pain. One familiar cause is a carpal tunnel syndrome. This is where the bony tunnel in the wrist is narrowed, entrapping the nerves that pass through and go into the hand.

Another cause for hand pain is a thoracic outlet syndrome. The thoracic outlet can be compressed in the shoulder girdle region causing hand pain, often at night.

The last thing to consider with hand pain is a neck problem such as a disk lesion compressing the nerves in the neck causing referred or radicular (nerve root) pain into the hand.

At Boca Health Care Center, Dr. Rosen believes that these three problems can independently cause hand pain or they can all co-exist to varying degrees. You are entitled to more than one cause, correct? Getting a proper diagnosis is the first key to a full correction of a problem. If your hand pain is being treated with analgesics (pain killers), there may be a reduction in pain sensations but pain medications cannot release an entrapped nerve. You might also want to consider that pain is a signal. The problem that is causing the pain should be a patient’s focus. When the fire alarm goes off at home do we think to put out the fire alarm, or put out the fire? Pain is the fire alarm, not the fire.

Recent research (Nord KM, et. al. False positive rate of thoracic outlet syndrome diagnostic maneuvers. Electromyogr Clin Neurophysiol 2008;48:67.) has shown that differentiating between these three unique disorders with clinical tests can be problematic, since false positive tests are more a rule, rather than an exception. Patients with carpal tunnel syndrome were one of the most frequently misdiagnosed groups of patients.

When you arrive at our clinic, we will conduct a thorough history and physical exam to determine if you are a candidate for non-surgical care. Treatment will include, along with restoring motion to the joints affected by the condition, advice on sleep (such as the use of a wrist splint at night), job/work station modifications (include working with your employer), teaching of exercises so you can help yourself in the treatment process, and other education approaches to help you avoid future episodes of CTS, and maybe even Spinal Decompression using the DRX 9000 Cervical Machine.

The examination usually includes various tests to determine whether CTS is present or not. Other diagnostic tests such as an EMG (nerve test) can help determine the degree or extent of the condition.

The chiropractic treatment approach may include (but is not limited to) wrist joint manipulation, muscle-stretching exercises of the forearms, the use of a wrist brace (especially at night), the use of Vitamin B6, and/or job modifications. Dr. Rosen may also discuss with the primary care physician the patients condition, which can lead to other management strategies such as changes or modifications of the patients medication(s), which can result in a decrease or eliminate significant negative side effects.

Because of the gradual onset of symptoms including finger numbness, wrist pain and/or loss of joint motion, the elbow, shoulder and neck often become affected and require treatment and exercise in order to obtain a good result. One exercise for stretching the forearm is performed by placing the palm of your hand on a wall in front of you (fingers pointing downward) while keeping your elbow straight. Then, reach over with your opposite hand, grasp your thumb and pull it back until you feel a good stretch in your forearm. Other exercises to the shoulder and neck may be appropriate and can be discussed. Most importantly, dont wait too long after symptoms start! The faster you present to our office, the better the outcome of treatment will be.

You may also need x-rays of your spine to fully get at the cause of your hand pain and determine the best course of action; pills, surgery or specific chiropractic care.

Chiropractic is an often-overlooked conservative form of care. It carries very low risks, and should be a considered option for anyone who is considering bracing, medications or wrist surgery

1. Scott, WJ. The Mechanization of Women’s Work. Scientific American 1982; 247: 162-87.
2. Donnedly H. Percentage of Aged to Grow Rapidly. Congressional Quarterly 1981: 2330-2.
3. Kaplan SJ, Glickel SZ, Eaton RG. Predictive factors in non-surgical treatment of carpal tunnel syndrome.J Hand Surg [Br] 1990;15B:106-108.
4. Stevens JC, Sun S, Beard MC, et al. Carpal Tunnel Syndrome in Rochester, Minnesota, 1961-1980. Neurology 1988; 38: 134.
5. Atcheson S, et al. Other causes of CTS. Archives of Internal Medicine 1998;158:1496, 1506-1512.
6. Upton ARM., McComas, AJ. The Double Crush in Nerve Entrapment Syndromes. Lancet 1973; 2:359-61.

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