True Carpal
Tunnel Syndrome
Paul R. Martin
Carpal Tunnel Syndrome is a condition of compressive entrapment of the
median nerve at the wrist segment with associated pain and possibly
motor deficit, predominantly of the thenar muscles. Hand and wrist
pain, including motor deficit, may be caused by any number of other
things other than Carpal Tunnel Syndrome.
There is a
specific and predictable path a chronic, cumulative, compressive
neuropathy will take. As the nerve is compressed certain changes begin
to take place which include both direct morphological changes in the
nerve fibers as well as ischemic changes. Usually the smallest
diameter, unmyelinated fibers are affected first. These are followed
by larger myelinated sensory fibers, and finally by myelinated motor
fibers.
By the time a
person presents with complaints of numbness, paresthesias, pain, or
motor deficit, nerve damage has progressed to the stage of larger
fiber sensory and/or motor loss. Changes can be measured at this stage
with conventional electroneurography and will manifest as slowed
conduction across the wrist segment and possibly reduction in
amplitude of the compound muscle action potential representative of
axonal loss of motor fibers. It can be reasonably determined if the
condition is early, moderate, or severe.
The problem with
the median nerve is that it is a relatively lonely soft tissue
structure sharing confined space with nine flexor tendons as it
travels through the carpal tunnel. Any condition which reduces that
space is likely to cause Carpal Tunnel Syndrome due to compression of
the vulnerable median nerve. Any solution which relieves pressure on
the nerve and promotes circulation in the microvascular neural blood
supply is likely to "cure" Carpal Tunnel Syndrome and relieve its
attendant symptoms of pain, etc.
Some women
experience transient Carpal Tunnel Syndrome during pregnancy due to
peripheral edema-a space-compromising problem. Inflamed tendons,
irritated by repetitive friction, compress this singular soft tissue
nerve. Therefore, anti-inflammatory (NSAIDS) drugs and corticosteroid
injections provide temporary relief from Carpal Tunnel Syndrome.
Biomechanical devices that restrict movement and ergonomic devices
that promote good hand posture relieve stress on the tendons, reduce
inflammation, and relieve Carpal Tunnel Syndrome symptoms. Anything
which will promote circulation, help to relieve inflammation, aid in
removal of local toxins, and soothe irritated muscles and tendons will
help Carpal Tunnel Syndrome. Certainly massage therapy is preferable
to drugs, splints, or surgery to treat Carpal Tunnel Syndrome. In
addition, in a whole body approach to treating Carpal Tunnel syndrome,
one should consider biomechanical devices to aid in retraining,
ergonomic devices to prevent additional stress, etc.
The cure for
Carpal Tunnel Syndrome, plain and simple, is to relieve pressure on
the median nerve at the wrist segment. Surgery does that quite
effectively by sawing through the roof truss and letting the dome
widen. The results are usually dramatic and the relieved nerve
generally quits screaming almost immediately from symptoms of carpal
tunnel syndrome. But a less invasive approach to treating carpal
tunnel syndrome is preferable if one is patient.
A word about
chiropractic and wrist pain. A variety of things can cause Carpal
Tunnel Syndrome-like symptoms. One frequent look-alike is a C7
radiculopathy. If, in fact, the source of trouble is more proximal,
then cervical adjustments may be just the thing, along with other more
proximal treatments. But if proximal treatment ALONE relieves the
problem, then it was not truly carpal tunnel syndrome.
Apparently Carpal
Tunnel Syndrome is sometimes treated with acupuncture. That disturbs
me a little. Pain has value-it is usually trying to tell us
something-and its mere removal may be dangerous to our overall
well-being. I am not sure how acupuncture works exactly, but in my
western mind it likely has something in common with the gate theory of
pain. If so, simply blocking the pain of Carpal Tunnel Syndrome does
not fix the problem. Eventually the person with carpal tunnel syndrome
will go on to lose the use of the hand, because the nerve is still
being injured, perhaps beyond the point of no return.
It seems to me
that any therapy offered to treat Carpal Tunnel Syndrome must focus on
the wrist and associated intrinsic hand muscles and forearm flexors
and must relieve pressure on the median nerve while increasing
circulation. Furthermore, a person with carpal tunnel syndrome must be
retrained in proper hand posture and biomechanical stress reduction to
prevent exacerbation of the problem. Medical massage therapy to treat
carpal tunnel syndrome is uniquely positioned to offer this therapy
without the side effects of NSAIDS, local injections, or surgery.
NOTE: Prolonged
nerve compression with attendant muscle wasting due to axonal damage
and degeneration may become irreversible resulting in permanent damage
to vital hand muscles. The one positive thing about treating carpal
tunnel with surgery in these cases is that relief of the compression
is immediate and recovery begins within hours of the surgery. But in
early stages of carpal tunnel syndrome, or even moderately advanced
stages of carpal tunnel syndrome, I would personally try anything
other than surgery to reverse the problem, and I am comfortable in
suggesting the same to others. However, for all these reasons, it is
best to have information on all aspects of carpal tunnel treatments
with attendant risks and to make an informed choice, including the
risk of any surgical procedure/anesthesia/infection/hospital stay,
etc., along with the risk of delay in decompressing the nerve with any
non-invasive approach.
I am inclined to
believe that a thorough and frequent massage of the hand and anterior
musculature, the wrist, and the forearm flexors combined with
self-massage between treatments and proper use of splints and
retraining should bring a variety of solutions directly to bear on the
locus of injury. I would suspect that if this approach to treat carpal
tunnel syndrome is going to work, the patient should experience
reduction of pain in a few weeks, and clinical restoration of function
within a few months. But this approach has yet to be demonstrated in
any controlled trial regarding carpal tunnel syndrome.
Copyright 1996 by Paul R. Martin and James H. Clay
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True Carpal Tunnel Syndrome: A Translation
There is a group
of small bones that make up your wrist and the base of your hand
called "carpals." To allow nerves and tendons to pass through to your
fingers, there is a tunnel through these bones called the "carpal
tunnel." Through this tunnel pass nine tendons and a bundle of nerve
fibers called the "median nerve." There is limited room in this carpal
tunnel, and if anything happens to cause swelling of any of the
tissues, the median nerve will be compressed, at first causing
irritation, then over time causing actual nerve damage and perhaps
carpal tunnel syndrome. Since the median nerve includes both sensory
fibers (carrying information about touch to the brain) and motor
fibers (carrying impulses from the brain to move the fingers), this
irritation or damage results in numbness, pain, and possibly even
partial paralysis. The muscles most likely to be affected with a
carpal tunnel syndrome condition are the muscles forming the ball of
your thumb. It is important to remember, though, that pain and even
movement problems in your wrist and hand can be caused by things other
than carpal tunnel syndrome.
The progress of
carpal tunnel syndrome is usually predictable. First, the small nerve
fibers that are not insulated are affected, then the larger insulated
sensory fibers, then the larger insulated motor, or movement, fibers.
These changes can be the result both of direct irritation to the nerve
and of loss of blood to the nerve.
By the time a
person goes to the doctor complaining of numbness, pain or movement
problems, the last condition -- damage to the motor fibers -- has
usually come about and possibly carpal tunnel syndrome. At that point,
a neurologist or a professional specializing in electrical
measurements of nerve performance can perform tests that will
determine whether the carpal tunnel condition is early, moderate or
severe.
The median nerve
is all by itself in the carpal tunnel among these tendons. Anything
that causes tissues to swell can cause a carpal tunnel condition, and
anything that reduces the swelling and increases the flow of blood to
the nerve can improve the carpal tunnel condition.
Some women get
temporary carpal tunnel syndrome when they are pregnant, because fluid
tends to collect in their hands causing swelling of the tissues.
Anti-inflammatory
drugs, such as aspirin and ibuprofin, and corticosteroid injections,
will help carpal tunnel syndrome temporarily. Things like wrist
braces, and wrist-rests on keyboards, help carpal tunnel syndrome by
relieving stress on the tendons. Anything that reduces swelling and
irritation and promotes blood flow to nourish the tissues and remove
the waste products will help carpal tunnel syndrome. Massage therapy
can help carpal tunnel by reducing the tightness in the muscles that
control these tendons and by increasing blood flow to the area. But
it's also important to use anything that will help retrain the person
with carpal tunnel syndrome in the positioning and use of the wrists
and hands.
The cure for
carpal tunnel syndrome is to do whatever is necessary to relieve
pressure on the median nerve in the wrist. Surgery does that very well
by opening the carpal tunnel and making it bigger, and the relief from
carpal tunnel syndrome is almost immediate. But if the same result to
“cureâ€
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