Archive for the ‘Carpal Tunnel Syndrome’ Category

CTS “Facts” (cont.)

Posted: December 11, 2013 in Carpal Tunnel Syndrome

Last month, we covered what Carpal Tunnel Syndrome (CTS) is, its symptoms, causes, who is at risk, and how it’s diagnosed. This month, we’ll center our focus on CTS treatment.

How is CTS treated? For the best success, treatment should begin as early as possible. Unfortunately, most people wait a long time before they get to the point where the symptoms interfere with daily activity enough to prompt them to act quickly and make an appointment. Once the cause or causes of CTS are determined, treatment can address ALL the presenting contributing conditions. The FIRST course of care should be NON-SURGICAL, though this is not always practiced – so be aware! Non-surgical care includes the following:

1. Chiropractic:
• Manipulation: This usually includes adjusting the small bones of the hand, the wrist, the forearm, elbow, shoulder, and/or the neck.
• Soft-tissue therapy: This includes loosening up the overly tight forearm muscles where the median nerve runs through (on the palm side of the forearm).
• Modalities: Such as electrical stimulation and/or laser/light therapy can be very beneficial in reducing swelling or inflammation. In chronic CTS, ultrasound may be helpful as well.
• Nutritional: Nutrients such as vitamin B6 have been shown in studies to be effective in some cases. Also, anti-inflammatory herbs (ginger, turmeric, bioflavinoids) and / or digestive enzymes (bromelain, papain, and others) taken between meals are quite effective.

2. Anti-inflammatory: The first important distinction is that ice can be very effective depending on how long the CTS has been present. In particular, ice cupping or rubbing ice directly on the skin over the carpal tunnel is the most effective way to use ice as an anti-inflammatory agent. When doing so, you will experience four stages of cooling: Cold, Burning, Achy, Numb or, “C-BAN.” It’s important to remember this as you are REALLY going to want to quit in the burning/achy stages when it feels uncomfortable. Once the skin over the wrist / carpal tunnel gets numb (which takes about four to five minutes) QUIT as the next “stage” of cooling is FROST BITE! Most medical practitioners promote the use of NSAIDs (non-steroidal anti-inflammatory drugs) like Advil, aspirin, or Aleve. However, these carry negative side effects including gastritis (burning in the stomach that can lead to ulcers), or liver and/or kidney damage. Try the nutritional anti-inflammatory approach FIRST as they are extremely helpful without the bad side effect potential!

3. Diet: An ant-inflammatory diet, like the Paleo-diet or gluten free diet, serves as a great tool in reducing the inflammatory markers in the body. Though only 7-10% of the population has celiac disease (gluten intolerance), it’s been estimated that over 80% of us are gluten “sensitive.” Reducing systemic inflammation can make a BIG DIFFERENCE in the management of many conditions including CTS!

4. Mechanical: Wrist “cock-up” splints can also be REALLY HELPFUL, especially for nighttime use. The reason for this is because when our wrist is bent forwards or backwards, which frequently occurs when sleeping, the pressure inside the carpal tunnel increases, and over time (minutes to hours), the increased pressure in the tunnel exerts compression on the median nerve which then creates numbness into the thumb, index, third and half of the fourth finger, which can wake you up out of a sound sleep. Keeping the wrist straight at night prevents you from curling your wrist under your jaw while sleeping.

5. Ergonomic Modifications: Changing your work station (computer station, line position, machine controls, pace or rate of repetitive movements, and more) is VERY effective.

NOTE: ALL of the above can be managed through the services offered at our clinic!!!


CTS “Facts”

Posted: November 1, 2013 in Carpal Tunnel Syndrome

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!

The goal of any treatment approach for Carpal Tunnel Syndrome (CTS) is to return the patient to normal. That means addressing all OTHER health related conditions that can cause CTS such as diabetes, hypothyroidism, birth control pill use, pregnancy, rheumatoid arthritis (and many of the other related arthritic-like disorders), as well as double or multiple crush (pinched nerve) syndromes. That’s right! CTS can be caused by MANY other conditions besides simply overusing the arms and hands. When overuse PLUS any of the above mentioned conditions “gang-up” on you, managing BOTH is necessary.

One “universal” goal in CTS treatment is to reduce inflammation. This can be accomplished by several approaches: 1) STOP, reduce, and/or modify the causing activity. Examples include repetitive use of a hammer, screw driver, stapler, assembly line work, typing/computer work, driving with a firm grip on the steering wheel, bicycle riding, and MANY more! The key to successful management of CTS is to slow down, stop/rest, and for long-term success, change how the task is performed (modify the work station). 2) Wearing a cock-up wrist splint. This is usually restricted to night time use since we cannot control our wrist position while sleeping and the pressure inside the carpal tunnel “normally” doubles at the extremes of the wrist forwards or backwards. Thus, keeping the wrist straight at night significantly reduces or eliminates the numbness/tingling that can cause multiple sleep interruptions. It can also be worn during the day IF it doesn’t interfere with the person’s activity. If the activity requires frequent bending of the wrist, you’ll end up fighting against the wrist splint and that can actually worsen your CTS! 3) Ice cupping or massage. Freeze water in a Styrofoam or paper Dixie cup (like home-made popsicles) and peel away the top third to expose the ice. Rub it over the palm side of the wrist until you feel numbness. At first, it will feel Cold, followed by Burning, Aching, and finally Numbness (hence the acronym, “C-BAN”). The length of time to achieve numbness is usually three to five minutes, but make sure you quit at the point of numbness as the next stage is frostbite! 4) Anti-inflammatory nutrients. An anti-inflammatory diet is one that is rich in fruits, vegetables, lean meats, omega-3 fatty acids, and avoids glutens, omega-6 fatty acids (fast foods, etc.), and refined carbohydrates (sweets, sodas, etc.). Also, there are many REALLY GOOD nutritional supplements that can effectively reduce inflammation without the typical side-effects that affect the stomach, liver, or kidneys which are common to NSAID drugs like aspirin, ibuprofen, or Aleve. Also, NSAIDs can inhibit an important chemical (a prostaglandin) that is needed for healing, and therefore, it can actually slow down the healing process (so try the nutritional approaches first)! Nutritional options include proteolytic enzymes, Bromelain, papain, bioflavonoid, Vitamin C, Vitamin D, Vitamin E, Coenzyme Q10, and many more.

Treatment options beyond those mentioned above are typically surgical, IF you decide to go to a surgeon. However, chiropractic care includes identifying and treating the source(s) of nerve irritation, as it is often more than just nerve pinching at the carpal tunnel. Other common locations of median nerve entrapment includes the pronator teres muscle in the forearm just past the elbow on the palm side, less often at the shoulder, and again quite frequently in the neck where the nerve exits the spine. If these areas of nerve pinching are not released, recovery is less likely (with or without surgery)! Bottom line, you can always have surgery but you can’t “un-do it.” Try chiropractic first as it’s the least invasive, least costly, and often the quickest way to find relieve from CTS!

Carpal Tunnel Syndrome (CTS) is technically a “pinched nerve” in the wrist (carpal tunnel) that results in numbness, tingling and later, weakness in the distribution of the median nerve (thumb, index, 3rd, and half of the 4th finger). There is a limited amount of space within the carpal tunnel. In addition to the median nerve, there are 9 tendons and their sheaths, a network of blood vessels, the joint capsules, the bony “roof” and ligamentous “floor.” Any condition that distorts the shape of the tunnel (inflammatory conditions like rheumatoid arthritis, ganglion cysts, bony spurs, or conditions that result in swelling like overuse, pregnancy, taking birth control pills, hypothyroid, obesity, and/or conditions that create neuropathy like a pinched nerve in the neck, shoulder or elbow, diabetes and post-chemotherapy) can result in median nerve irritation. The carpal tunnel naturally changes its shape when we flex and extend the wrist, so occupations that require wrist bending (especially if it’s prolonged and a fast pace is required) such as carpentry (especially the use of vibrating tools), waitressing, assembly line work, typists, and even sleeping at night with the wrist bent can result in CTS.

The diagnosis can be tricky because of all the possible causes (of which, some are described above) and to make matters even more challenging, there can be two, three, or more of the causes all contributing to the problem at the same time! In the clinic, there are certain positions to test how long (in seconds) it takes for the numbness, tingling and/or pain to occur when we place the wrist in extreme flexion or extension. We’ll compress the carpal tunnel (and nerve pathways at the elbow, shoulder, and neck), as well as tap over the carpal tunnel with a reflex hammer creating a “funny bone” sensation usually into the 2nd or 3rd finger. Blood tests for rheumatoid (and other inflammatory) arthritis, diabetes and thyroid dysfunction are very helpful when trying to differentiate between several possible causes. An electrical conduction test called electromyogram (EMG) and nerve conduction velocity (NCV) can also be very helpful in determining the severity of CTS.

So the question is, can you “self-diagnose” CTS? The answer is: sometimes. However, with that said, if the symptoms are “classic” (numbness/tingling in the thumb, fingers 2-4, which shaking and flicking your fingers relieves at least partially; it’s waking you up at night especially, if a night splint helps reduce the frequency of waking and intensity of numbness), then you “probably” have CTS. Here are some common questions included in a CTS questionnaire that we often use in the clinic to assist with the diagnosis: SYMPTOM SEVERITY (score each on a 0-4 scale): 1) Pain severity at night? 2) Nighttime frequency of waking with pain? 3) Amount of daytime hand/wrist pain? 4) Frequency of daytime hand/wrist pain? 5) Duration (in minutes) of daytime pain/numbness? 6) Severity of numbness? 7) Severity of weakness? 8) Tingling intensity? 9) Nighttime severity of numbness or tingling? 10) Nighttime frequency of numbness or tingling? 11) Difficulty grasping / using small objects like keys or pens? FUNCTION SEVERITY (0-4 scale): 1) Writing. 2) Buttoning clothes. 3) Holding a book while reading. 4. Gripping of a telephone handle. 5) Opening jars. 6. Household chores. 7. Carrying grocery bags. 8. Bathing and dressing. The maximum score for SYMPTOM SEVERITY is 11×4 = 44 and for FUNCTION 8×4 = 32. To determine the percentage, divide your score by 76 (the maximum possible) and multiply it by 100. In general, scores >50% may be indicative of CTS. However, as previously stated, a definitive diagnosis must include a detailed history, examination, sometimes special tests. Therefore, it is important to see us! If you have CTS, we will outline the type and length of care with you and MOST IMPORTANT, we can usually manage CTS without the need for surgery!

Obviously, the goal of all health care providers, including chiropractic management of Carpal Tunnel Syndrome (CTS), is to AVOID surgical intervention, but this is not always possible. Last month, we looked at herbal approaches to reduce inflammation with the focused goal of preventing surgical need. But, as chiropractors, we also care for patients post CTS surgery, and one of our treatment approaches beyond manual therapies includes nutritional management.

As we all know, during the surgical process, tissue damage occurs due to incisions, removal of injured tissue, and other factors. Depending on the “success” of the surgical procedure, damage to the nerves causing numbness, weakness, and/or other nerve related symptoms can occur. Often, nerves will regenerate during the healing process but not always 100%. This may be due to factors such as the amount of tissue damaged during the surgery, the length of time CTS had been present pre-surgery, how well the patient follows post-surgical instructions, as well as the general health and overall condition of the patient. A healthy diet along with certain specific vitamins can play a positive role in tissue healing and nerve regeneration. Here are some examples:

1. Folate or vitamin B9 has been reported to have beneficial effects on the genes located within the nerve cells that help to regulate the healing process. One study published in 2010 reported that folate helped to promote nerve repair in the central nervous system (CNS) in rats, which is unique as typically nerve damage in the CNS does not usually regenerate. Anti-inflammatory benefits have also been reported with vitamins B6, B9, and B12.
2. Cobalamin or Vitamin B12 has also been reported to facilitate nerve regeneration after injury. This, along with the anti-inflammatory benefits, supports the use of B12 in the post-surgical CTS patient.
3. Vitamin D may also play a significant role in nerve regeneration after surgery. In one study, vitamin D2 was found to have a positive effect on nerve regeneration. Another study reported that D3 and calcium together has strong anti-inflammatory benefits.
4. Vitamin B6: There is evidence that supports the use of B6 both before and after surgery. Some feel B6 acts directly on nerve repair and others report a diuretic (fluid reducing) benefit. One cause and/or complication of CTS is fluid retention, which commonly occurs in conditions such as pregnancy, the use of birth control pills, obesity, diabetes, and others. Thus, keeping fluids in our tissues under control can certainly help CTS patients. Most studies agree that less than 200mg of B6 per day is safe. The dosage should be carefully monitored as numbness/tingling (a common CTS symptom) can be a sign of B6 toxicity.
5. Vitamin C has long been reported to facilitate in the wound healing process. It also is an effective anti-inflammatory agent, a common problem in the cause of CTS as well as a negative post-surgical side effect. A dose of 1000-3000mg/day spread out throughout the day is beneficial to the post-surgical healing process.
6. Vitamin E: As far back as 1967, Vitamin E been reported to reduce inflammation. More recent studies report that when used in combination with vitamin C, the two together works even better in reducing inflammation than either one alone. Also, this combination was found to improve the body’s ability to use insulin, which may also facilitate healing in the post-surgical CTS patient.

There are many others we didn’t get to (such as B1, 3, 5; zinc, Bromelain, and Quercetin). Bottom line: Eat healthy, exercise, don’t smoke, and fortify your diet with these nutrients!

Carpal Tunnel Syndrome (CTS) is a condition caused by the compression of the median nerve as it travels through the carpal tunnel in the wrist. The “source” of median nerve compression can be soft tissue swelling, such as tendonitis, bursitis, synovitis, capsulitis, etc. Last month, we discussed nutritional supplementation for CTS in general. This month, the focus is on specific herbs that can help this potentially disabling condition.

1. Chamomile functions as a natural “tranquilizer.” It’s used for muscle pain (as a relaxant), but can also help other problems such as menstrual disorders, headaches, and tension. Chamomile facilitates relaxation of tight muscles and has an anti-inflammatory property that soothes cramps.
2. Kava Root is an herbal plant that is well known for its muscle relaxing benefits. It is particularly helpful with extreme muscle pain.
3. Valerian is a very effective relaxant that dates back to the medieval times for curing ailments associated with muscle spasms such as muscle cramps and neck problems.
4. Catnip is also a natural muscle relaxant, and is a member of the mint family. It is used as a sedative and muscle relaxer. Headaches due to tension have been treated using a poultice containing catnip. Catnip has also been found to reduce swelling in joints and reduce soft tissue injuries such as tendonitis, bursitis, and capsulitis.
5. Cayenne Pepper is a popular herb used in cooking and can be found in many recipes. Cayenne pepper has been found to significantly relieve the pain of muscle cramping.
6. Horseradish has been reported to relieve extreme muscular stress involved in cramps and muscle pain. One approach is mixing a few drops of horseradish oil in bath water to reduce soreness associated with muscle aches.
7. Lavender flower oil is well known as a very effective muscle relaxant that provides relief caused by muscular tension. Using a circular motion while massaging the oil over the achy muscle can be particularly soothing. In addition to the mind/body relaxation benefits, an increase in circulation allows the tense muscles to relax and heal.
8. Licorice has the ability to reduce inflammation associated with muscle pain.
9. Devil’s Claw is a very popular anti-inflammatory herb that dates back to the 18th century for the treatment of arthritis and many other painful conditions. It’s also used as an effective muscle relaxer.
10. Peppermint oil has been used to treat conditions associated with muscles aches. Pouring some drops of peppermint oil in a hot bucket of water to soak a foot, ankle or lower leg (possibly combined with Epson salt) can be very relieving.
11. Other natural muscle relaxants include Cramp bark, Passiflora, Bergamot, Cardamom, Basil, Ginger root, and others.

It is appropriate to COMBINE these natural herbal approaches with other treatments that are known to work well in the treatment of CTS. Chiropractic can provide: 1. Manipulation and mobilization of the neck, shoulder, elbow forearm, wrist, hand, and fingers; 2. Cock-up splints to be worn at night and at times during the day such as driving; 3. Physical therapy modalities such as electric stimulation, ultrasound, light or laser therapy, magnetic field; 4. Work station and other ergonomic modification recommendations; 5. Exercise training, and more.

We realize you have a choice in who 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 require care for CTS, we would be honored to render our services.


Carpal Tunnel Syndrome (CTS) is a common complaint presented to chiropractic offices. Usually, patients wait for weeks, months, or even years before seeking care, thus making management more challenging. The history of the “classic” CTS patient includes a mild, sporadic onset that gradually becomes more frequent and intense. This usually leads to continued problems that start to affect other areas proximal to the hand, such as the elbow, shoulder and/or neck. We usually find that people will compensate during their activities, and instead of moving the wrist and hand to perform a task, they will start to move their elbow and shoulder more to avoid irritating movements of the hand/wrist. Over time, overloading the muscles in these areas can lead to one or more conditions commonly referred to as “cumulative trauma disorder” (CTD), which includes many diagnoses including (but not limited to) tendonitis of the thumb (de Quervain’s Disease), ganglion cysts, tennis elbow (lateral epicondylitis), golfer’s or bowler’s elbow (medial epicondylitis), cubital tunnel syndrome (ulnar nerve pinch at the medial elbow), tunnel of Guyon syndrome (ulnar nerve pinch at the wrist), shoulder tendonitis (biceps, rotator cuff), thoracic outlet syndrome (pinched nerve at the shoulder), and / or neck strain, neck herniated disk, pinched nerve, and/or headaches. Many times, these conditions co-exist if the patient has really abused themselves (such as music majors who may practice playing their instrument for 4-5 hours a day) to a point where they are REALLY injured in multiple areas.

Limiting this discussion to pinched nerves in the neck and upper limb, the question often arises, “…how do you know where the nerve is pinched?” The answer centers around determining an accurate history to find out EXACTLY where the patient feels numbness, tingling, weakness, and/or pain as each nerve innervates a different area. For example, if a patient says, “…I feel numbness in my 4th and 5th finger,” this tells us that the ulnar nerve is pinched (as opposed to numbness in the 2nd, 3rd, or 4th fingers which suggests median nerve pinch — more classic of CTS). If the patient says the numbness affects the arm from the elbow down to the 4th and 5th finger, this suggests cubital tunnel syndrome (ulnar nerve pinch at the medial elbow). If the numbness affects the person from the shoulder to the 4th and 5th finger, thoracic outlet syndrome becomes a probable diagnosis. And lastly, if the neck, shoulder, arm and hand on the pinky side are numb, we are suspicious of a pinched nerve in the neck.

Then, we confirm our suspicions with a more detailed physical examination. Here, we test for compression of a nerve at the neck by positioning the head in a backwards, rotated position and holding it for about 10 seconds to see if the numbness is reproduced. We can also manually (with our hands/fingers) compress the various nerve pathways to see if numbness occurs at the front of the neck, the shoulder under the collar bone, at the elbow and wrist counting the seconds to time the onset of numbness and mapping the numbness location. Placing the shoulder, elbow, and wrist in different positions can pinch the nerve as well, and mapping the location of the numbness tells us where and to what degree the nerve is pinched. We will also perform a neurological exam testing reflexes and strength, as well as sensory function using a sharp object. A special test called an EMG/NCV (electromyography and nerve conduction velocity) can be obtained to further verify the location and degree of nerve pinching and damage.

The advantage of chiropractic management is that we will treat EVERY LOCATION that may be contributing to the CTS symptoms, whether the pinch is in the neck, shoulder, elbow and/or wrist. Managing the WHOLE PERSON, not just the wrist or CTS is KEY to a successful outcome.

We realize you have a choice in who 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 require care for CTS, we would be honored to render our services.