Treatment of carpal tunnel syndrome

The 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 prevent the patient from worsening pain or symptoms by limiting movement of the wrists. They are helpful to some, but are not intended to be curative. At best, they should be expected to prevent aggravation from stressful postures of the wrists while sleeping. Many patients with carpal tunnel have surgery recommended immediately. All the risks of surgery in general must be taken into account when choosing this path. The risks include all those associated with exposure to hospitals and surgical operators that are well documented elsewhere, as well as possible surgical failure. Those who have contraindications to surgery, including long-standing circulatory compromise, such as that seen in late-stage diabetes, are often not suitable candidates.

The use of pain and anti-inflammatory medications may provide temporary relief, but rarely results in lasting corrections. Local steroid injections often provide good relief, but again mostly on a temporary basis.

An additional difficulty with carpal tunnel management arises when additional contributing conditions have not been recognized. Only from a neuromechanical point of view, it is necessary to evaluate the involvement of the thoracic outlet, as well as the involvement of the cervical spine, which can give rise to the so-called “double crush” syndrome.

A new diagnostic and treatment protocol has been developed and successfully used in the chiropractic profession that reduces compression of the median nerve in the carpal tunnel. These protocols are primarily based on manual adjustment methods applied to the structures of the wrist and hand. One particularly effective of these protocols tests the strength of the opposing muscle of the affected limb. The most common variation includes a standard muscle testing assessment of the opponent muscle in the prone forearm position as well as the supine forearm position, maintaining a careful and consistent position when moving from the supine to the prone testing position so as not to allow no change in wrist posture, such as lateral deviation. of the wrist in an attempt to recruit the adjacent musculature that would mask a true weakness. If the opponent muscle is weak in the prone forearm but normally strong in the supine forearm, the only change that has been made is rotation of the forearm structures, primarily the radius and ulna and their fascial attachments. In this simple scenario, which is a common presentation, the assumption should be that something about a change that occurred during the course of forearm rotation caused the opponent muscle to weaken. To the extent that the opposing muscle is exclusively innervated by the median nerve then what happened during the rotation of the forearm had to impact the median nerve in one position but not the other position which was strong. When the radius or ulna have been predisposed to misalignment due to injury, overuse, or other causes, it is possible for that misalignment to be exaggerated in one of the test positions enough to cause median nerve compression and opponent muscle weakness. . When the opposite position is tested, there is not enough disturbance to the median nerve and therefore the opposing muscle is tested strong. This leads to a presumption of misalignment of the radius or ulna, although a misaligned carpal bone can sometimes be found to be the culprit.

The confirmatory test to determine if the above assumption is correct is to give the examiner a test push on the ulna or radius in a direction that would move that bone away from the central carpal tunnel. Experience has taught that misalignments of the radius or ulna, in a typical ambulatory setting, will almost invariably be internal rotational misalignments. One or both of these bones may be involved in the internal misalignment that compresses the median nerve. A test push of the suspicious radius or ulna is usually enough to release enough compression of the median nerve so that an immediate retest of the previously weakened opponent muscle will now normally be strong. This serves as confirmation that it was indeed that structural misalignment that was causing the compression of the median nerve and proves the opponent muscle’s ability to function normally due to normalized innervation as evidenced by restored strength. This is usually a temporary result and is intended for testing purposes only. In this examiners’ experience, misalignments of the radius and ulna generally account for approximately 85% of the cases seen. Associated joint swelling and myofascial disorder should also be taken care of during a course of care for these types of carpal tunnel cases.

The actual correction of most of the injury that causes carpal tunnel syndrome is a specific manual adjustment of the misaligned structure. It is often helpful to use an electronic backlash adjustment tool as an additional aid in achieving the desired correction. Complementary physical therapy may be helpful in speeding up the healing process. Interferential therapy is often preferred to the affected wrists to help remove inflammatory debris and relieve pain. When causal pain/burning is a presenting symptom, it may be helpful for the patient to use a TENS (transcutaneous electrical nerve stimulation) unit at home.

Using this clinical approach over a period of about 18 to 20 visits over about 3 to 4 months is usually a treatment regimen sufficient to achieve near or complete resolution of the condition. Occupational insults to the condition, such as in pressure washer operators, can result in longer treatment periods but with excellent results. The very elderly and those with significant circulatory impairment (as occurs in late-onset diabetes with capillary bleeding directly over the nerve), who would not necessarily be the best surgical candidates, may undergo the procedures prescribed above, carefully modified for their relative contraindications. and generally achieve results of 40% – 60% improvement with few outright failures.

Home care for most patients includes simply wearing simple elastic wristbands intermittently throughout the day as tolerated and when engaging in strenuous activity. Only a very small number of people actually require brace splints, usually for comfort during sleep, only in the initial stages of treatment. Most of the time, patients who may have been wearing splints for years can go without them at the start of treatment. Additional home care might include the use of a vitamin C B-complex supplement as a way to cover the occasional situation where vitamin B-6 may play a direct role in the underlying condition.

An important part of clinical carpal tunnel case management is to ensure that the patient is educated to avoid using the wrists as weight-bearing joints, as they are not designed for this purpose. The clinician should be vigilant in observing the patient rising from a chair and noting whether or not he uses his wrists to assist in weight bearing. They can be re-taught to jump out of chairs in a healthier way, propelling themselves up and out primarily with their knees and hips and using their hands as special guiding tools/proprioceptors.

The treatment scenario above represents the basic and most common presentations seen in primary care practice. It is important to screen carpal tunnel patients for thoracic outlet involvement with the Adson test, the Roos test, and best of all, with the kinesiologic challenge applied to the supraclavicular structures above the thoracic outlet itself. In addition, cervical foraminal compression testing, firm digital probing of the lower cervical vertebrae in multiple directions to determine if radicular symptoms are elicited, makes the examination more complete. Myofascial affections of the extensor muscles of the forearm are common but easy to treat comorbid conditions that will favor a more complete recovery.

Greater consideration of conservative approaches to carpal tunnel syndrome may result in less surgical expense and risk and more satisfactory outcomes for patients.