Carpal Tunnel Syndrome (CTS) costs billions of dollars in treatment and lost work time each year and causes undo stress and suffering to millions. CTS may be misdiagnosed and therefore mistreated. True CTS is when the nerve that runs down the middle of the forearm and wrist, called the median nerve, is compressed by a ligament that stretches across it at the wrist. When this ligament compresses the median nerve, this may lead to pain and tingling in the hands, fingers, and wrist, but the pain may radiate up the arm, and in some cases, all the way to the shoulder and neck. In other cases, some people may suffer from swollen, cold, and clammy hands and fingers, and complain of weakness with various activities such as typing, unscrewing a jar lid, and grasping.
Health care professionals can utilize several different tests to diagnose CTS. When the median nerve reaches the wrist, it splits into two branches called roots. The motor root contains nerves that control some of the small muscles of the hand. This root passes beneath the ligament (flexor retinaculum) across the wrist and is susceptible to compression. One particular muscle of the thumb, called the abductor pollicus brevis, becomes weak with CTS. This muscle moves the thumb away from the index finger when it is working properly. Weakness of this muscle, detected upon examination or with an electrical diagnostic test, can help confirm or deny CTS. Other nerve fibers in the motor root control blood vessels and sweat glands in the hand and fingers. With more severe CTS compression, the hands may be swollen, cold, and clammy.
What causes the pain? As discussed, pain, weakness, and other symptoms of CTS are caused by the compression of the median nerve (motor branch) by a wrist ligament (flexor retinaculum). When a nerve is compressed, the tissues that the nerve supplies are deprived of nutrients and stimulation, and muscles and blood vessels begin to break down. Waste products accumulate, which stimulate pain nerve endings which send pain messages to the brain. The other branch of the median nerve that carries pain messages from the hand to the brain is unaffected by CTS, as this sensory root passes above the wrist ligament.
Compression of median nerve fibers may occur at other locations such as at the elbow (by the pronator teres muscle), and the neck (by the scalene muscles). These compression sites can give symptoms mimicking CTS, so a proper diagnosis is crucial before treatment begins. In some unfortunate cases, a proper diagnosis may be formulated by a failed CTS surgery. If CTS surgery is performed in the wrist area, but pain continues, it is possible the problem is elsewhere. Due to the inherent side effects of surgery and the high failure rate of CTS surgeries in particular, other less invasive treatments should be exhausted first after the proper diagnosis is made.
How does compression occur? One common cause of median nerve compression at the wrist is when the muscles on the front part of the forearm are too tight and strong as compared to the back muscles of the forearm. Typical daily work, computer, and home activities strengthen the flexor (front) muscles of the forearm too much, ignoring the extensor (back) muscles of the forearm, causing an imbalance. Typical gym weight workouts also strengthen the front muscles more than the back. The stronger, tighter flexor muscles (and the weaker extensor muscles) tug on the front (palm) of the hand, buckling the ligament slightly, which may compress the median nerve. Also, the brain controls background tone of the muscles of the front and back of the forearm, and if the nerve messages from the brain are faulty, the front to back muscle tone of the forearm may be further out of balance.
Proper muscle tone control of the forearm and healthy brain circuits are imperative in the treatment and prevention of CTS. One of the most important sources of input to the brain which keeps it functioning well comes from special nerve sensors in spinal joints and soft tissues. These nerve sensors are called mechanoreceptors and muscle spindles. Mechanoreceptors stimulate the brain properly when the spine and spinal joints are functioning properly. When spinal joints are stuck or out of alignment, this condition is called spinal subluxations. The focus of chiropractic is to improve the motion and position of the spine and spinal joints, and to reduce spinal subluxations, as well as joints in the arm. If the spinal joints remained stuck, out of alignment, or subluxated, this robs the brain of mechanoreceptor input, which may adversely affect the muscle tone balance of the front and back muscles of the forearm, possibly causing CTS. In my office, we not only look at the wrist joint for alignment and motion, but we also address problems that may exist in the elbow, shoulder, muscles, and examine the spine for dysfunction and subluxations. In other words, we address the whole person, not just the wrist. Chiropractic treatments, known as adjustments, are designed to improve spinal and extremity joint health. Chiropractic adjustments may be needed in the wrist and arm, as well as the spine, to increase the chances of success with CTS. Scar tissue in muscles and other soft tissues is addresses as needed. In addition, I teach home exercises to strengthen the weak forearm extensor muscles. I teach improved posture habits and recommend workstation improvements to try to help prevent future problems. I have Cold Laser therapy available (Low Level Laser Therapy or LLLT) to work along with chiropractic adjustments, home exercises, better posture, and workstation improvements.
What can you do now for home treatment? (NOTE: Perform the following exercises only under the supervision of your health care practitioner)
1. Raise computer monitors so they are at least at eye level. Slightly above eye level is ideal to promote better spinal posture and remove irritation to the neck.
2. Perform reverse wrist curls to strengthen the back (extensor) muscles of the forearm. Start with very light weight, even one pound or no weight at all, especially if you are in acute CTS pain. Others may start with a 3-5 lb. dumbbell. Support your forearm on the edge of a desk or counter, with your wrist and hand over the edge, and your fingers toward the floor, grabbing the weight with a closed fist. Start with your wrist bent toward the floor, and slowly lift the back of your hand up as far as you can without increasing pain. Hold for a second or two in the extension position, and slowly drop the hand back down toward the floor. The key is to perform this maneuver SLOWLY, in your comfortable, pain-free zone. Do 2-3 sets per day of 8-15 slow repetitions, and you can do both wrists even if you only have pain in one.
3. Perform rubber band exercises. Place a typical postal rubber band around your distal fingertips. Hold your fingers almost straight, with a slight bend, in a claw-like position. Open the fingers slowly as far open as you comfortably can against the tension of the rubber band, then relax your fingers to the start position, making sure you keep a little tension on the rubber band in the start position. Repeat this opening and closing of the fingers against the tension of the rubber band. Try to keep the fingers spread equidistant apart, and work on slow, smooth finger motion. You may find your fingers will shake in the beginning and seem uncoordinated, but this will improve. Start with a few repetitions only and donít overdo it. Rest, and try a few more later. Start with a couple sets of 8-15 repetitions per day, and increase to several sets per day as you see fit. If your strength improves, you may use 2 bands to increase tension.
4. Perform specific spinal extension and flexibility exercises daily as we teach in my chiropractic office.
5. Avoid slumped over, round-shouldered, chin-down postures for long periods.
6. Get out of your chair frequently, even if it is for only a few seconds, every 15 minutes.
7. Use these recommendations and exercises in conjunction with chiropractic care. Either call my office or consult a chiropractor knowledgeable on CTS care.
Dr. Scott Fuller, DC updated October 2007 (originally written April 1998)
Fuller Chiropractic 576 Main St., Woburn, MA 01801 781-933-3332