What is Carpal Tunnel?

Carpal tunnel syndrome occurs when the nerve (median), which runs from the forearm into the hand, becomes compressed between the displaced bones of the wrist (called subluxation). Nerve signals originate in the brain and follow tracts down the spinal cord through openings between the neck bones (vertebrae). The nerves then travel down the arm and into the hand. At the wrist, a semicircular tunnel allows the nerves to travel through the highly mobile wrist area. The tunnel is a narrow and rigid passageway of ligaments and bones at the wrist and contains the median nerve and tendons. The tunnel deforms when there is sprain or damage to the ligaments allowing the bones to move away from their normal positions.


There are also other causes for compression, such as inflammation. Sometimes, the nerve is more susceptible to compression at the wrist if it is also pinched or irritated at the neck level. When the nerve is compressed or irritated at both the wrist and neck area it is called a double crush injury or syndrome.


Sometimes, thickening from irritated tendons or other swelling narrows the tunnel and causes the median nerve to be pinched. This is why sometimes anti-inflammatory drugs such as aspirin or ibuprofen will decrease the pain in some patients. But these medications really are a no-end kind of treatment that never gets at the cause of why there is inflammation in the first place. They also have significant side effects, especially in older patients where they can cause stomach or intestinal bleeding (ulcers).


The median nerve controls sensations to the palm side of the thumb and fingers except the little finger as well as impulses to some small muscles in the hand that allow the fingers and thumb to move. Pain, tingling and numbness in the hand can be caused by neck problems such as a herniated disk, sprains or subluxations, and arthritis.


When carpal tunnel syndrome strikes, the result may be pain, weakness, or numbness in the hand and wrist. Sometimes, the pain runs from the wrist and back up the forearm. Many patients will also say that they have other bothersome symptoms such as back and neck pain or stiffness.


Many patients believe surgery will help their condition or have had it recommended to them. It is important to make sure a comprehensive diagnosis is obtained prior to contemplating surgery. Surgery is a very drastic and last resort type of option so one should try conservative treatments first. If the problem is an irritated or compressed nerve in the neck, no amount of wrist surgery will help that type of problem.

Five Stretches to Help Your
Carpal Tunnel Syndrome

Carpal tunnel syndrome is a debilitating disorder affecting the nerves that pass through the wrist and into the hand. In addition, compression can also occur in the neck region, making some patients' problems more complex. At its essence, carpal tunnel syndrome is a disease of nerves but other tissues can also be affected. For example, the joints of the wrist may lose their mobility through a combination of wrist braces or pain-avoidance behavior. Because the hand is used less, the shoulder and upper arm region may also get affected with tightness and weakness.

As pain continues, we may stop using a keyboard or playing certain sports or hobbies. All of this lack of activity makes muscles weaker and joint function further impaired. This is why it is important to maintain flexibility of your joints and muscles if you have this disorder.


Two good stretches for the forearm and hand involve stretching into flexion, which lengthens the tissues on the back of the wrist and moving your fingers backwards, stretching the palm and the front of the forearm. You can do these two stretches by using your other hand to bend the fingers backwards and pulling the back of the hand forward. If either of these motions causes more pain, then you should avoid them.


Three additional stretches involve the elbow, wrist and neck. For the elbow, extend your arm out, stretching the front of the upper arm. You can also rotate the wrist by twisting it until the thumb points down maximally and outwards maximally. Check to see if you have the same flexibility on both sides; your goal will be to create symmetrical side to side movements.


The shoulder and neck are often neglected in carpal tunnel stretches but are critical because the nerve that goes through the wrist starts in the neck area and passes through the shoulder. Put both hands over your head and "reach for the stars." You might also rotate your shoulders by moving your arms in large circles. This stretch will also affect the neck. It's important to do your stretches slowly. Little by little, the nerve will have more flexibility as it courses down the arm and this may help your hand symptoms.


Carpal Tunnel Syndrome In Your Neck?

Over the decades, we have come to expect a pain or tingling in the hand and wrist means there is a local injury in the area. Since many surgeries are done each year on the wrist to relieve these symptoms, it seems logical that this is the case. But many patients with "successful" surgeries still have problems over time. Others only receive temporary relief and the problem quickly returns. Other patients can develop wrist and hand symptoms that mimic carpal tunnel syndrome, after a whiplash injury or sprain/strain of the neck. These patients may not have any trauma at all to the wrist and hand area but have severe hand pain. Why does this occur?


One possibility is the carpal tunnel diagnosis was incorrect. Because your body is interconnected with joints and nerves, symptoms often occur at another location from that of the actual problem. Taking this approach is more holistic, vs. the often-fragmented medical view of things. We have doctors of the feet, the eyes, and various other body parts. These types of specialists, while often good at specific problems, can sometimes miss diagnoses that are complex and involve multiple body systems.


More and more research has shown this to be the case in carpal tunnel patients. A study from 2006 looked at the spines of patients with carpal tunnel syndrome. MRI's, x-rays, and nerve testing were done on patients with carpal tunnel syndrome, and another group with referred pain from the neck and into the wrist and hand. Another group of subjects, with no symptoms at all, served as the control. The x-rays showed that degeneration of the disks in the neck were present in both patient groups. The MRI took things a step further, to see if the tiny holes between the neck bones showed narrowing and a pincer effect on the nerves.


This study showed that in carpal tunnel syndrome there is often degenerative changes in the neck and supported the "double-crush" nerve hypothesis. Seeing a doctor of chiropractic to make sure that your wrist and neck is properly examined is key to proper diagnosis. Without proper assessments, treatments are often unsuccessful, especially surgery. Before embarking on the more invasive option of surgery, consider conservative chiropractic care. If the problem in your wrist is more a problem in your neck, specific wrist treatments will be ineffective.


Results of a Clinical
Trial of Two Treatments

Carpal tunnel syndrome occurs when the median nerve, which starts at the neck and runs from the forearm into the hand, becomes compressed or squeezed at the wrist. In some cases, there may also be compression at the spine.


The median nerve controls sensations to the palm side of the thumb and fingers (but not the little finger), as well as impulses to some small muscles in the hand that allow the thumb and fingers to move.


A recent study in the Journal of Manipulative and Physiological Therapeutics compared two different conservative treatments for patients with mild to moderate carpal tunnel symptoms. One treatment was the Graston technique, which uses an instrument to rub the forearm, wrist and hand areas to breakdown scar tissue and adhesions. In the other treatment, a chiropractor applied deep pressure by hand to the same areas. These treatments are thought to release tight muscles and myofascial restrictions.


The patients received the treatments twice each week for four weeks, followed by one treatment a week for two additional weeks. The patients also did at-home stretching exercises. They did not use common treatments such as wrist splints and anti-inflammatory medications.


After both interventions, there were objective improvements to nerve conduction latencies (nerve function), wrist strength, and wrist motion. The patient symptoms of pain also improved, and both groups reported high satisfaction with the care they received.


Despite surgery's widespread use in the US for carpal tunnel syndrome, it is important for conservative treatments to be tried prior to an invasive operation.


The surgical complication rates are low but when they do occur, can be devastating. In addition to direct surgery costs, one has to also consider disability payments (not working), and rehabilitation that may take several weeks. These costs can be substantial. For this reason, many medical doctors recommend conservative treatments first.


Of all the conservative options, manual therapy by a chiropractor is an excellent choice. It comes without the side effects associated with long-term use of medications.


A comprehensive examination by a Doctor of Chiropractic can determine if your carpal tunnel symptoms are likely to respond to care. He or she can also advise on at-home stretching exercises that can be done to help recovery. In some cases, hidden spinal and neck problems can influence carpal tunnel symptoms, and be the key to treating the cause vs. the symptom.


Is Carpal Tunnel Surgery the
Only Potential Solution?

For many patients with carpal tunnel syndrome (CTS), surgical release is too often the only discussed option for treatment. Why is this? How medical doctors are taught, as well as what is read, drives many to their decisions.


So what does the medical literature actually say? A recent article published in a scientific journal (Adv Tech Stand Neurosurg 2007;32:175-249) may provide some perspective.

The paper is titled, "Carpal Tunnel Syndrome-a comprehensive review."


Unfortunately, the "comprehensive" review pretty much only discusses the surgical approach to this most difficult problem. The conclusion states, "Surgery for carpal tunnel syndrome requires meticulous attention to history-taking, investigation, counseling, training and surgical technique if unsatisfactory results and complications are to be avoided."


The authors are to be commended for providing a sober perspective on the potential outcome and pitfalls of surgery for CTS.


The part that makes me feel this review is very incomplete, is that chiropractic care is not discussed. That is too often '"to be expected."


But, patients deserve to be told their many options for care, including alternatives to surgery such as chiropractic care. When all you have is a hammer, everything starts to look like a nail.

So, that is what this Health Update is all about, a chance for you to consider surgical alternatives. No one doctor has all the answers but it's important to hear the various perspectives so you can make an informed decision.


Our office always offers complementary consultations. You can come by for a visit, tour our facility and ask any questions you may have. I want to explain the various types of techniques we use to address carpal tunnel symptoms. Sometimes the neck is involved, affecting the nerves that go to the hand and wrist. This is called the double-crush syndrome, and is often overlooked by providers who only examine the wrist for the cause of the wrist and hand symptoms. If your neck was injured in a whiplash or sports trauma, this may be one aspect of your health that has not yet been addressed. By adjusting the problem in the neck region, the nerves to the wrist may function more normally.


Carpal Tunnel and Casual Observations

I still find myself surprised when I see a person with a brace on their wrist, it never fails. It could be the waitress at my favorite restaurant or the cashier at the supermarket, but that little wrist brace always gives me pause and compels me to ask the question, "what's wrong with your wrist?"


Almost to a person, the answer is: carpal tunnel. But the thing that surprises me more is that the person usually says how much pain they're still in, despite the brace. Maybe it's because their work is so stressful on the wrist? Serving tables is hard work and holding a couple of heavy plates with one hand can put a considerable strain on the wrist.


For many patients, the brace can be a life saver, getting us back to work and providing for our families. But for many others, they don't solve the problem. That's because simply limiting motion, while good in theory, could make the muscles of the wrist weaker. Also, wrist problems aren't always just a problem in the wrist. If the wrist and hand pain is actually coming from a pinched nerve in the neck, then the wrist brace will do little to help.


The important thing is to get the problem checked out. Is a small bone of the wrist out of its normal position? Is the mobility of the wrist asymmetrical and uneven? Is there a double-crush problem, with a pinched nerve not just in the carpal tunnel, but also where the nerves exit the neck area?


Our clinic does our best to help the pain of carpal tunnel. Usually a comprehensive approach is needed and we may need to adjust the bones of your neck and wrist to help restore proper alignment. If the vertebrae are twisted in the neck, they can narrow the openings where the delicate nerves emerge and travel down the arm to the hand. Sometimes the posture of the neck is affected and there is a loss of the normal forward curve of the neck. This can cause a stretch to the spinal cord and nerve roots.


If possible, we try to limit the use of braces and instead focus on strengthening the muscles of the forearm, or use deep tissue massage and stretching to increase muscle flexibility.