abstract: Carpal tunnel syndrome is a general term used to describe a myriad of conditions. It is often diagnosed when a patient complains of a feeling of 'pins and needles' in the hand and wrist. Tests for this include electromyography, X-ray, or magnetic resonance imaging, as well as nerve conduction studies. Conservative care can include manipulation, physiological therapeutics, or splinting; medication is another option, as is surgery if conservative care fails. Patients suffering from carpal tunnel syndrome are not often referred for rehabilitation. This paper discusses a case of carpal tunnel syndrome in a 59-yr-old patient who was successfully treated using a combination of chiropractic manipulation and active and passive care.

key word: Carpal Tunnel Syndrome; Chiropractic Manipulation; Rehabilitation

Introduction

    Carpal tunnel syndrome (CTS) is defined as an entrapment of the median nerve in the area of the volar wrist canal beneath the flexor retinaculurn which causes neural symptoms that refer into the hand, wrist, and upper extremity (1).There are eight irregularly shaped carpal bones that articulate with one another by arthrodial joints connected by interosseous ligaments. The carpal arch and the flexor retinaculum help form the carpal tunnel. The volar carpal ligament is attached to the pisiform and hamate on one side and the scaphoid and trapezium on the other.

    The median nerve enters the carpal tunnel just beneath the flexor retinaculurn; it does so along with the forearm flexor tendons on the ulnar side of the flexor pollicis longus, running volar to the flexor digitorurn profundus. The recurrent branch of the median nerve usually arises after it has entered the carpal tunnel but has on occasion pierced the flexor retinacuum.

    The median nerve has both sensory and motor fibers. The motor innervation includes the thenar region, the elbow joint, anterior forearm, intrinsic muscles of the hand, and the first two lumbrical muscles. The sensory innervation includes the dorsal and palmer area of the thumb, index, and middle finger, along with the radial side of the ring finger. Wrist flexion decreases the space available to the median nerve; wrist extension increases space available to the median nerve (2-6).

Case Report

    A 59-yr-old male machine operator suffered from numbness, burning, and a feeling of either "tingling" or "pins and needles" in both wrists and hands. The patient's complaints were bilateral, involving the median nerve distribution, but was worse on the left side. CTS is bilateral in 50% of the diagnosed patients (7). As a result, both upper extremities should be examined and evaluated carefully in all patient with suspected CTS. The patient's symptoms were consistent throughout the day and would occasionally wake him during the night. This is a common finding in carpal tunnel patients; up to 95% of sufferers wake in the middle of the night with pain symptoms (7). These symptoms can be described as either a paresthesia or dysesthesia.

    The patient stated that his condition came on gradually and worsened progressively over time. The patient stated that he had trouble holding a coffee cup, an early indication of loss of grip strength. Patients with more severe CTS often experience a noncommittal loss of grip strength (7).

    The patient worked for a corporation that manufactures tubes, operating equipment that vibrates and constantly using his arms, hands, and fingers. He had previously been under the care of a health facility that used conservative medical care initially consisting of anti-inflammatory medication. He had not benefited from this treatment. He was then put through a course of physical therapy, which also included wrist braces. He noted that this course of treatment was also ineffective.

    Electrodiagnostic studies were performed by a board-certified electromyographer and neurologist. Findings from that study indicated the presence of bilateral mild-to-moderate CTS. Nerve conduction velocity, and needle electromyography are perhaps the best method of confirming the diagnosis of CTS (7). His family and social history did not contribute to the condition. The condition was aggravated by certain activities the patient performed at work during the normal course of his job. When asked how he relieved these episodes of symptoms, he stated that he was able to relieve his symptoms by shaking and rubbing his hands. This is descriptive of the Flick test. This test has been shown to be highly sensitive and specific in 93% of CTS cases (7).

    A cervical, thoracic, and upper extremity examination was performed. The patient had positive Phalen's, Tinel's, and pinch tests bilaterally. Phalen's test is positive in 80% of the patient with classic CTS; however, Tinel's sign is usually positive in only 60% to 70% of patients with CTS and the carpal compression test is positive in 90% of the patients with CTS (7). Thus, these tests are all good indicators of CTS but are not completely reliable. It is for this reason that electrodiagnostic: test are important in confirming the diagnosis of CTS. The patient also had mild muscle weakness with some sensory deficit along the C6 dermatome bilaterally, although it was more pronounced on the left side. All other cervical, thoracic, and extremity orthopedic and neurological tests were negative.

    A cervical and bilateral wrist series were performed. The cervical X-rays demonstrated mild degenerative changes at C6 and C7 levels. The wrist films were unremarkable. Erythrocyte sedimentation rate, C-Reactive protein, and Rheumatoid factor tests performed were within normal limits.

   The patient had no visual abnormalities and appeared to be normal in all respects. Motion and static palpation revealed bilateral decreased range of motion in extension. Compared with the right wrist, the left wrist exhibited less motion in all ranges, more so in flexion. There was also some hamate fixation in the left wrist upon motion palpation. There was fixation of C6 with a listing of PL.

Treatment

    The patient was treated with the CTD-Mark I pneumatic decompression device. The CTD-Mark I decompresses the median nerve by altering the biomechanics of the carpal bone with specific pneumatic traction of the wrist. In this case, the patient was treated in the thumbs up, down and out positions, initially at 60 pounds of pressure. The pneumatic decompression consisted of 18 tractions for 5 seconds at each position, with the pneumatic decompression pressure gradually in increased to patient tolerance. The treatment is performed and ~aluated until the patient's symptoms resolve, he reaches pain-free full range of motion, or his progress reaches a plateau.

   Each position alters the biomechanics in a different manner. The procedure described above is the typical protocol used to treat a patient initially. The protocol can be altered based on patient response. Positions can either be added, subtracted, or changed depending on what conditions dictate. Rotational torque is an example of a position that can be added or substituted.

    The doctor must be constantly evaluating the treatment protocol to achieve the desired results. The patient's wrist is then motion palpated; when articular dysfunction is present, it is corrected by manipulation. The cervical spine is evaluated and manipulated, when necessary, to correct any articular dysfunction (7). George's test should always be performed before cervical adjusting to rule out a compromised vertebral artery and/or possible stroke potential (8). The elbow and shoulder were also evaluated and manipulated to correct articular dysfunction and the overall biomechanics of the upper extremity (9).

    Microcurrent was performed initially for relief of the symptoms of acute pain associated with CTS. The pads were placed distal and proximal to the site of pain. The initial settings were a frequency of 80 Hz, just below patient perception, for 20 min. This was followed by a variation of the 'dermatome technique.' Pads were again placed distal and proximal to the involved areas. The settings were at a frequency of 0.3 Hz, just below patient perception, for 10 min (10). This helps accelerate the healing process and reduce symptoms.

    A nutritional supplement combining tumeric concentrate, magnesium glycinate, niacinamide, folic acid and vitamins B5, B6, and B 12 is recommended twice daily during the course of treatment. Initially, the patient was given only a product that contained B vitamins concentrated in B6. This helped reduce his symptoms. A second supplement containing the above-mentioned minerals concentrated in niacinamide was added to the B vitamins that had been concentrated in B6. The combination of the two supplements was significantly more effective. I also recommended that this supplement be continued after the completion of treatment as a nutritional support. These supplements should help accelerate the healing process and assist in diminishing the patient's symptoms by reducing inflammation, pain, and paresthesia. They may also help reduce stress, relax tense muscles, and increase blood flow, which in turn increases oxygen intake along with other essential nutrients, preventing fatigue that can lead to ischemia followed by inflammation. Niacinamide has been used to increase joint mobility and reduce stiffness (11).

    The patient is typically treated three times a week for a period 8 to 16 wk with monthly evaluation to determine the efficacy of the treatment and to alter the protocol if necessary. Patients usually respond well to this protocol, their conditions resolving within that 8- to 16-wk period. The treatment time frame can be increased proportionally to the severity of the patient's symptoms. Age, sex, body type, activities of daily living, and the patient's job requirements are factors that may increase the treatment time frame.

    The mechanical element involved should be determined from the activities of daily living and the patient's job requirements. A correlation should be drawn between the mechanical vector and the patient's symptoms. The mechanical element should be dealt with by altering job ergonomics and the performance methods of activities of daily living. This will help prevent compensatory muscular system imbalances from occurring. The patient's job requirements were physically demanding, which indicated the need for a return of maximal function capacity to a preinjury level.

    Muscular imbalances often occur in conjunction with CTS and should be managed before initiating a rehabilitation program. Evaluation of muscle imbalances should be performed once the patient has reached or almost reached pain-free full range of motion. It is important to recognize the difference between muscle spasm and muscle tightness. Tight muscles are usually stronger than normal. These muscles can develop a "tightness weakness," as described by Vladimir Janda, in which a decrease in muscle strength occurs (12). Strengthening a tight muscle can cause increased weakness. Stretching is the typical protocol for muscle tightness. The patient, during his course of care, was able to perform a progression of rehabilitation exercises ranging from proprioceptive neuromuscular facilitation (PNF), stretching and isometric exercise to active resistive isotonic exercise. PNF and exercise facilitate neuromuscular re-education. The PNF and isometric exercise was performed for 4 wk. The stretching and muscle imbalances were considered throughout the whole rehabilitation program. The Hettinger-Muller method of I set of 20 repetitions for 6 sec daily was used (13). This was performed during the final 4 wk of passive care.

    The passive and active care during this stage of treatment were blended. Wrist flexion and extension exercises were especially effective in restoring function. The active exercise protocol was performed to the Oxford technique. The Oxford technique consists of 10 sets of 10 repetitions with decreasing weight in each set. This exercise protocol was performed because it benefits decreased joint strain, without an increase in pain or swelling (14).

    These exercises were performed in conjunction with kinetic and aerobic activities focused to increase his strength, flexibility, range of motion, and endurance. The kinetic activities were performed for 30 min/session. The patient performed 10 min on a stationary bike, a Cardioglide, and a ski machine. These particular devices were used because their performance requires the use of both upper and lower extremities. This protocol allows for cross education (14). This enhances the neuromuscular education and increases power and endurance. These were performed until the patient progress reached a plateau.

    The patient's symptoms completely resolved in 16 wk. The progress from his work conditioning rehabilitation program reached a plateau after another 8 wk of care. He achieved a return to a level of functional capacity equal to the performance level necessary to carry out the requirements of his job. His condition resolved functionally in 24 wk. The patient has had no further irritations, aggravations, or exacerbations of his symptoms since his release from care.

Discussion

    This patient was diagnosed as suffering from bilateral CTS with cervical involvement. A differential diagnosis was considered to determine if the patient's condition was emanating entirely from the wrist, from a cervical problem with extremity distribution of symptoms, or from a "double crush syndrome," which is a combination of both. The true CTS rarely exists clinically. The diagnosis of carpal tunnel often arises from a combination of cervical involvement, along with problems arising along the path of the median nerve from the wrist to the brachial. plexus. The nerve root most commonly involved is C6.

    The patient's vascular system was evaluated to rule out Raynaud's syndrome. His hands were placed in cold water in an attempt to duplicate the symptoms. Reflex sympathetic dystrophy is a condition that sometimes occurs in conjunction with CTS and contributes to the symptoms. This condition will often respond to soaking the hands and wrists in warm water, thus giving the patient symptomatic relief Adson's, Allen's, Eden's, and Wright's tests were performed to rule out neurovascular compression syndrome. Finkelstein's test was conducted to rule out stenosing tenosynovitis of the abductor pollicis muscle. Froment's sign was not present, which ruled out u1nar nerve paralysis (15).

    Acute CTS may be caused by trauma from bums, hemorrhage, displaced fracture, unreduced dislocation of the carpal bones, or Colle's fracture. Chronic CTS is more prevalent and can be separated into two types. Chronic CTS can result from conditions that are either osseous or edematous in nature as a result of soft tissue swelling. Osseous conditions can be brought on by a mechanical problem that causes articular dysfunction in the carpal bones, which results in compression of the median nerve. Edematous conditions can arise from thickening of the soft tissues, such as the flexor synovialis, which results in nonspecific inflammation of the tendons. Edematous conditions such as gout and Lupus can cause carpal tunnel-like symptoms. These conditions can be ruled out by lab test, which were negative in this patient. The history also would also contain information of activities such as the use of vibratory tools and wrenches, sewing, peeling potatoes or other vegetables, typing on a computer keyboard or any other action involving repetitive wrist motions. These activities would cause symptoms during the day from swelling of the nerve or soft tissues; later that night, the nerve would suffer nocturnal ischemia caused by a lack of motion, which would wake the patient.

CONCLUSION

    Carpal tunnel treatment, including rehabilitation if necessary, cannot follow a cookbook approach. The care must be specific to each particular case. The doctor must be alert in his or her evaluation of the patient and alter therapeutic protocols as the case dictates. This protocol can have multiple factors, such as scar tissue from a previous CTS surgery, complicating the case. The doctor must make sure that the protocol selected is not limiting from a biomechanical standpoint. Traditionally, a rehabilitation program usually does not follow CTS treatment either by surgery or conservative care. The _~cess of this particular case study leads me to believe that this concept should be reconsidered, with a rehabilitation program being made an intricate part of the case management. This type of case management can be a viable alternative to surgery in treating CTS.

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