Cascade Wellness Clinic "Dr. Rick Online" Rick Allen, DC 221 NE 78th Avenue Portland, OR 97213 503/257-1324 663 Sunnyside Rd Trout Lake WA 98650 509/395-0024

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Treating Carpal Tunnel and Other Repetitive Strain Injuries Without Drugs or Surgery

By Rick Allen, DC

Overview

Ask yourself:

• Do your wrists and hands ache from overuse?
• Do you wake up with your fingers curled and stiff?
• Do your hands burn, tingle, or feel numb?
• Do you fumble when lifting objects?
• Do your hands seem to have less than normal strength?

You may have carpal tunnel or a related repetitive strain injury/cumulative trauma disorder (RSI/CTD). Some form of repetitive stress disorder - mostly carpal tunnel - is now occurring in fully 15 percent of the U.S. workforce. The U.S. Department of Labor reports that CTD's currently account for over 60 percent of workplace injuries. The American Academy of Orthopedic Surgeons estimates CTD's cost $27 billion annually in medical treatment and lost income. According to Newsweek (6/26/95), claims for repetitive strain disorders cost employers some $100 billion annually.

RSI/CTD is epidemic.

Medical treatment focuses on the carpal tunnel, where the median nerve crosses the underside of the wrist. The most common medical treatment is a combination of wrist/forearm bracing and anti-inflammatory medication (steroids or nonsteroidal - ibuprofen, etc.). If that doesn't help, surgery is suggested - cutting the flexor retinaculum across the wrist. While this gives dramatic short-term relief of the symptoms, it can create additional problems:

• Rigid bracing is uncomfortable. Long-term, it increases the sticky adhesions that form in the connective tissue covering of the muscles and tendons. While the arm, wrist and hand feel better when kept from moving, the underlying problem is still present and may be even worse when the brace is removed.

• Anti-inflammatory drugs also block the pathways that heal connective tissue. With chronic use, this creates a cycle of incomplete healing and a dependency on the drugs to reduce recurring swelling and pain.

• Anti-inflammatory drugs are damaging to the lining of the stomach and intestines. In fact, they are the number one cause of admissions to hospitals for gastrointestinal bleeding.

• Scar tissue often grows over the carpal tunnel. In approximately 80 percent of the surgeries the symptoms return within two years.

A better route is conservative treatment: chiropractic, massage, myofascial release, neurolymphatic reflex points, acupuncture, nutrition, specific exercises, and correction of poor ergonomic working conditions. In addition to carpal tunnel, these treatments address related problems, such as trigger points in the muscle of the forearm and neck, vertebral subluxations of the neck, and chronic forward postural strain.

I have successfully treated a number of people with carpal tunnel and other RSI/CTD (including myself). It has been my experience that conservative, non-surgical, non-drug treatment is effective in most cases. It is certainly the route to follow first. Most importantly, it has no unwanted side effects.

In the unlikely event that your case is beyond the body's ability to repair itself with conservative care, the medical/surgical route is still available. If you do not experience some improvement within three weeks, your case may unfortunately be so severe that a neurological consultation is advisable and surgery may be required.

My experience is that even with a difficult case of RSI/CTD, you can expect improvement to start within two weeks. While the course of recovery varies with each case, if both you and your chiropractor perform your healing tasks diligently, you can expect good, lasting recovery within three to four months.

In closing, remember that if you continue the same conditions that led to the injury in the first place, you will be back at square one - in pain and, perhaps, unable to work. As outlined in phase three below, ongoing preventative care is imperative to stay healthy.

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Typical Case Overview

History:

• Occupational repetitive wrist motion - microtrauma - from hammering, typing, sewing, or assembly line work.
• No major, overt trauma to the wrist - no macrotrauma.

Warning Signs - Complaints by the Patient:

• Pain in the arm, wrist and hand - location and intensity may vary.
• Decreased sensation of the hand - may tingle or feel numb.
• Weak grip - may fumble or drop objects.
• Tenderness along the median nerve into the hand when the underside of the wrist is tapped sharply (Tinel's test)
  
  
  
  
• Numbness or tingling of hands when wrists are bent downward at 90 degrees for more than 30 seconds (Phalen's test)
  
  
  
  

Professional Examination:

• Observe the hand for natural symmetry and color.
• Check for muscle atrophy - wasting of the thumb muscle (th enar eminence).
• Check active and passive ranges of motion of the neck, arm, wrist and hand.
• Check sensation, especially the area supplied by the median nerve - index and middle finger.
• Check deep tendon reflexes of the biceps, brachioradialis and triceps.
• Check for myofascial adhesions and trigger points in the neck, back, shoulder, arm, forearm, and hand.
• Check for pain with pressure on the side of the neck ("doorbell sign").
• Perform tests for carpal tunnel: Phalen's and Tinel's tests.
• Perform grip strength tests - manual or dynamometer.
• Order appropriate blood chemistry tests if arthritis is suspected.
• Order x-rays of neck and wrist if necessary.
• Request nerve conduction velocity tests (sensory and motor latency) if case is severe.

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Features of an Anatomically Friendly PC Station

• Sufficient indirect lighting to prevent eyestrain and glare
• Monitor at eyelevel to prevent hunching over
• Keyboard at elbow height for arms and shoulder alignment
• Padding in front of keyboard for wrist alignment and relaxation
• Adjustable seatback support for lower back
• Footrest for comfort and stability

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Conservative Treatment:

Phase 1 -- Acute phase (first one to three weeks):

1. Rest the hands and wrist. Minimize or eliminate the activity that is causing the problem.
2. Only if absolutely necessary, rest with cock-up splint worn all day and night for up to three weeks.
3. Cryotherapy - Ice massage of the inflamed area.
4. Chiropractic manipulation of the shoulder, neck, forearm, wrist and hand for subluxations.
5. Nutritional supplementation: Start a good, natural multi-vitamin and multi-mineral supplement each day and an additional B-complex supplement.
6. Wean patient from NSAIDs (nonsteroidal anti-inflammatory drugs), such as ibuprofen, etc.
7. Replace with natural anti-inflammatory herbs (I prefer a combination called PSI from NF Formulas in Wilsonville, OR), natural proteolytic enzymes (bromelain is the most common and is an ingredient contained in PSI), and beneficial omega-3 oils (salmon and a borage/flax combination).
8. Have workstation evaluated for proper ergonomics and have corrections made. If necessary, order protective devices.

Phase 2 - Post-acute phase (next two to four weeks):

1. Continued rest or modified work, as necessary, to prevent aggravation.
2. Chinese "spooning" as tolerated to improve blood flow and break superficial adhesions of the skin and underlying fascia.
3. Pre-manipulative physiotherapy - ultrasound is most common.
4. As tolerated, extensive release of the deeper soft tissues - muscles, tendons, and tendon sheaths - with massage, active muscle stripping, trigger point therapy, transverse friction massage.
5. Continue chiropractic manipulation of the shoulder, neck, forearm, wrist and hand for subluxations.
6. Complementary acupuncture treatment of the arm and supportive structures of the neck and back.
7. Continue nutritional supplementation.
8. Add glucosamine hydrochloride or sulfate and chondroitin sulfate, which are building blocks for healthy connective tissue. (GSCS NF Formulas is a good choice, call 800/547-4891.)
9. At home, rub salve on the arms to promote circulation and reduce inflammation. I use one specially made for treating this type of injury. It is available from Kate Montgomery, LMT (www.sportstouch.com).
10. As adhesions and tenderness of the hands and wrists diminishes, start home exercises specifically designed to strengthen the extensor muscles of the forearm. This will counterbalance the excessive strengthening of the flexor muscles that occurs with typing, hammering, etc. The best exercise aid I have found is the Flextender Glove by Balance Systems (www.repetitive-strain.com).

Phase 3 - Ongoing Preventative Treatment:

1. Self-massage and treatment of trigger points of the forearm and hand. Kate Montgomery has a good 12-step program that I endorse (www.sportstouch.com).
2. Stretches and strengthening exercises while at work, much the same as wearing a hard hat and safety glasses for prevention of injury. This keeps the muscles in proper balance.
3. Continued nutritional support, including omega-3 oils and GSCS.
4. Continued monitoring of ergonomic conditions.
5. Regular massage and chiropractic care to prevent buildup of adhesions and subluxations.

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References:

Background about the extent of the problem

• "A Spreading Pain, and Cries for Justice," New York Times, 6/5/94.

Treatment, including myofascial release techniques

• Carpal Tunnel Syndrome: Prevention and Treatment, Kate Montgomery (www.sportstouch.com).
• "A Case for Self-Management of CTS," Workplace Ergonomics, 10-11/97.
• "Carpal Tunnel: A Case Study," The Axis, 11/93.
• "Another Look at Carpal Tunnel," Dynamic Chiropractic, 3/12/93.
• "A Conservative Chiropractic Approach to the Treatment of Carpal Tunnel Syndrome," The American Chiropractor, 1-2/97.
• "Releasing the Myofascial Lesion," Chiropractic Products, 10/97.
• "Myofascial Release Technique and Mechanical Compromise of Peripheral Nerves of the Upper Extremity," Chiropractic Sports Medicine 6(4):139-150, 1992.
• "Upper Extremity Repetitive Stress Injuries," Massage Therapy Journal, Spring, 1994.
• "Balancing Muscle Groups: A Solution to Repetitive Stress Injuries," Chiropractic Products, 5/97.
• Flextender Glove by Balance Systems (www.repetitive-strain.com).

Nonsteroidal Anti-inflammatory Drugs (NSAIDs - ibuprofen, etc.) - dangers and alternatives

• "NSAIDs Cause GI Bleeding and Death," Epidemiology, 1996.
• "Deadly Risk with Antacid and NSAID Use," CAO Journal, 9/96.
• "The Problem with NSAIDs," Dynamic Chiropractic, 4/10/95.
• "NSAIDs - The Unintended Consequences," Dynamic Chiropractic, 11/3/97.
• "Glycosaminoglycans and Derivatives for Treatment of Arthritis," Chiropractic Products, 5/97.

Workstation ergonomics

• "Adapting the Workstation to the User and Task," Workplace Ergonomics, 5-6/96.

Dr. Rick Allen is a chiropractor, massage therapist and dance student in Portland, Oregon. Dr. Rick welcomes your questions and suggestions for future articles. However, he cannot make specific diagnoses or treatment recommendations unless you visit him in person. He can be reached by phone: 503-257-1324, mail: 221 NE 78th Avenue, Portland, OR 97213, e-mail or World Wide Web: www.CascadeWellnessClinic.com

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