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President
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As seen on the Sally Show 4/17/2000

 

 


[info]Correct diagnosis

SYMPTOMS - Numbness and tingling sensation in one or both hands.
Frequently accompanied by sharp pains radiating through the arm or shoulder.
Muscle weakness of index and middle fingers and thumb.
Discomfort / aching in one or both hands.
Lack of feeling in hand may cause person to drop objects.
Activities requiring fine hand motor skills may prove difficult if not impossible.

A correct diagnosis is essential before correct treatment can be recommended. It is important to be examined by a knowledgeable physician, preferably an orthopaedic surgeon or a neurologist, to make sure you do have carpal tunnel syndrome and not one of the many other conditions that can have symptoms that are similar to those of carpal tunnel syndrome but are treated differently.

A pinched nerve in your neck, shoulder or forearm can cause numbness and tingling in the hand similar to carpal tunnel syndrome. So can diabetic neuropathy. Arthritis at the base of the thumb or in the hand can also cause similar symptoms. And so on.
Therefore the first step to correct treatment is an exam by an experienced physician to determine the correct diagnosis.

Carpal Tunnel Syndrome is a common problem that affects the hand and wrist. This condition, or syndrome, has become the focus of much attention in the last few years due to suggestions that it may be linked to occupations that require repetitive use of the hands - such as typing.
The Carpal Tunnel is an opening into the hand that is made up of the bones of the wrist on the bottom and the Transverse Carpal Ligament on the top. Through this opening, the Median Nerve and the Flexor Tendons run into the hand. The median nerve runs into the hand to supply sensation to the thumb, index finger, long finger, and half of the ring finger. The nerve also supplies a branch to the muscles of the thumb, the thenar muscles.
The Flexor Tendons allow us to move the hand, such as when we grasp objects. The Tendons are covered by a material called Tenosynovium. The Tenosynovium is very slippery, and allows the tendons to glide against each other as the hand is used to grasp objects. Any condition which causes irritation or inflammation of the tendons can result in swelling and thickening of the Tenosynovium. As all of the tendons begin to swell and thicken, the pressure begins to increase in the Carpal Tunnel because the bones and ligaments that make up the tunnel are not able to stretch in response to the swelling. Increased pressure in the Carpal Tunnel begins to squeeze the Median Nerve against the Transverse Carpal Ligament. Eventually, the pressure reaches a point when the nerve can no longer function normally. Pain and numbness in the hand begins.
One of the first symptoms of Carpal Tunnel Syndrome is numbness in the distribution of the median Nerve. This is quickly followed by pain in the same distribution. The pain may also radiate up the arm to the shoulder, and, sometimes the neck. If the condition is allowed to progress, weakness of the thenar muscles can occur. This results in an inability to bring the thumb into opposition with the other fingers and hinders one's grasp.
The Key Concept to remember is that anything which causes abnormal pressure on the Median Nerve will result in the symptoms of pain, numbness and weakness of Carpal Tunnel Syndrome. Recently, physicians have begun to recognize that activities that involve highly repetitive use of the hands can result in Carpal Tunnel Syndrome. This is thought to be caused by inflammation of the tenosynovium due to overuse.

Treatment options:

Wearing splints-
Only 3% get better wearing splints.

Wristalive
Unlike conventional supports that try to reduce swelling through immobilization, Wristaleve works by lifting the roof of the carpal tunnel to relieve the compression of the nerves and tendons running through it. Wristaleve creates its patented lifting and freeing effect by applying focused pressure to two specific points on the wrist. More important, Wristaleve will liberate you from hand and wrist pain without restricting your freedom to work.
Look for it in a drug store or pharmacy near you. Or visit their web site:
http://www.niche-inc.com/niche/homepage.html

Change work habits.

Reconstructive Therapy -
Wrist instability is commonly mistaken for Carpal Tunnel Syndrome. Reconstructive therapy (also known as sclerotherapy, prolotherapy, and proliferative therapy) offers a biologic alternative, which increases ligament and tendon structures and can strengthen wrist instability up to forty percent.
The main effect of proliferative therapy is increased strength, which results in upgraded endurance. Popping and snapping of the injured joint also decreases with time as the treatment progresses. This therapy is also effective in weakened ligaments, joints, disc trouble and arthritis. When weak joints, tendons, and ligaments are strengthened, the pain is then eliminated. As a result, the joints continue to become stronger. Your endurance level will rise, you will be able to do more activities, and even some activities you couldn't do before. You can usually feel the joint becoming stronger with each treatment.
The therapy is permanent. Since the controlled irritation process produces new tissue, the therapy becomes permanent.

Chiropractic manipulation -
Chiropractic treats "CTS" with the adjustment of the wrist to align the carpal bones back into their proper place. This alleviates the mechanical pressure in the Carpal Tunnel, and also allows the physiological irritation caused by misaligned joints to resolve. I personally have suffered from median nerve impingement from all the computer work that I do, and I have found that the adjustment of the wrist is the quickest and easiest solution to the problem. My patients also have found that adjusting the wrist when the median nerve is affected is the best solution to their problem...not only taking care of the symptoms, but solving the underlying problem.
Other syndromes have the same or similar symptomatology as does CTS. Tendinitis of the elbow and myospasm of the forearm will also irritate the median nerve above the wrist proper. These two conditions are treated differently than CTS, and probably are much more common. I have had several patients that were scheduled for CTS relief surgery consult with me to find out that the problem was not in the wrist at all, but in the elbow. Upon pressuring their MD to research the problem a little further, they avoided unnecessary surgery. We helped each one of them with their problem by solving the TRUE cause, not just alleviating the symptoms for a while. I have also had a handful (sorry for the pun) of patients who had the CTS relief surgery to no avail, and their problem was also in their forearm/elbow, not the wrist. We were able to solve their REAL problem even after surgery forever altered the biomechanics of their forearm and wrist.

Acupuncture-
As treatment with accupuncture releases the body's endorphins and enkephalines, natural pain-killing chemicals, a very high percentage of people with pain, including Carpal Tunnel Syndrome pain, can benefit.
Reported by Maxine Karpen, R.N., "in a study of acupuncture treatment of Carpal Tunnel Syndrome, a positive response was demonstrated in 35 of 36 patients, 14 of whom had been previously treated unsuccessfully with surgery.

Vitamin B6 -
A vitamin B6 deficiency may be the cause.
You need to take 100mg after breakfast and 100mg after dinner.
You may find improvement in 90 days.
Also, avoid excessive consumption of protein and foods high in yellow dyes.

Researchers looked at the influence of vitamin B6 and vitamin C on carpal tunnel syndrome. 441 volunteers took part in this study.

The authors think that a vitamin C supplementation along with low vitamin B6 might have a negative effect on the median nerve leading to symptoms of the hand and wrist. Researchers looked at the influence of vitamin B6 and vitamin C on carpal tunnel syndrome. 441 volunteers took part in this study.
The results showed that the vitamin B6 and C ratio was linked with more pain, tingling, and awakening at night. It was found that that higher blood levels of vitamin B6 were associated with less frequent pain and discomfort. On the other hand, higher vitamin C levels, or a relative deficiency of vitamin B6, was linked with more frequent symptoms.
The authors think that a vitamin C supplementation along with low vitamin B6 might have a negative effect on the median nerve leading to symptoms of the hand and wrist.

Vitamin B6, vitamin C, and carpal tunnel syndrome.
A cross-sectional study of 441 adults.
Keniston RC, Nathan PA, Leklem JE, Lockwood RS J Occup Environ Med 1997 Oct;39(10):949-959

An Alternative Therapy to Treat the Painful Symptoms of Carpal Tunnel Syndrome

If you suffer from carpal tunnel syndrome, there is a new therapy currently being researched with optimistic results. The key strength of this therapy is that it can be performed at home by the patient. For more information on this therapy, please order the booklet:
Naeser Laser Home Treatment Program for the Hand (Laser Acupuncture and Microamps TENS)
It costs $24.95 plus $2.00, S&H and is made available through the American Association of Oriental Medicine, a non-profit professional organization (610) 266-1433)

Hand and arm stretches will help.
These stretching exercises should be done 4 times each day, first in the shower in the morning and then during the day at your work station. At the time of each stretching session, concentrate on a slow, gradual stretch creating a sense in your wrist and forearms that you are slowly stretching the muscles, feeling a slight discomfort and tight sensation. Stretch slowly to the "count of 10" and repeat the same stretch 10 times, each time quite slowly.

Place your hands together in front of you, palms touching, in a praying position
Maintain the palms together, then elevate your elbows until both forearms are horizontal i.e. parallell with the floor
If this hurts, it means the muscles are indeed tight and need this stretching more than ever! If you keep it up, each day it will get easier and your carpal tunnel symptoms will improve.
http://www.catalog.com/global/wristsol.htm

Anti-inflammatory med's may help.

Cold Laser Treatment
For those patients who object to the use of needles in acupuncture treatments, the cold laser is an excellent substitute. It's power output is such that cells are not damaged.
According to Maxine Karpen, R.N., the infrared of the cold laser penetrates the cells of the skin, entering the tendons and surrounding tissue. The laser deposits photons into the cells, and nerve stimulation is immediate. Within minutes circulation is improved, and so is oxygen flow.
The cold laser also blocks enzymes that accompany pain and activates the synthesis of endorphins that block pain. It also reduces the ability of lymphocytes to react to antigens, therefore also acting as an anti-inflammatory.
Swelling can reduce in hours, depending on the level of trauma and swelling. However, in chronic situations, 2 to 3 treatments per week may be necessary.
Cold laser has the ability to increase the rate of nerve regeneration and increase growth of connective tissues and tendons.

Endoscopic CTS Release -
Endoscopic technique. Through a small 3/4 inch incision at the base of the palm the surgeon puts a small telescope into the tunnel. Using a small knife inside the tube the surgeon then cuts the ligament to release the tunnel. The advantages are a smaller incision. I however do not recommend this technique because there is a higher risk of injury to the nerve because the surgeon cannot see the anatomy as clearly as in the standard technique which already has a small incision and does so well.

Cortisone -
Many doctors say, NO!
Corticosteroids cause osteoporosis or softening of bones, making them weak and more easily fractured. Injection of a steroid into an infected area can cause the spread of the infection.
There are a few contraindications to cortisone injection:

uncontrolled diabetes, as cortisone will frequently raise blood sugar levels by 50-100 points
uncontrolled hypertension or congestive heart failure
infection

And some rare complications:

depigmentation of the skin overlying an injection site; we always try to elimimnate this possibility by giving injections deep within a joint or around a tendon so that the skin is not likely to be affected, but rarely this happens anyway
tendon rupture, usually if the tendon is already unhealthy

ART - provides a way to diagnose and treat the underlying causes of cumulative trauma disorders that result is symptoms of numbness, tingling, burning and aching. ART is a type of manual hands-on therapy that corrects muscular and soft tissue problems caused by adhesion formation as a result of injury, overuse or cumulative trauma.
Cumulative Trauma disorder (CTD), Repetitive Stress Injury (RSI), Repetitive Motion injury, are all used to describe problems that arise from the cumulative injury cycle (CIC). Some common names of these conditions are Carpal tunnel syndrome, rotator cuff syndrome, chronic low back pain, whiplash injury and poor posture. CTD's create physical signs and symptoms that are predictable and correctable using ART.
ART is not a magic bullet or cure-all. Active Release Techniques is noninvasive, very safe, has virtually no side effects and comes with a record of very good results. Treatments can be uncomfortable during the movement phases as the scar tissue or adhesions "Break up". This is temporary and subsides almost immediately after the treatment. It is common to feel a duplication of your symptoms during the treatment, a good indication that the problem has been identified. Treatments are about 8-15 minutes per area treated and vary in number from 2 to 10 visits typically. Chiropractic manipulation is frequently done inaddition to ART to increase the effectiveness. Patients report that "It hurts good".

If you elect surgery, keep in mind that if you continue to do the same repetitive motion that caused the pain in the first place, CTS will return.

SYMPTOMS OF PERIPHERAL NERVOUS SYSTEM LUPUS

In peripheral nervous system lupus, a variety of symptoms may occur depending on which nerves are involved. Involvement of the cranial nerves can cause visual disturbances, facial pain, drooping of the eyelid(s), ringing in the ear(s), and dizziness. Inflammation of the blood vessels supplying the peripheral nerves can lead to symptoms of numbness or tingling in the arms or legs. Occasionally, loss of sensation or muscular weakness in the extremities (e.g., carpal tunnel syndrome in the hands) can occur. These symptoms may be due to conditions other than lupus. Electrical studies, such as electromyogram (EMG) and nerve conduction tests are usually helpful in determining if symptoms are due to some other cause. For example, a herniated disc or a metabolic abnormality as in diabetes can cause similar nervous system symptoms, but show different electrical study results. Inflammation of the peripheral nerves (called mononeuritis multiplex) is treated with corticosteroids.

Diagnosis of CTS & other disorders:

CTS vs C6 radiculopathy
The two conditions can coexist.

C6 radiculopathy:

Neck and shoulder pain
Weakness in C6 innervated muscles, reflex changes
Sensory loss restricted to the thumb
The absence of nocturnal paresthesias, and reproduction of the paresthesias with root compression maneuvers.

CTS vs Pronator Syndrome

The most proximal median nerve entrapment.
The nerve enters the forearm passing between the two heads of the pronator teres and then deep to the arch of the flexor digitorum superficialis, continuing between the flexor digitorum superficialis and flexor digitorum profundus in the forearm.

There are four reported sites of compression

supracondylar process/ligament of struthers
lacertus fibrosis (bicipital aponeurosis)
pronator teres: most common site of compression caused by muscle hypertrophy or thickening of the aponeurotic fascia between the two heads of the pronator teres.
flexor digitorum superficialis arch: second most common, fibrosis of the flexor digitorum superficialis arch

Symptoms & Signs:
Pain in the proximal forearm, fatigue with exercise, and hand numbness.
Pain usually worsens with activity, with numbness and parathesias in hand.
Nocturnal symptoms seen with carpal tunnel syndrome are typically absent.
Negative Phalen's test
Weakness of the median innervated muscles is rare.

Provocative tests
Resisted pronation of the forearm for 30 to 60 seconds demonstrates compression at pronator teres when symptoms are reproduced.
Resisted elbow flexion and supination of the forearm can localize compression to the lacertus fibrosis.
Resisted long-finger flexion localizes the lesion at the level of the flexor digitorum superficialis (FDS) arch.
The supracondylar process can be palpated on the medial humeral surface and confirmed with radiographs.
EMG/NCV is inconsistent and diagnosis should be made clinically.

Flexor pollicis longus
innervated by anterior interosseus nerve.
flexion of the distal phalanx of the thumb not involved in CTS.

CTS vs Anterior Interosseous Syndrome

The anterior interosseous nerve (AIN) is a purely motor nerve branch from the median nerve. A rare compression syndrome
Signs & symptoms:
Vague discomfort in the proximal forearm
Parathesias and numbness are rare
Excessive supination/pronation, seen in baseball pitcher or hockey/lacrosse player, seems to aggravate the AIN.
Diagnosis is made clinically.

CTS vs de Quervain's Syndrome

Associated with activities that require forceful grasp coupled with ulnar deviation or repetitive use of the thumb.
Those at risk include golfers, fly fishers, racquet sport players, knitters, laboratory technicians, filing clerks, and mail sorters.
Tenosynovitis develops in the APL and EPB tendons that are held in a groove of the radius by a firm segment of the extensor retinaculum.

Signs & Symptoms:
Pain in the radial aspect of the wrist and thumb, aggravated by movement of the wrist and thumb.
If inflammation is severe, the dorsal sensory branch of the radial nerve can become irritated, and patients complain of pain and paresthesias radiating to the thumb, dorsum of the hand, and index finger.
There is an increased frequency of trigger finger and carpal tunnel syndrome in patients with de Quervain's syndrome.
Physical exam: swelling and tenderness proximal to the radial styloid.
Finkelstein's test: pain when the thumb is flexed into the palm while the examiner ulnarly deviates the wrist.

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