Carpal Tunnel Syndrome (CTS)

Re-posted from Academia.edu 
http://independent.academia.edu/GregMillar/Blog/360221/Carpal-Tunnel-Syndrome-CTS


Carpal Tunnel Syndrome (CTS)

Authors: Greg Millar, DC CCEP; Dana Berthiaume, DC; Jamie Bunis, DC; Adam Shafran, DC
Jack Langston, DC; Marie Krause, DC; Sherri Hogendobler, DC.

Carpal Tunnel Syndrome (CTS) has become one of the most widespread occupational health problems we face today. It affects millions of people a year, and with our growing reliance on computers there seems to be no end in sight.  As a Madison AL Chiropractor we see this condition almost daily in our clinics.The syndrome is caused by entrapment or pressure on the median nerve just above the wrist in the carpal tunnel. The pathophysiology is not completely understood but can be considered compression of the median nerve traveling through the carpal tunnel.[1].

Pressure on this nerve can be caused by an injury, repetitive or sustained use, or from common activities like typing, chopping, hammering, or pushing (over use syndrome).  It can even be caused or made worse by sleeping with your hand bent at the wrist, often tucked up under your neck, body, or chin.  Symptoms of CTS range from wrist pain, numbness, tingling, burning, weakness or loss of grip strength, and loss of sleep due to discomfort. The most common symptom of CTS is numbness and or tingling to the thumb and first two fingers. People often report that they have lost grip strength in the affected hand. This is usually noticed when trying to pick up a cup of coffee. Weakness and atrophy of the thenar muscles may occur if the condition remains untreated.[2]. If the symptoms involve just the last two fingers it is often misdiagnosed as CTS but is actually something just at treatable (ulnar nerve entrapment).

Causes:
Most cases of CTS are of unknown causes, or idiopathic.[3] There is lots of debate in medical circles about work related CTS. The Occupational Safety and Health Administration (OSHA) has adopted rules and regulations regarding cumulative trauma disorders. Occupational risk factors of repetitive tasks, force, posture, and vibration have been cited. Carpal Tunnel Syndrome can be associated with any condition that causes pressure on the median nerve at the wrist. Some common conditions that can lead to CTS include trauma, work related activities, arthritis, diabetes, obesity, oral contraceptives, sleep posture, and hypothyroidism.  Carpal tunnel can also be associated with a form of Charcot-Marie-Tooth syndrome Type 1. Other causes of this condition may include lesions that exert pressure within or outside the carpal tunnel, and include benign tumors such as lipomas, ganglion, and even some vascular malformations.

Diagnosis:
Clinical diagnosis is made by taking a history and performing a physical examination. Common test used include:

Phalen's Test is performed by flexing the wrist gently as far as possible, then holding this position and awaiting symptoms. This non specific test is often used by clinicians as a quick diagnositc tool.  A positive test is one that results in numbness in the median nerve distribution when holding the wrist in acute flexion position within 60 seconds. The quicker the numbness starts, the more advanced the condition. Phalen's sign is defined as pain and/or paresthesias in the median-innervated fingers with one minute of wrist flexion.

Tinel's sign, a classic — though non specific - test is a way to detect irritated nerves. Tinel's is performed by lightly tapping or rapping the skin over the wrist (flexor retinaculum) to reproduce the tingling sensation or "pins and needles" in the median nerve distribution. A positive Tinel's sign (pain and/or paresthesias of the thumb, first and second finger with tapping over the median nerve) is more specific than Phalen’s sign.

Durkan test, carpal compression test, or applys a firm pressure to the palm over the nerve for up to 30 seconds to trying to elicit carpal tunnel type symptoms.

Other conditions may also be misdiagnosed as carpal tunnel syndrome. Thus, if history and physical examination suggest CTS, patients will sometimes be tested electrodiagnostically with nerve conduction volicity (NCV) studies and electromyography. The goal of electrodiagnostic testing is to compare the speed of conduction in the median nerve with known normals and also compare the conduction speed of other nerves supplying the hand.

Treatment:
There are a number of different ways to treat CTS. In most cases, a chiropractic adjustment to the affected area is an extremely effective solution. In some cases, a misalignment in the neck and upper back (C5-T1) can cause this condition, and chiropractic manipulation of the neck and/or spine can also serve as an effective
treatment option. These treatments, along with physical therapy, stretching, and strengthening exercises, and physical modality treatments such as e-stim, ultra sound, and cold laser treatments can in most cases effectively alleviate the symptoms associated with CTS.  Some cases require us to tape the hand into a position re-approximating the carpal tunnel. The patient is then asked to perform exercises in this taped position.

In severe cases we often work in conjunction with our Medical Doctors doing steroid injections into the carpal area. We like to use the steroid approach sparingly due to the effects of the steroid on the body. Some cases however do require surgery. If surgery is required we highly recommend a hand surgeon or a hand fellowship trained orthopedic specialist as opposed to a general orthopedist. For our patients that do have surgery we highly recommend the Endoscopic technique vs the open surgery. Endoscopic techniques or endoscopic carpal tunnel release involve one or two smaller incisions (less than half inch each) through which instrumentation is introduced and used to visualize the underside of the transverse carpal ligament. A prospective randomized study done in 2002 by Trumble revealed that good clinical outcomes and patient satisfaction are achieved more quickly with the endoscopic method.

Home Remedies: 
For home remedies as a Madison AL Chiropractor we recommend the use of a cock-up splint that can be purchased at most any drug store or mass retailer. We have found a nice home remedy for the end of the day. Take a dixie cup fill it 1/2 full of water and freeze it. Then tear off the paper around the ice and apply directly to the wrist area.  We also recommend soaking the wrist in warm salt baths. We like the use of the anti-inflammatory Boswellin. (check with your healthcare professional before taking and don't use if you have stomach issues or problems).

1.  Scott, Kevin R.; Kothari, Milind J. (October 5, 2009). "Treatment of carpal tunnel syndrome."
2.  Lazaro, R (1997). "Neuropathic symptoms and musculoskeletal pain in carpal tunnel syndrome:             Prognostic and therapeutic implications". Surgical Neurology 47 (2): 115–7; discussion 117–9.
3.  Sternbach, G (1999). "The carpal tunnel syndrome". Journal of Emergency Medicine 17 (3): 519–23.

Early Start Leads to Wellness!

Early Start Leads to Wellness!

As a Madison AL Chiropractor, we feel that getting up in the morning is an essential part of your wellness program.  Tissues, cells, and other parts of the body all need to be doing their tasks. They all need to be interacting with each other successfully. Hormones and nutrients need to appear at the same time in the right amounts. Metabolic procedures need to be in harmony. All of these complex procedures are under the immediate management of your neurological system.

Chiropractic health care helps your neurological programs operate at optimum performance. By reestablishing alignment to your spine, your body immediately increases actions within your neurological programs. As a result, cells, tissues, muscles, tendons, organs and other parts of the body function better and your body now has the power it needs to wake up starting the day - healthier, rejuvenated, and ready to go!

We all know individuals who get up with the first light of the sun. Some individuals wake up even before daybreak. In comparison, for many individuals getting out of their comfortable bed is an everyday exercise in disappointment. They know they "should" get up, they know they should "be on time", but each day they find themselves choosing the Snooze sleep option "just once more". "Really, this is it," they announce to their aggravated partners and children. "I'm getting up. Just nine minutes more."

What is the difference between those who are able and willing to toss off the covers at the beginning of the day and those who battle mightily fighting the alarm and the snooze button? The characteristics and attributes of your biorhythms - your set of inner clocks - provide most of the answer.

The field of chronobiology - the study of biologic time - investigates various physiologic biorhythms. In animals these rhythms are associated with sleeping,1 eating, metabolic and hormonal regulation,2,3 cellular regeneration, and mating. In plants biorhythms are associated with photosynthesis and movements of leaves and stems. Circadian rhythms describe 24-hour cycles. Diurnal and nocturnal rhythms are active during the day and night, respectively.

There is good news for those who would appreciate the benefits of getting a head-start on their daily routines but nevertheless continually get out of bed half an hour or more late. Circadian rhythms can be modified. It takes time and effort, but it can be done. Will power is not enough, as anyone who has tried to tell themselves to get up earlier on a day-to-day base can testify. Diet plans and frequent, exercise are key to making any long-lasting change in our biorhythms. Add a powerful desire to the mix and long-term results can happen.

Managing your light exposure can help tremendously.  Try taking a short walk outdoors early in the day - ideally every day.  And leave your sunglasses at home.  You want your eyes to receive and process the early sunlight which will help your pineal gland to get in sync with the natural rhythms of sun. You can also use a low watt light bulb in your bedroom before going to bed.

It is equally important to avoid bright light exposure in the evening, especially the blue light tones from computers and televisions.  This will help prepare your body to fall asleep more easily, early enough so that you will feel rested in the morning when your alarm goes off.  If you need to use your computer in the evening, you might want to try a free program called f.lux which reduces the blue light your monitor normally emits that can interfere with your sleep.   Also, minimize the light in your home in the evening, and make sure your bedroom is as dark as possible, wearing an eye mask if you can't otherwise block out the light.

Ideally, you will begin getting out of bed normally with the dawning sunshine, even before your alarm goes off.  Some individuals use special alarm clocks that simulate the sun rising, gradually improving the lighting in your bed room to wake up you carefully before any alarm is sounded.

It is also essential to not sleep in on Saturdays and Sundays.  Keeping a constant rest routine throughout the week is one key to resetting your circadian rhythms. As a Madison AL Chiropractor, we often talk to our patients about sleep issues, as there are many illnesses such as Fibromyalgia and Chronic Fatigue Syndrome that are directly linked to sleep issues.

1Priano L, et al: Non-linear recurrence analysis of NREM human sleep microstructure discloses deterministic oscillation patterns related to sleep stage transitions and sleep maintenance. Conf Proc IEEE Eng Med Biol Cos 1:4934-4937, 2010
2Kalsbeek A, et al: Hypothalamic control of energy metabolism via the autonomic nervous system. Ann NY Acad Sci 1212(1):114-129, 2010
3Eisenberg DP, et al: Seasonal effects on human striatal presynaptic dopamine synthesis. J Neurosci 30(44):14691-14694, 2010

What is Your Spinal IQ?

What's Your Spinal IQ?

Dr Greg Millar DC CCEP               Dr Dana Berthiaume DC              Dr Jamie Bunis DC

As a Madison AL Chiropractor I am often asked questions about the spine.  When you think of the term IQ, you probably think of those intelligence tests that are given in schools.   Those IQ tests attempt to measure a person's problem solving ability - a form of mental gymnastics, if you will. Your spinal IQ also has to do with problem solving, but these are "problems" of the physical kind. How far should you bend over to lift those grocery bags out of your car's trunk, and which muscles must be engaged to bend and lift safely? How much muscle force is necessary to pick up and carry your young child? What specific muscles are needed to maintain your "downward dog" position for 30 seconds during your yoga class? How far can your back muscles stretch when you do a back bend at the ballet barre? These are the problems your brain solves daily using it's spinal IQ. Spinal IQ is an inborn ability. Our bodies were designed for the rigors of physical work - they are very smart and very adaptable. One of our built-in control systems is the specialized set of nerve endings known as proprioceptors. Proprioception is our internal awareness of position in three-dimensional space and time.1,2 This three-dimensional positioning allows us to track where our body is in space, and to keep our balance when we walk or run. Proprioception tells our muscles and joints how to work together to throw a baseball from third to first, to drive to the basketball hoop and sink a lay-up, or to hit a tennis ball to the corner of the opponent's service box and win the point. Proprioception is very important in spinal IQ. The spine is a complex system of bones, joints, muscles, ligaments and tendons.  Our proprioception system helps all the parts work together smoothly and seamlessly. Proprioception though important is just part of the picture. Spinal IQ also takes into account balance, flexibility, range of motion, strength, and endurance. We need to take an active role in order to keep all the parts functioning in an ideal manner. In modern society, if we're not proactive, it's easy for our bodies to break down. The most important strategies for maintaining high levels of spinal IQ are regular strenuous exercise and regular chiropractic check-ups. As a Madison AL Chiropractor we are often asked to design a personal program to improve spinal IQ. Exercise helps our bodies stay smart.3 When we exercise, our joints are mechanically stressed and challenged throughout their complete ranges of motion. This activity stimulates proprioceptors - training them to do their job well and building new and stronger connections between nerve cells. Exercise also builds muscle strength and flexibility, and in the process the muscles are getting smarter, too.  It also helps to reset the "fight or flight" response to stress that becomes "locked in" when we are stressed but fail to exercise. Chiropractic care enhances the benefits of your exercise program by helping ensure optimal functioning of your spine and nerve system. With regular chiropractic care, your proprioceptive system is optimized and your body's ability to adapt to physical challenges is restored. Your Millar chiropractor will be happy to assist you in designing an exercise program that will work for you - helping you to improve both your spinal IQ and your health. Call your Madison AL Chiropractor today.  1Armstrong B, et al: Head and neck position sense. Sports Med 38(2):101-117, 2008 2Chow DH, et al: Changes in spinal curvature and proprioception of schoolboys carrying different weights of backpack. Ergonomics 50(12):2148-2156, 2007 3Akuthota V, et al: Core stability exercise principles. Curr Sports Med Rep 7(1):39-44, 2008

Core Strengthening and Your Spinal IQ In the old days, football players, ballet dancers, and gymnasts went to practice and class and did what they did, but no one talked about core strengthening. We now understand that much of what these highly trained athletes were doing worked to strengthen their core musculature. Your core muscles include your deep abdominal muscles and your deep spinal, pelvic, and hip muscles. Core muscles are trained by large, compound movements that use your body's own weight as a gravitational load. Lunges, squats, push-ups, pull-ups, and jumping jacks are all excellent core exercises. Again, decades ago athletic coaches never talked about core exercises. They just knew these basic, fundamental exercises were critically important for their students' success. Other important core exercises include abdominal crunches, elbow planks, and pelvis press-ups. Your Millar chiropractor understands the importance of exercise and core strength for a healthy spine, and will be able to help select a group of exercises that will work for you.

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