Carpal Tunnel Syndrome – Are There Other Tunnels?
Carpal Tunnel Syndrome (CTS) refers to the median nerve being pinched in a tunnel at the wrist. As the name implies, “carpal” refers to the 8 small bones in the wrist that make up the “U” shaped part of the tunnel and “syndrome” means symptoms that are specific and unique to this condition. As we learned last month, CTS can be affected by nerve pinches more proximal to the wrist, such as at the forearm, elbow, mid-upper arm, shoulder or neck.
To make matters more complex, there are two other nerves in the arm that can also be pinched in different tunnels, and the symptoms of numbing and tingling in the arm and hand occur with those conditions as well. This is why a careful clinical history, examination, and sometimes special tests like an EMG/NCV (electromyogram/nerve conduction velocity) offer the information that allows for an accurate diagnosis of one or more of these “tunnel syndromes” in the “CTS” patient. Let’s look at these different tunnels and their associated symptoms, as this will help you understand the ways we can differentiate between these various syndromes or conditions.
Let’s start at the neck. There are seven cervical vertebrae and eight cervical spinal nerves that exit the spine through a small hole called the IVF (intervertebral foramen). Each nerve, like a wire to a light, goes specifically to a known location which includes: the head (nerves C1, 2, 3), the neck and shoulders (C4, 5), the thumb side of the arm (C6), the middle hand and finger (C7) and the pinky side of the lower arm and hand (C8). If a nerve gets pinched at the spinal level (such as a herniated disk in the neck), usually there is numbness, tingling, and/or pain and sometimes, usually a little later, weakness in the affected part/s of the arm and hand (or numbness in the scalp if it’s a C1-3 nerve pinch).
So, we can test the patient’s sensation using light touch, pin prick, vibration, and/or 2-points brought progressively closer together until 1-point is perceived and then comparing it to the other arm/hand. Reflexes and muscle strength are also tested to see if the motor part of the nerve is involved in the pinch. The exam includes compression tests of the neck to see if the arm “lights up” with symptoms during the test.
Next is the shoulder. Here, the nerves and blood vessels travel through an opening between the collar bone, 1st rib and the chest muscles (Pectorals). As you might think, the nerves and blood vessels can be stretched and pinched as they travel through this opening and can cause “thoracic outlet syndrome.” Symptoms occur when we raise the arm overhead.
Hence, our tests include checking the pulse at the wrist to see if it reduces or lessens in intensity as we raise the arm over the head. At the shoulder, the ulnar nerve is the most commonly pinched nerve, which will make the pinky side of the arm and hand numb, tingly, and/or painful. A less common place to pinch the nerves is along humerus bone (upper arm) by a bony process and ligament that is usually not there or resulting from a fracture. Here, an x-ray will show the problem.
The elbow is the MOST common place to trap the ulnar nerve in the “cubital tunnel” located at the inner elbow near the “funny bone” which we have all bumped more than once. Cubital tunnel syndrome affects the pinky side of the hand from the elbow down. The median/carpal tunnel nerve can get trapped here by the pronator teres muscle, thus “pronator tunnel syndrome.” This COMMONLY accompanies CTS and MUST be treated to obtain good results with CTS patients. The radial nerve can be trapped at the radial tunnel located on the outside of the elbow and creates thumb side and back of the hand numbness/tingling.
Any or all of these nerve can get “trapped” by the muscles that run near them. This is where Active Release Techniques (ART) treatment separates itself for other modalities. ART is the only system that trains providers how to check these entrapment spots muscle by muscle. Once identified, the trained and certified ART provider knows how to release the muscles and remove the pressure. This goes way beyond standard chiropractic treatment or basic physical therapy.
So now you see the importance of evaluating and treating ALL the tunnels when CTS is present so a thorough job is done (which is what we do at Denver Chiropractic Center). Try the LEAST invasive approach first – non-surgical treatment – as it’s usually all that is needed!
This seems like an easy question to answer, doesn’t it? The answer of course being, YES!!! However, there are many people who suffer with headaches who have never been to a chiropractor or have not even ever considered it as a “good option.”
So, rather than having me “reassure you” that chiropractic works GREAT for headache management, let’s look at the scientific literature to see if “they” (the scientific community) agree or not.
In a 2011 meta-analysis, researchers reviewed journals published through 2009 and found 21 articles that met their inclusion criteria and used the results to develop treatment recommendations. Researchers discovered there is literature support utilizing Chiropractic care for the treatment of migraine headaches of either episodic or chronic migraine. Similarly, support for the Chiropractic treatment of cervicogenic headaches, or headaches arising from the neck region (see last month’s Health Update), was reported
In addition, joint mobilization (the “non-cracking” type of neck treatment such as figure 8 stretching and manual traction) or strengthening of the deep neck flexor muscles may improve symptoms in those suffering from cervicogenic headaches as well. The literature review also found low load craniocervical mobilization may be helpful for longer term management of patients with episodic or chronic tension-type headaches where manipulation was found to be less effective.
We add Active Release Techniques to this treatment arsenal to release tension in the muscles in the neck and at the base of the skull. These tight muscles are often the overlooked culprit in people with headaches,
Okay, we realize this is all fairly technical, so sorry about that. But, it is important to “hear” this so when people ask you why are going to a chiropractor for your headaches, you can say that not only that it helps a lot, but there are a lot of scientific studies that support it too!
Bottom line is that it DOES REALLY HELP and maybe, most importantly, it helps WITHOUT drugs and their related side effects. Just ask someone who has taken some of the headache medications what their side-effects were and you’ll soon realize a non-drug approach should at least be tried first since it carries few to no side effects.
We realize that you have a choice in where you choose your healthcare services. If you, a friend or family member requires care for headaches, we sincerely appreciate the trust and confidence shown by choosing our services and look forward in serving you and your family presently and, in the future.
I (Glenn) want to apologize for being unavailable last week from Monday through Wednesday. I had surgery on Monday and was required to take a few days to recover before going back to work. (I actually went back Thursday before I was supposed to. Don’t tell.) I’ll have more to say about this in the near future, but for now, just know that I am back and ready to help you.
Best Halloween idea I’ve ever heard of:
I got this one from a patient years ago: The Halloween Goblin. In order to cut down on how much junk the kids get in relation to Halloween, we offer them the opportunity to pick out a few pieces from their Halloween bounty, and then trade the rest to the Halloween Goblin for a toy. They simply leave the candy on the porch, and the toys magically appear the next day. We’ve been doing this for 5 years now and it works great. I don’t have a problem with the candy per se, but it’s the way it tends to hang around the house that I don’t like. The Halloween Goblin takes care of that. The key is giving the kids the option to participate instead of forcing it on them.
And here is this week’s 1-Page Health News.
Mental Attitude: Benefits of Green Tea. Previous studies have shown that green tea consumption aids in both weight loss and lowering cholesterol levels. Green tea is full of anti-oxidants and has also been known to reduce the risk of esophageal cancer, depression symptoms, wrinkles, the risk of high blood pressure. Green tea also benefits diabetics because it slows the rise of blood sugar after eating. A new study reveals that it may also benefit memory and spatial awareness. (Note: Green tea decaffeinated with CO2 retains as much as 95% of the original anti-oxidant levels. If the ethyl acetate process was used, only about 30% of the anti-oxidants will be retained.) Molecular Nutrition & Food Research, September 2012
Health Alert: $750 Billion Lost A Year! America’s health care system is inefficient, suffers from data overload, and is both complex and costly. Each year, $750 billion (roughly $.35 per dollar spent) is wasted nationwide on inflated administration costs, fraud, and pointless services. These problems can also result in needless patient suffering and deaths. Institute of Medicine. September 2012
Diet: Anorexia. Patients with anorexia have trouble accurately judging their own body size, but not the bodies of others. In a test, when asked if they could pass through a doorway, anorexic patients felt they could not pass through the door even when it was easily wide enough. However, anorexic patients were more accurate at judging others’ ability to pass through the doorway than their own. The study also found a correlation between the perception of the patients’ own ability to pass through the aperture and their body size prior to becoming anorexic, suggesting that the patients may still think of themselves as their previous size. PLOS ONE, August 2012
Exercise: The Elderly. The benefits of exercise are positive for all seniors, including those who are considered frail. The advantages appeared after just three months and included increased cognitive and physical abilities, as well as increased quality of life. Journals of Gerontology, August 2012
Active Rlease Technique / Chiropractic: Lack of Motion. A joint that is not mechanically stimulated will atrophy, leading to degeneration. However, even passive motion (ex: someone else bending your leg for you) is beneficial to cartilage regeneration. (Our work at Denver Chiropractic Center is all about improving joint mobility). Arthritis Care and Research, 2006
Wellness/Prevention: Coconut Oil and Tooth Decay. Digested coconut oil is able to attack the bacteria that cause toothdecay. The study found that enzyme-modified coconut oil strongly inhibits the growth of most strains of Streptococcus bacteria, including Streptococcus mutans (an acid-producing bacterium that is a major cause of tooth decay). Society for General Microbiology, September 2012
Quote: “Ouch.” ~ Glenn Hyman, after surgery.
Low back pain (LBP) can be localized and contained to only the low back area or, it can radiate pain down the leg. This distinction is important as LBP is often less complicated and carries a more favorable prognosis for complete recovery. In fact, a large part of our history and examination is focused on this differentiation. This month’s Health Update is going to look at the different types of leg pain that can occur with different LBP conditions.
We’ve all heard of the word “sciatica” and it (usually) is loosely used to describe everything from LBP arising from the joints in the back, the sacroiliac joint, from the muscles of the low back as well as a pinched nerve from a ruptured disk. Strictly speaking, the term “sciatica” should ONLY be used when the sciatic nerve is pinched; causing pain that radiates down the leg.
The sciatic nerve is made up of five smaller nerves (L4, 5, S1, 2, 3) that arise from the spine and join together to form one large nerve (about the size of our pinky) called the sciatic nerve – like five small rivers merging into one BIG river. Sciatica occurs when any one of the small nerves (L4-S3) or, when the sciatic nerve itself, gets compressed or irritated.
This can be, and often is caused from a lumbar disk herniation (the “ruptured disk”). A term called “pseudosciatica” (a non-disk cause) includes a pinch from the piriformis muscle where the nerve passes through the pelvis (in the “cheek” or, the buttocks), which has been commonly referred to as “wallet sciatica” as sitting on the wallet in the back pocket is often the cause.
When this occurs, the term “peripheral neuropathy” or “ peripheral nerve entrapment” is the most accurate term to use. Direct trauma like a bruise to the buttocks from falling or hitting the nerve during an injection into the buttocks can also trigger “sciatica.”
The symptoms of sciatica include low back pain, buttocks pain, back of the thigh, calf and/or foot pain and/or numbness-tingling. If the nerve is compressed hard enough, muscle weakness can occur making it hard to stand up on the tip toes creating a limp when walking. In the clinic, we will raise the straight leg and if pinched, sharp pain can occur with as little as 20-30° due to the nerve being stretched as the leg is raised.
If pain occurs anywhere between 30 and 70° of elevation of either the same side leg and/or the opposite leg, this constitutes a positive test for sciatica (better termed, “nerve root tension”). When a disk is herniated into the nerve, bending the spine backwards can move the disk away and off the nerve resulting in relief, which is very diagnostic of a herniated disk. Having a patient walk on their toes and then heels and watching for foot drop as well as testing the reflexes, the sensation with a sharp object, and testing the reflexes at the knee and Achilles tendon can give us clues if there is nerve damage.
At our clinic we’ve gone beyond simple traditional chiropractic adjustments to “align the spine.” We use more advanced techniques, like Active Release Techniques to address the pressure that the muscles can exert on the sciatic nerve. We will also use motion-restoring spinal adjustments to restore healthy mobility to the spine. By utilizing these advanced techniques, we are usually able to get excellent results for our patients with low back pain and sciatica in a relatively short period of time.
It all starts with the initial exam. Call us to schedule yours 303.300.0424. We’re here to help you!
Does mobilization (MOB) get less, the same, or better results when compared to spinal manipulative therapy (SMT)? To answer this question, let’s first discuss the difference between the two treatment approaches.
Mobilization (MOB) of the spine can be “technically” defined as a “low velocity, low amplitude” force applied to the tissues of the cervical spine (or any joint of the body, but we’ll focus on the cervical region). This means a slow, rhythmic movement is applied to a joint or muscle using various methods such as stretching.
Spinal Manipulative Therapy (SMT) can be defined as a “high velocity, low amplitude” type of force applied to joint which is often accompanied by a audible release or “crack,” which is the release of gas (nitrogen, oxygen, and carbon dioxide).
Some joints “cavitate” or “crack” while others are less likely to release the gas. Studies that date back to the 1940s report an immediate improvement in a joint’s range of motion occurs when the joint cavitates. Many people instinctively stretch their own neck to the point of release, which typically, “…feels good.” This can become a habit and usually is not a big problem. However, in some cases, it can lead to joint hypermobility and ligament laxity.
As a rule, if only a gentle stretch is required to produce the cavitation/crack, it’s typically “safe” verses the person who uses higher levels of force by grabbing their own head and twisting it beyond the normal tissue stretch boundaries. The later is more likely to result in damage to the ligaments (tissue that strongly holds bone to bone) and therefore, should be avoided.
Since SMT is usually applied in a very specific location (where the joint is fixated or “stuck”, or, partially displaced), it’s obviously BEST to utilize chiropractic, as we chiropractors do this many times a day (for years or even decades) and we know where to apply it and can judge the amount of force to utilize, especially the neck where there are many delicate structures.
Back to the question: Which is better, MOB or SMT? Or, are they equals in the quest of rid of neck pain? A recent study of over 100 patients with “mechanical neck pain” (strain/sprain) showed that those who received SMT had a significantly better response than the MOB group as measured by a pain scale, a disability scale and 2 tests that measure function!
In our clinic (Denver Chiropractic Center) we’ve found that the best approach uses BOTH. Mobilization in the form of Active Release Technique combined with safe and gentle (never forced) adjustments get better results in a shorter time frame. It all starts with the initial exam, so call us to schedule yours – 303.300.0424.
Carpal Tunnel Syndrome (CTS) is a very common problem. The American Association of Orthopedic Surgeons (AAOS) reported that in 2007, there were 330,000 carpal tunnel release surgeries performed. (WHOA!) The main reason to have the surgery is to “open up” the tunnel. That is, the transverse carpal ligament or “floor” of the tunnel is released so the contents inside the tunnel are able to move more freely, reducing the pressure inside the tunnel.
Essentially, this is the goal of any treatment (surgical or not): improving the depth of the tunnel, thus reducing the pressure from inside the tunnel allowing the tendons to slide better as the muscles on the palm-side forearm contract to move the nine tendons that pass through the tunnel and attach to the fingers and thumb.
However, there are non-surgical methods for reducing the pressure within the tunnel that should be first attempted as surgery is always reported to be the “…last resort” for good reason. There can be surgical complications, the effects may be only partial, and there is an average of 30% grip strength loss following the transverse ligament surgical release. So, the question is, how can chiropractic approaches reduce the pressure inside the carpal tunnel without somehow changing the length of the transverse carpal ligament?
By going beyond traditional chiropractic care and using Active Release Techniques (ART), we can often release the transverse carpal ligament by hand, taking pressure off of the nerve and relieving symptoms. We can also address possible muscular entrapment sites for the median nerve, like the pronator teres muscle. These muscular entrapments mimic Carpal Tunnel Syndrome, but can be easily released with ART treatment. In the last 15 years, we’ve helped literally hundreds of patients avoid carpal tunnel surgery by using Active Release Techniques. We don’t claim to have a 100% success rate, as some cases do require surgery. But we believe it’s best to try us first and see what we can do.
The use of a night splint to keep the wrist in a straight or slightly “cocked-up” position is also highly beneficial as the pressure inside the tunnel goes up as much as 6-8x when CTS is present when the wrist bends.
If you, a friend or family member require care for CTS, we would be happy to help. Just call 303.300.0424 to set up your first appointment.
Whiplash can result from a number of causes, not just from motor vehicle accidents. A fall on the ice or a slippery floor, from a sports related injury, or even at the county fair on one of those rides that throws you around can result in the same type of injury. Whiplash occurs when the head is literally “whipped” either forwards and backwards or from side to side. It can include hitting the head but often does not.
Symptoms vary considerably and therefore the term, “whiplash associated disorders” or WAD has been adopted, based on the clinical presentation of the patient and on the specific tissues injured. Common symptoms include neck pain, loss of motion, headache and sometimes arm pain or numbness resulting in difficulty driving, working, sleeping and concentrating.
Active Release Techniques and adjustments of the neck can be highly effective in the treatment of whiplash associated disorder, and hence, Chiropractic is often the recommended first order of treatment for patients suffering from this condition. We have previously discussed the steps involved when presenting to a chiropractic clinic, from taking a detailed history and performing a thorough physical examination, and well as the many types of treatment options that exist.
Exercise is one of the most important forms of treatment as they can and should be performed multiple times a day as directed by us, so that a return to normal function with no pain can occur as quickly as possible. Presented here are a few VERY EFFECTIVE exercises that we frequently give to patients suffering from WAD:
- For #3, ALWAYS apply a push or resistance with your hand through the FULL range of comfortable motion in that plane. That means, in one direction let the head “win” (like in arm wrestling) and when moving in the opposite direction, let the hand “win,” (but don’t let up pushing with the head). In other words, you are ALWAYS resisting against the movement in both directions moving as far as you can in both directions.
We work with patients who’ve been in car accidents and work accidents, and accept all auto insurance, including Med Pay. We also take most major health insurance plans. Are treatment plans are focused on solving the problem, not extending the case. If you’re suffering from accident injuries, call us today at 303.300.0424. We can help.