CTS Warning Signs

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Headaches are REALLY common! In fact, two out of three children will have a headache by the time they are fifteen years old, and more than 90% of adults will experience a headache at some point in their life. It appears safe to say that almost ALL of us will have firsthand knowledge of what a headache is like sooner or later!

Certain types of headaches run in families (due to genetics), and headaches can occur during different stages of life. Some have a consistent pattern, while others do not. To make this even more complicated, it’s not uncommon to have more than one type of headache at the same time!

Headaches can vary in frequency and intensity, as some people can have several headaches in one day that come and go, while others have multiple headaches per month or maybe only one or two a year. Headaches may be continuous and last for days or weeks and may or may not fluctuate in intensity.

For some, lying down in a dark, quiet room is a must. For others, life can continue on like normal. Headaches are a major reason for missed work or school days as well as for doctor visits. The “cost” of headaches is enormous—running into the billions of dollars per year in the United States (US) in both direct costs and productivity losses. Indirect costs such as the potential future costs in children with headaches who miss school and the associated interference with their academic progress are much more difficult to calculate.

There are MANY types of headaches, which are classified into types. With each type, there is a different cause or group of causes. For example, migraine headaches, which affect about 12% of the US population (both children and adults), are vascular in nature—where the blood vessels dilate or enlarge and irritate nerve-sensitive tissues inside the head. This usually results in throbbing, pulsating pain often on one side of the head and can include nausea and/or vomiting. Some migraine sufferers have an “aura” such as a flashing or bright light that occurs within 10-15 minutes prior to the onset while other migraine sufferers do not have an aura.

The tension-type headache is the most common type and as the name implies, is triggered by stress or some type of tension. The intensity ranges between mild and severe, usually on both sides of the head and often begin during adolescence and peak around age 30, affecting women slightly more than men. These can be episodic (come and go, ten to fifteen times a month, lasting 30 min. to several days) or chronic (more than fifteen times a month over a three-month period).

There are many other types of headaches that may be primary or secondary—when caused by an underlying illness or condition. The GOOD news is chiropractic care is often extremely helpful in managing headaches of all varieties and should be included in the healthcare team when management requires a multidisciplinary treatment approach.

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Can Carpal Tunnel Be Prevented? 

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Carpal Tunnel Syndrome (CTS) is a VERY common condition where the median nerve is compressed or squeezed as it passes through the wrist. One reason that it’s so common is because MANY daily activities require fast, repetitive use of the fingers, hands, and arms, and the friction of the rapidly moving muscle tendons inside the tunnel results in swelling and compression of the nerve. So, can CTS really be prevented?

There are many factors associated with CTS, and some risks can be prevented. For example, some conditions like diabetes, rheumatoid arthritis, and IBS increase the risk of CTS. Therefore, it would be safe to assume those who better manage such conditions would have a lower risk for developing CTS.

Due to the many factors associated with CTS, there is no “one size fits all” when it comes to treatment and prevention of CTS. With that said, here are some VERY effective methods:

1)  Ergonomic workstation modifications: Altering the work space (monitor height, keyboard/mouse style, different chair, chair/desk height, etc.) to reduce the number and speed of movements needed to perform commons work tasks.

2)  Rest periods: Insert “micro-breaks” into a busy task. Combine breaks with stretching exercises of the wrist/hand/fingers and vary job tasks between fast and slow repetitive types.

3)  Exercise: Shake the fingers and hands, lean back in a chair with the arms/shoulders stretched back (“Brugger’s Exercise”), move the neck (chin tucks, rotations, etc.), bend the hand/wrist backwards on a wall or the desk’s edge, self-massage and deep tissue release of the forearm and hand muscles. Do regular aerobic exercise (walking, swimming, biking, etc.) several times each week.

4) Posture: Sit up straight, elbows about 90° on height-adjustable arm rests or comfortably at the sides, forearms parallel to the floor; knees level or slightly lower than the hips, feet flat on the floor or on a footrest or box, if needed. Place typing materials at eye level / avoid prolonged head/neck rotation. Use a wrist rest for the keyboard and mouse, and use a headset when on the phone.

5)  Reduce hand tool forces: Choose a tool that allows the wrist to remain neutral. Avoid side to side and flexion/extension wrist positions—especially if they’re prolonged! Tool handles should NOT dig into the palm of the hand or the wrist, and should not have sharp edges. A textured handle can improve grip. Minimize vibration from power tools. Wear shock absorbing gloves. Avoid cold work environments and cold tools.

6)  Diet: Cut down on caffeine and smoking. Avoid obesity—a known risk factor of CTS! Consider an anti-inflammatory diet (Paleo, Mediterranean).

7)  Splints: A wrist cock-up splint at night prevents prolonged faulty positions and REALLY helps!

This is a partial list of preventative measures that can REALLY help. Doctors of chiropractic treat the WHOLE person and can teach you the right exercises, ways to modify your diet, offer manual therapies and modalities, and help guide you in your self-management of CTS, as this can be a lifelong affliction. A multi-modal treatment approach generally works best!

Is Surgery Always Required?

Carpal tunnel syndrome (CTS) is the most common peripheral entrapment neuropathy—that is, it’s the most common place to trap a nerve in the extremities (arms or legs). CTS affects 6-11% of adults in the general population, and it occurs in women more often than men. The cause is often difficult to determine but the most common reasons can include trauma, repetitive maneuvers, certain diseases, pregnancy, being over the age of 50, and obesity.

So, is surgery the only answer? The short answer is NO! In fact, in a recent randomized clinical trial published in the Journal of Pain, researchers observed similar improvements in function when they compared the outcomes of patients who underwent surgery vs. those who received manual therapies (such as those performed several times a day at chiropractic clinics around the world) at both six months and one year later. The improvements included increased strength, function, and decreased hypersensitivity in both the surgical and non-surgical groups. Interestingly, the manual therapy group did BETTER at the one and three month assessments when compared with the surgical group (again, with no difference at six and twelve months)!

The median nerve, the culprit behind CTS, starts in the neck and travels down through the shoulder, elbow, forearm, and finally through the carpal tunnel, which is made up of eight small carpal bones that form the arch of the bridge. Entrapment of the median nerve occurs when the normally tight quarters within the carpal tunnel combine with the inflamed nine sheathed muscle tendons that push the nerve into the floor of the tunnel (a ligament), which results in CTS! The goal of therapy—both surgical and manual therapy—is to reduce the pressure within the tunnel and free up the compression of the median nerve.

Manual therapies focus on joint mobilization and manipulation to reduce joint fixations, muscle release techniques in the forearm and hand, stretching techniques, and at-home exercises that emphasize a similar stretch, the night brace, and management of any underlying contributing factor. These “underlying factors” might include diabetes, hypothyroid, taking birth control pills, weight management, and inflammatory arthritis.

 

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CTS at Night.

For those who have carpal tunnel syndrome (CTS), it’s no surprise that CTS is frequently most expressive during the night, often to the point of interrupting sleep and/or making it difficult to fall back to sleep. So why is that?

The primary reason for nighttime CTS symptoms has to do with the wrist, as it is very difficult to sleep with the wrist held in its “ideal” or least irritating position. In fact, most people favor “curling” the back of the hand under the chin or bending the hand/wrist backwards under the head. When the wrist is bent in either direction, it can increase the pressure inside the wrist, which can generate the various symptoms associated with CTS.

One study evaluated the pressure inside the carpal tunnel while participants slowly moved their wrists. The researchers found many movements didn’t need to exceed 20 degrees before the pressure increased enough within the carpal tunnel to generate symptoms.

Because it doesn’t take a lot of movement to build up excessive pressure in the wrists of those with CTS, many doctors recommend the use of a “cock-up splint” for the non-surgical treatment of CTS in order to help keep the wrist in a neutral position.

Wrist posture is also an important factor during the day. One study looked at typing on a tablet PC, which allowed people to work in non-traditional settings. As screen size reduced, the posture required to type became more limited and accelerated the usual rate of pain onset in the neck, elbows, and wrists.

This study also looked at three different positions used when working on touch-screen devices: desk, lap, and bed. The healthy subjects completed six, 60-minute typing sessions using three virtual keyboard designs: standard, wide, and split. The researchers monitored the position of the wrist, elbow, and neck while the participants typed and followed up each session with questionnaires designed to measure discomfort.

The research team reported that typing in bed required greater wrist extension but resulted in a more natural elbow position than typing at a desk. The angled split keyboard significantly reduced the wrist deviation vs. the standard or wide keyboard designs. All three regions—the neck, elbow, and wrist—exhibited more movements (13% to 38%) towards the end of the one hour sessions, which correlated with a significant increase in pain in every body region investigated. Overall, using a wider keyboard while sitting at a desk was the most tolerable position among study participants.

 

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Why do so many suffer with CTS?

According to the literature, carpal Tunnel Syndrome (CTS) is one of the most prevalent upper extremity complaints. In fact, it IS the most common “compression neuropathy” (of which there are many) and affects 3-6% of adults in the general population. Additionally, CTS can affect BOTH hands in up to 50% of patients with the condition!

The CAUSE of CTS is often unknown and typically comes on gradually, making it difficult to determine a definite cause or specific “date of onset” for CTS.

Symptoms such as numbness, tingling, loss of dexterity, loss of strength (like pinch or grip), and the need to shake the hand or flick the fingers to restore sensation are ALL VERY COMMON CTS SYMPTOMS. The REASON for these symptoms boils down to one thing: The median nerve in the wrist gets pinched! The cause/s can include:

1)  Repetitive motion from either work or hobbies like assembly line work or playing a musical instrument can cause swelling within the carpal tunnel, placing extra pressure on the median nerve as it passes through.

2)  Obesity can contribute to CTS due to extra fluids or fatty deposits that can build up within the carpal tunnel.

3)  Pregnancy: Elevated levels of the hormones estrogen and progesterone can cause the body to retain fluids and increase pressure in the carpal tunnel.

4) Arthritis: Osteoarthritis can lead to CTS (such as when a spur forms inside the tunnel). Rheumatoid arthritis can lead to an autoimmune response and antibodies that end up attacking the cartilage of the joints in the wrist, which can lead to CTS.

5)  Hormone-related conditions: In diabetes mellitus, the blood becomes thicker due to high sugar levels (like syrup) and can’t pass through the small blood vessels, resulting in “neuropathy,” which can make CTS more likely. In hypothyroid, low thyroid function results in “myxedema,” a specific type of swelling that makes CTS more likely to occur.

6)  Trauma: A wrist fracture could cause the carpal tunnel to “collapse” or change in shape resulting in less space for the nerve to travel through.

7)  Mass lesions: A “ganglionic cyst” is a good example. This is where joint fluid leaks out and forms a “bump” on the INSIDE the carpal tunnel, which reduces space and increases pressure in this anatomical structure.

8)  Amyloidosis: This is a rare condition where a protein substance called “amyloid” builds up in any tissue or organ. If this occurs in the wrist, it can “pinch” the median nerve as it passes through.

9)  Sarcoidosis: This is the growth of small collections of inflammatory cells called “granulomas,” which can accumulate in different parts of the body. If it occurs in the wrist, pinching can occur.

10)  Multiple Myeloma: This is a type of cancer that affects the bone marrow, and inflammation in the wrist can occur creating the pressure increase on the median nerve that can lead to CTS.

11)  Leukemia: This too is a type of cancer that involves the white blood cells, and CTS can result from its effects on the tissues in the wrist.

12)  Anatomy: The size and shape of the carpal tunnel is hereditary, and some of us have a smaller tunnel than others. If CTS is present in multiple family members, this “genetic” factor may play a role.

There are other conditions that can “mimic” CTS, but doctors of chiropractic are trained to perform an accurate history and examination so treatment can be directed in the proper manner!

Mind = Blown

Carpal tunnel syndrome (CTS) is a very common condition. According to a report by the Bureau of Labor Statistics (BLS), CTS ranks SECOND among the major disabling diseases and illnesses in ALL private industries. The BLS states that workers with CTS may eventually have to give up their livelihood. They cite one study in which almost half of all CTS patients changed their jobs within 30 months following their diagnosis. Due to the controversy surrounding the issue of CTS and worker’s compensation, workers do not always receive compensation benefits.

The KEY to long-term cost containment associated with CTS is EARLY DIAGNOSIS and PREVENTION! The challenge is getting the worker to identify early symptoms and NOT feel intimidated to report them, which could then lead to prompt care and possibly job modifications, resulting in the best chance of preventing a more complicated and far more costly problem.

Because of the many factors that contribute to and/or cause CTS, there is similarly no one way to prevent it from happening. Treating any/all underlying medical condition(s) is important. Using simple common sense can go a long way to help minimize some of the risk factors that predispose a person to work-related CTS and other cumulative trauma disorders (CTDs).

For example, watching and mimicking veteran workers can be a great guide as to how to maximize efficient work methods while minimizing unnecessary stresses and strains. Other preventative “tricks” include learning how to adjust the work area, handle tools, or perform tasks that minimize hand/wrist strain. Maintaining proper posture and exercise programs to strengthen the fingers, hands, wrists, forearms, shoulders, and neck may also help prevent CTS.

Many companies have taken action to help prevent repetitive stress injuries. In one study, 84% of the companies surveyed reported that they were modifying equipment, tasks, and processes as part of a prevention effort; nearly 85% analyzed their workstations and jobs; and 79% purchased more ergonomic equipment. Unfortunately, there is NO EVIDENCE that any of these methods can completely protect a worker against CTS. Often, the best approach is to relocate the worker to a less repetitive job, but this is not always an option.

Doctors of chiropractic can observe the worker through a video or during a factory tour/visit and often identify ergonomic problems that can result in a low-cost, easy modification. Simple modifications coupled with quality care, patient education, and cooperation from BOTH the worker and the employer can typically help yield the best outcome for the CTS patient.

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Carpal Tunnel Basics

Here it is: carpal tunnel syndrome (CTS) in a nutshell!

WHAT: CTS is caused by an injury to the median nerve (MN) as it travels through the wrist.

WHERE: The eight small carpal bones and a ligament form a tunnel in which tendons and nerves pass through to reach the hand.

HOW: The MN gets pinched/irritated from repetitive stress.

WHY: The tunnel is tight as it includes the MN and nine rapidly moving muscle tendons!

PROGRESS: CTS usually starts slow and often progresses over weeks, months, even years.

SYMPTOMS: Pain, numbness, tingling, and/or weakness of the hand, sparing the little finger.

PROGNOSIS: CTS is easier to treat shortly after it starts, and waiting too long to seek care may lead to worse outcomes.

RISK FACTORS: 1) family history (genetics); 2) women are more likely to suffer from CTS than men; 3) age over 50; 4) manual jobs; 5) pregnancy; 6) conditions like diabetes, hypothyroid, rheumatoid arthritis (RA), osteoarthritis, autoimmune diseases (includes RA, certain types of thyroid disease), gout, kidney disease (especially dialysis patients), Down syndrome, amyloidosis, acromegaly, tumors on the median nerve; 7) medications (those that affect the immune system such as interleukin-2, possibly corticosteroids), anti-clotting drugs such as warfarin, hormone replacement, BCPs; 8) obesity; 9) smoking; 10) alcohol abuse; and 11) trauma/injuries (fractures, tendonitis).

TREATMENT: Ideally, treatment should begin as soon as possible after symptoms first start, but this RARELY occurs due its slow and gradual onset. Non-surgical care includes anti-inflammatory care (ice, anti-inflammatory nutrients—ginger, turmeric, bioflavonoids; NSAIDs like ibuprofen), wrist splinting (primarily at night), corticosteroid injections, job/ergonomic modifications, exercises (yoga, stretching, strengthening, and aerobic fitness), low level laser therapy, ice, acupuncture, and chiropractic care. Chiropractic care includes MANY of the above PLUS manual therapies applied to the neck, shoulder, arm, wrist, and hand.

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