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True Carpal Tunnel Syndrome

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  "What is the evolutionary significance of plant toxins and animal anti-toxin behaviour? From a plant's evolutionary perspective, a seed should be high in nutrients to support germination and seedling growth; the ripe fruit around the seed should also be nutrient-rich and attractive to animals, encouraging them to pluck and eat the fruit and disperse the seed. On the other hand, the seed itself should be repulsive to animal consumers, inducing them to regurgitate or defaecate it, and the unripe fruit should be repulsive, lest animals harvest it before the seed is viable. From an animal's evolutionary perspective, an ability to defeat the plant's toxin defences would enable it to obtain the nutrients in the seed as well as those in the ripe fruit, and to outcompete other animal consumers by harvesting the fruit while it is unripe and still unpalatable to them.

"Any textbook of animal biology describes the resulting evolutionary arms race, in which plants evolve increasingly potent toxins (such as strychnine and quinine), and animals evolve increasingly potent means of detoxification. While enzymatic detoxification has previously received the most attention, the work of Gilardi et al.10 and the wide distribution of geophagy among animal herbivores suggest an additional important means of detoxification by adsorption on ingested soil minerals."

- Jared M. Diamond, Department of Physiology, University of California Medical School, Los Angeles

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True Carpal Tunnel Syndrome

Article by Pual R. Martin,
McHenry NeuroDiagnostics, McHenry, Illinois, copyright 1996

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Carpal Tunnel Syndrome is a condition of compressive entrapment of the median nerve at the wrist segment with associated pain and possibly motor deficit, predominantly of the thenar muscles. Hand and wrist pain, including motor deficit, may be caused by any number of other things other than CTS.

There is a specific and predictable path a chronic, cumulative, compressive neuropathy will take. As the nerve is compressed certain changes begin to take place which include both direct morphological changes in the nerve fibers as well as ischemic changes. Usually the smallest diameter, unmyelinated fibers are affected first. These are followed by larger myelinated sensory fibers, and finally by myelinated motor fibers.

By the time a person presents with complaints of numbness, paresthesias, pain, or motor deficit, nerve damage has progressed to the stage of larger fiber sensory and/or motor loss. Changes can be measured at this stage with conventional electroneurography and will manifest as slowed conduction across the wrist segment and possibly reduction in amplitude of the compound muscle action potential representative of axonal loss of motor fibers. It can be reasonably determined if the condition is early, moderate, or severe.

The problem with the median nerve is that it is a relatively lonely soft tissue structure sharing confined space with nine flexor tendons as it travels through the carpal tunnel. Any condition which reduces that space is likely to cause CTS due to compression of the vulnerable median nerve. Any solution which relieves pressure on the nerve and promotes circulation in the microvascular neural blood supply is likely to "cure" CTS and relieve its attendant symptoms of pain, etc.

Some women experience transient CTS during pregnancy due to peripheral edema-a space-compromising problem. Inflamed tendons, irritated by repetitive friction, compress this singular soft tissue nerve. Therefore, anti-inflammatory (NSAIDS) drugs and corticosteroid injections provide temporary relief from CTS. Biomechanical devices that restrict movement and ergonomic devices that promote good hand posture relieve stress on the tendons, reduce inflammation, and relieve CTS symptoms. Anything which will promote circulation, help to relieve inflammation, aid in removal of local toxins, and soothe irritated muscles and tendons will help CTS. Certainly massage therapy is preferable to drugs, splints, or surgery. In addition, in a whole body approach, one should consider biomechanical devices to aid in retraining, ergonomic devices to prevent additional stress, etc.

The cure for CTS, plain and simple, is to relieve pressure on the median nerve at the wrist segment. Surgery does that quite effectively by sawing through the roof truss and letting the dome widen. The results are usually dramatic and the relieved nerve generally quits screaming almost immediately. But a less invasive approach is preferable if one is patient.

A word about chiropractic and wrist pain. A variety of things can cause CTS-like symptoms. One frequent look-alike is a C7 radiculopathy. If, in fact, the source of trouble is more proximal, then cervical adjustments may be just the thing, along with other more proximal treatments. But if proximal treatment ALONE relieves the problem, then it was not truly carpal tunnel syndrome.

Apparently CTS is sometimes treated with acupuncture. That disturbs me a little. Pain has value-it is usually trying to tell us something-and its mere removal may be dangerous to our overall well-being. I am not sure how acupuncture works exactly, but in my western mind it likely has something in common with the gate theory of pain. If so, simply blocking the pain of CTS does not fix the problem. Eventually the person will go on to lose the use of the hand, because the nerve is still being injured, perhaps beyond the point of no return.

It seems to me that any therapy offered to treat CTS must focus on the wrist and associated intrinsic hand muscles and forearm flexors and must relieve pressure on the median nerve while increasing circulation. Furthermore, a person must be retrained in proper hand posture and biomechanical stress reduction to prevent exacerbation of the problem. Medical massage therapy is uniquely positioned to offer this therapy without the side effects of NSAIDS, local injections, or surgery.

NOTE:   Prolonged nerve compression with attendant muscle wasting due to axonal damage and denervation may become irreversable resulting in permanent damage to vital hand muscles. The one positive thing about surgery in these cases is that relief of the compression is immediate and recovery begins within hours of the surgery. But in early stages, or even moderately advanced stages, I would personally try anything other than surgery to reverse the problem, and I am comfortable in suggesting the same to others However, for all these reasons, it is best to have information on all aspects with attendant risks and to make an informed choice, including the risk of any surgical procedure/anesthesia/infection/hospital stay, etc., along with the risk of delay in decompressing the nerve with any non-invasive aproach.

I am inclined to believe that a thorough and frequent massage of the hand and anterior musculature, the wrist, and the forearm flexors combined with self-massage between treatments and proper use of splints and retraining should bring a variety of solutions directly to bear on the locus of injury. I would suspect that if this approach is going to work, the patient should experience reduction of pain in a few weeks, and clinical restoration of function within a few months. But this approach has yet to be demonstrated in any controlled trial.

Copyright 1996 by Paul R. Martin and James H. Clay

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