Is Conservative Care Right for Your CTS Patients?
Techniques
Written by Rebecca S. Fischer, D.C.   
Tuesday, 14 November 2006 16:11 Read : 1903 times

Published research shows treatment options for carpal tunnel syndrome (CTS) are mixed and often conflicting. In general, there are a number of accepted treatments for CTS that range from invasive (surgical and steroid injections) to non-invasive (manipulation, splints, topical patches, laser light) or combinations of all of the above. The American College of Rheumatology states, “Despite the prevalence of CTS and its considerable economic impact—in terms of both worker absenteeism and compensation claims—there is no universally accepted therapy.”

Previously, surgery was the standard of care, but now is the time for the chiropractic profession to step up and share the medical researchers’ findings about the effectiveness of non-surgical options. The truth is that, when given the choice, patients prefer conservative treatment alternatives over surgery, which makes certain types of chiropractic care the best option for early symptoms of CTS.

The good news for chiropractors is that carpal tunnel syndrome is now classified as a musculoskeletal disorder, and categorized as Repetitive Stress Injuries (RSI’s).  RSI’s occur when the body’s natural ability to heal itself is overpowered by factors of stress and fatigue.  Repetitive movements cause a reduction of the natural lubrication levels within the tendon sheaths, leading to a buildup of friction, producing swelling, and, ultimately, the growth of fibrous tissue, which then constricts the movement of the tendons.  This narrows the carpal tunnel, creating an entrapment neuropathy, the true definition of CTS.

Recognizing the causal factors, it would make sense that the following occupations are included as risk factors for developing CTS:

•  Food processing (meat/poultry workers)
•  Manufacturing (seamstresses)
•  Logging
•  Construction
•  Pneumatic tools
•  Jackhammer
•  High Repetition (bar code testing in supermarkets)

Accepted Treatments Get Mixed Reviews

Even with those promoting surgery or injection there is conflicting information about the effectiveness of one treatment method over another. Published in Neurology, June 2005, “Decompressive surgery and steroid injection are widely used forms of treatment for CTS but there is no consensus on their effectiveness in comparison to each other.”

Thus, a recent randomized controlled trial (RCT) of surgery versus a single steroid injection for CTS was performed. Patients were followed up at six and twenty weeks.  Attwenty weeks, patients who underwent surgery had greater symptomatic improvement than those who were injected; they had greater improvement in nerve conduction studies, but there was an interesting mix of findings. The surgery group actually had a loss in grip strength by 1.7 kg, compared with a gain in the injection group of 2.4 kg. 

Even though carpal tunnel release procedures can be “curative,” many patients experience postoperative complications, such as scar sensitivity, pillar pain, recurrent symptoms, and grip weakness, regardless of whether the release was done through an open, mini-open, or endoscopic approach.  Release of the carpal tunnel has an effect on carpal anatomy and biomechanics, including an increase in carpal arch width, carpal tunnel volume, and changes in muscle and tendon mechanics.

A year-long clinical trial was conducted and published in Arthritis & Rheumatism, February 2005.  The research suggested that “local steroid injection is just as effective as surgery for the long-term symptomatic relief of CTS—for a year, at least—and actually more effective over the short term.”  Eleven of the 101 randomized patients in the surgery group rejected the treatment, leading one of the authors, Dr. Domingo Ly-Pen to note, “This finding coincides with our daily clinical practice, in which patients usually prefer conservative therapies.”

CTS & Chiropractic

With patients pushing for conservative care and conflicting data plaguing invasive options, we see insurers like Blue Shield of California, who posted the following about chiropractic and holistic approaches that may be helpful: “A small, preliminary trial assessed a chiropractic treatment program consisting of exercises, soft tissue therapy, and manipulation of the wrist, the upper extremity, the spine, and the ribs. The treatment resulted in improvement in grip and thumb strength, muscle function, flexibility, and overall function, as well as a decrease in pain among people with CTS. In a follow-up study six months later, most of the improvement had been maintained. A controlled clinical trial compared traditional medical and chiropractic care for CTS. People with CTS received either standard medical care (ibuprofen and nighttime wrist supports) or chiropractic care (manipulation of the wrist, elbow, shoulder, neck, and spine, as well as massage to the soft tissues). Ultrasound and nighttime splints were also used in the chiropractic treatments. People in both groups improved significantly and similarly in terms of pain reduction, increased function, and improved finger sensation and nerve function, but the chiropractic group reported fewer side effects.” (See References: Bonebrake AR, Davis PT)

The best outcomes occur with early detection.  The most reliable clinical prediction rule (CPR) consists of the question, “Does shaking your hand relieve your symptoms?”  In a recent study, this CPR was more useful for the diagnosis of CTS than any single test item, which included Phalen’s Test and Tinel’s Sign. By using this question as the diagnosis for CTS, treatment was utilized quicker and resulted in better outcomes with posttest probability changes of up to fifty-six percent.  The next main consideration in evaluating the patient is the symptoms must occur along the distribution of the medial nerve. (Figs. 1 & 2.)

Conservative treatment is where we, as chiropractors, are the best, and research is recommending combinations of conservative treatments. Consider the randomized controlled trial of nocturnal customized splints for active workers with symptoms of CTS that were worn for six weeks, with benefits maintained at twelve months. The results in the splinted group showed improvement in terms of hand discomfort, regardless of the degree of median nerve impairment; whereas, the controls showed improvement only among subjects with normal median nerve function. Results suggested that a short course of nocturnal splinting may reduce wrist, hand, and/or finger discomfort among active workers with symptoms consistent with CTS.

Other new published research indicates the surgical, invasive treatment of CTS is only necessary if the symptoms persistently interfere with the normal lifestyle (for a period of at least several months), and if the diagnosis has been established beyond reasonable doubt.

Conservatively, utilizing The Activator Method is an excellent way to determine where and when to adjust a patient with CTS. By using Activator Method’s prone leg checks and Isolation Tests, the specific carpals, upper extremity involvements and related cervical vertebrae can be targeted for your CTS patients. The controlled force of the Activator enables a safe, effective adjustment for the carpals, cervicals and any other areas of nerve entrapment, more so than manually performed adjustments.

New tools

Chiropractically, we can add a new product that works like an anti-inflammatory, instead of an injection or drug, by utilizing a Theraderm® topical patch. Additionally for CTS, a wrist splint/support, the Wristivator®, can aid healing by maintaining warmth and the benefits of new far-infrared technology. Information on these new products can be accessed at www.activator.com.

By combining conservative care, as research recommends, you will provide your patients with the level of care and peace of mind they seek. The Activator Method incorporates Isolation Tests, Stress Tests, and Leg Length Analysis to determine specific contact points and Lines of Drive in the corrections of neuro-biomechanical dysfunctions with the Activator Instrument. The Activator Method is unique as a chiropractic technique because there are post-adjustment analysis procedures that give the doctor peace of mind and confidence in their adjustive treatment of the patient. The 2006-2007 Activator Methods Seminar season includes advanced, concentrated studies on the subject of carpal tunnel syndrome and headaches.


 
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