Carpal Tunnel Syndrome

 

The double crush syndrome is a compression neuropathy of two areas, one usually distant from the other. A growing number of researchers have suggested a correlation between some peripheral neuropathies, of which carpal tunnel syndrome is one and cervical nerve root compression another. The nerve is “crushed” or irritated in the spine, “priming” more distal areas of the nerve for dysfunction when that part is stressed (second “crush”).

Peer Reviewed Publications:

1) Comparative efficacy of conservative medical and chiropractic treatments for carpal tunnel syndrome: a randomized clinical trial. Davis PT, Hulbert JR, Kassak KM, et al. Journal of Manipulative and Physiological Therapeutics, June 1998, vol.21/no.5, pp317-26.

• This study showed that chiropractic was as effective as medical treatment in reducing symptoms of CTS. Chiropractic care included spinal adjustments, ultrasound over the carpal tunnel, and the use of nighttime wrist supports. Carpal tunnel syndrome (CTS) can affect just about everyone, but particularly people involved in occupations requiring repetitive use of the hands and wrists (i.e., office and skilled labor jobs). Medical doctors commonly prescribe anti-inflammatory drugs, which prove ineffective in some patients and cause adverse side effects in others, for patients diagnosed with carpal tunnel syndrome.

2) Clinical commentary: pathogenesis of cumulative trauma disorders. Mackinnon S. Journal of Hand Surgery, Sept. 1994, 873-883.

• Dr. Susan MacKinnon professor of surgery at Washington University School of Medicine in St. Louis in a study of 64 patients with repetitive stress disorders of whom 34 had wrist surgery it was discovered that wrist pain or discomfort was not the only symptom the patients complained of. Most patients had multiple problems, especially muscle imbalance. The high failure rate of surgery has caused her to rethink the cause of CTS: “Unnatural postures for extended periods creating pressure on the nerves in the neck, leading to neurological and other symptoms...even when extremity surgery improves the peripheral symptoms such as numbness in the hands, other associated problems like neck stiffness and shoulder pain persist,” her article states.

3) A treatment for carpal tunnel syndrome: evaluation of objective and subjective measures. Bonebrake AR, Fernandez JE, Marley RJ et al. JMPT Vol.13 No.9 Nov/Dec 1990.

• Thirty eight CTS sufferers underwent spinal manipulation and extremity adjusting. In addition, soft tissue manipulation, dietary modifications or supplements and daily exercises were prescribed. Post treatment results showed improvement in all strength and range of motion measures. A significant reduction of nearly 15% in pain and distress ratings were documented.

4) Resolution of a double-crush syndrome. Flatt DW. Journal of Manipulative and Physiological Therapeutics, July/August 1994; 17(6): 395-397.

• A 63-year-old man suffered from a 36-month history of right anterior leg numbness and recurrent lower back pain. Complete resolution of right anterior leg numbness followed chiropractic treatment. Although not a carpal tunnel problem the double crush phenomenon, in this case involving the leg, and its resolution under chiropractic care is of interest.

5) The double crush in nerve entrapment syndromes. Upton, ARM, McComas AJ. Lancet 2:329, 1973.

• 67% to 75% of patients studied who had carpal tunnel syndrome or ulnar neuropathy also had spine nerve root irritation.

6) Impaired axoplasmic transport and the double crush syndrome: food for chiropractic thought. Czaplak S, Clinical Chiropractic/Jan. 1993 p.8-9.

• “Chiropractic has an extensive anecdotal history of patients being relieved of classic carpal tunnel symptoms with spinal adjustments and/or cervical tractioning only.”

7) Carpal tunnel syndrome as an expression of muscular dysfunction in the neck. Skubick DL, Clasby R, Donaldson CCS et al. J Occup Rehabil 3:31-44, 1993.

• Carpal tunnel syndrome can occur from increased forearm flexor activity caused by muscle dysfunction in the neck. Study of 18 patients.

8) Comparison of physiotherapy, manipulation, and corticosteroid injection for treating shoulder complaints in general practice: randomized, single blind study. Sobel JS, Winters JC, Groenier K, Arendzen JH, Meyboom de Jong B. British Medical Journal 1997; 314:1320-5.

• From the article: 198 patients with shoulder complaints were divided into two diagnostic groups: 58 in a shoulder girdle group and 114 into a synovial group. Patients in the shoulder girdle group were randomized to manipulation or physiotherapy and patients in the synovial group were randomized to corticosteroid injection, manipulation or physiotherapy. In the shoulder girdle group, the duration of complaints was significantly shorter after manipulation compared to physiotherapy. The number of patients reporting treatment failure was less with manipulation. In the synovial group duration of complaints was shortest after corticosteroid injection compared with manipulation and physiotherapy. (Note: either G.P.s or physiotherapists performed the manipulations).

9) Physical examination of the cervical spine and shoulder girdle in patients with shoulder complaints. Sobel JS, Winters JC, Groenier K, Arendzen JH, Meyboom de Jong B.JMPT 1997; 20:257-62.

• From the abstract: In the population of patients without shoulder complaints the mobility in the cervical and upper thoracic spine was found to decrease with aging…functional disorders in the cervical spine, the higher thoracic spine and the adjoining ribs are not extrinsic causes of shoulder complaints, but an integral part of the intrinsic causes of shoulder com-plaints..

10) The neuron and its response to peripheral nerve compression. Dahlin LB, Lundborg G. J Hand Surg (Br Vol, 1990) 15B: 5-10.

11) Physical examination of the cervical spine and shoulder girdle in patients with shoulder complaints. Sobel JS, Winters JC, Groenier K, Arendzen JH, Meyboom de Jong B.JMPT 1997; 20:257-62.

• From the abstract: In the population of patients without shoulder complaints the mobility in the cervical and upper thoracic spine was found to decrease with aging…functional disorders in the cervical spine, the higher thoracic spine and the adjoining ribs are not extrinsic causes of shoulder complaints, but an integral part of the intrinsic causes of shoulder com-plaints.

12) The neuron and its response to peripheral nerve compression. Dahlin LB, Lundborg G. J Hand Surg (Br Vol, 1990) 15B: 5-10.

13) The relationship of the double crush syndrome (an analysis of 1,000 cases of carpal tunnel syndrome). Hurst LC, Weissberg D, Carroll RE. J Hand Surg 10B: 202, 1985. A significant correlation was found between bilateral carpal tunnel syndrome and radiologically diagnosed cervical arthritis.

14) Carpal tunnel syndrome in 100 patients: sensitivity, specificity of multi-neurophysiological procedures and estimation of axonal loss of motor, sensory and sympathetic median nerve fibers. Kuntzer T. Journal of the Neurological Sciences, 1994 Dec 20, 127(2): 221-9.

15) Double crush syndrome: chiropractic care of an entrapment neuropathy. Mariano KA; McDougle MA; Tanksley GW. Journal of Manipulative and Physiological Therapeutics, 1991 May, 14(4): 262-5.

16) Thoracic outlet syndrome: diagnosis and conservative management. Liebenson, CS JMPT Vol. 11 No. 6, Dec 1988.

• Thoracic outlet syndrome is caused by compression or irritation of the nerves as they exit the neck toward the upper extremity. Often it is the compression or irritation of the brachial plexus, not from compression of the subclavian artery. In this discussion, the author notes some researchers who believe that the sacroiliac plays a large role in the etiology of this condition. Others feel an abnormal thoracic curve is the cause.

17) The role of thoracic outlet syndrome in the double crush syndrome. Narakas AO.. Annales de Chirurgie de la Main et du Membre Superieur, 1990, 9(5): 331-40.

18) Treating Shoulder Dysfunction and “Frozen Shoulders”. Ferguson LW. Chiropractic Technique, 1995; 7:73-81.

• Author’s Abstract: This article presents three case histories to illustrate the treatment of “frozen shoulder” and related shoulder dysfunction as a combined disorder involving joint dysfunction and myofascial pain syndrome. The author reviews the literature and questions the traditional treatment approaches, which focus on treating inflammation and breaking adhesions. The concept of adhesive capsulitis as the only cause of “frozen shoulder” is challenged. The author proposes an alternative treatment protocol that addresses specific patterns of joint dysfunction and myofascial disorder.
• Comment: Dr. Ferguson utilized spinal adjustments and shoulder adjustments.

Additional Publications:

1) Surgery of the peripheral nerve. MacKinnon SE, Dellon AL. Thieme Medical Publishers. New York, 1988.

• Nerve compression near the spine is found in people with carpal tunnel syndrome.

2) Double crush syndrome: cervical radiculopathy and carpal tunnel syndrome. Osterman AL, Pfeffer G, Chu J, et al. Presented at the 41st annual American Society for Surgery of the Hand, New Orleans, LA 1986. Describes in detail the double crush syndrome.

3) Double crush syndrome: a chiropractic/surgical approach to treatment. Cramer SR, Cramer LM Dig of Chiropractic Economics Mar/April, 1991.

• From the abstract: Seventy five patients had dual treatment of chiropractic and hand surgery/rehabilitation, “concluding that these two...treatments are complementary and can be effective in improving the lives and prognoses of patients....”

4) The relationship of the double crush syndrome (an analysis of 1,000 cases of carpal tunnel syndrome). Hurst LC, Weissberg D, Carroll RE. J Hand Surg 10B: 202, 1985.

• A significant correlation was found between bilateral carpal tunnel syndrome and radiologically diagnosed cervical arthritis.

5) Carpal tunnel syndrome: a case report. Ferezy, JS, Norlin, WT. Chiropractic Technique, Jan/Feb 1989 P.19-22.

• Electromyelography demonstrated objective improvement in this case of CTS following chiropractic care.

6) Spinal Manipulation, 5th edition by Bourdillon JE, Day EA, Bookhout MR: Oxford, England, Butterworth-Heinemann Ltd, 1992:

• “Faulty innervation caused by spinal joint lesions is one of the main factors in the production of carpal tunnel syndrome. p. 207.

7) Research finds surface EMG useful in treatment of CTS. Prosanti MP. Advances For Physical Therapists, July 6, 1992.

• From the article: “The notion that muscles of the neck could be involved in problems within the arm and wrist has been a subject of discussion for several years.”

8) The double lesion neuropathy: an experimental study and clinical cases. Nemoto et al Abstract 123, Second Int’l Congress. Boston, MA Oct. 1983.

• Shows that nerve compression such as in the neck will block the distribution of necessary cellular material to the distal nerve axon such as in the wrist, making it more susceptible to injury.

9) Double crush syndrome: what is the evidence? Swenson RS. J Neuromusculoskeletal System, Spring 1993; 1(1): 23-29.

• The hypothesis that a nerve injury close to the spine may weaken the nerves further away is discussed. The author concludes that more data is needed.

10) [Diagnostic tests in carpal tunnel syndrome] Megele R. Nervenarzt, 1991 Jun, 62(6): 354- 9. Language: German.

11) The numb arm and hand. Bracker MD, Ralph LP American Family Physician 51(1): 103- 116, 1995.

• Medical article that discusses thoracic outlet syndrome.
• Abstract: Trauma and compression along the course of the median, ulnar or radial nerve from the brachial plexus to the fingers may cause pain, weakness, numbness or tingling the upper extremity. Diabetes, smoking, alcohol consumption, rheumatoid arthritis and hypothyroid-ism are risk factors for nerve entrapment although these disorders typically produce bilateral symptoms.

References from Koren Publications’ brochure: Help for Carpal Tunnel Sufferers

• Nonsurgical relief for carpal tunnel sufferers. Let’s Live, August 1993.
• Pfeffer, G.B. & Gelberman, R.H. The carpal tunnel syndrome. In N.M. Hadler (Ed.), Clinical concepts in regional musculoskeletal illness. Orlando, FL: Grune & Stratton, Inc., 1987, pp. 201-215.
• Brody, J.E. Epidemic at the computer: Hand and arm injuries. New York Times, March 3, 1992, pp. C1; C10.
• Rietz, K.A. & Onne, L. Analysis of sixty-five operated cases of carpal tunnel syndrome. Acta Chir Scand, 1967, 133, pp. 443-447.
• Mendelsohn, R. Treating carpal tunnel syndrome. The People’s Doctor, 8 (9), p.7.
• Fisher, H. Prevention Magazine.
• Ferezy, J. & Norlin, W. Carpal tunnel syndrome: A case report. Chiropractic Technique, Jan/Feb 1989, pp. 19-22.
• Upton, A.R.M. & McComas, A.J. The double crush in nerve entrapment syndromes. Lancet, 1973, 2, p. 329.
• Nemoto, K. et al. The double lesion neuropathy: An experimental study and clinical cases. Abstract 123, Second Int’l. Congress. Boston, MA, Oct. 1983.
• Hurst, L.C., Weissburg, D. & Carroll, R.E. The relationship of the double crush syndrome (an analysis of 1,000 cases of carpal tunnel syndrome). J Hand Surg, 1985, 10B, p. 202.
• Czaplak, S. Impaired axoplasmic transport and the double crush syndrome: Food for chiropractic thought. Clinical Chiropractic, Jan. 1993, pp. 8-9.
• Bonebrake, A.R. et al. A treatment for carpal tunnel syndrome: Evaluation of objective and subjective mea-sures. JMPT,1990, 13, pp. 507-520.
• Stoddard, A. Manual of osteopathic practice (2nd ed.). Melbourne, Australia: Hutchinson & Co., 1983, p. 228.
• Bourdillon, J.F. Spinal manipulation (3rd ed.). New York: Appleton-Century-Crofts, 1984, pp.207; 210-211;219-224