Carpal Tunnel Syndrome: An Alternative Treatment Approach
Carpal tunnel syndrome is diagnosed with increased frequency as more workers are required to perform repeated hand and wrist activities.
Over 5,700 cases were reported in Wisconsin alone in 1987 according to Worker Compensation statistics. Many of these workers take medications, steroid injections, physical therapy and surgery without satisfactory results.
Reconstruction therapy (also known as sclerotherapy, prolotherapy and proliferative therapy) offers a biological alternative, increasing ligament, tendon structure and strength up to 40%[ 2, 3] for wrist instability commonly mistaken for carpal tunnel syndrome.
The Traditional Cause of "Carpal Tunnel Syndrome"
The carpal tunnel is bound on three sides by bone. The remaining area is surrounded by the transverse carpal ligament. Engaging in prolonged repetitive motion and vibratory activities can result in irritation which causes an excess of synovial fluid to be excreted into the carpal tunnel. This excess fluid creates inflammation and the pain associated with this process which is usually diagnosed as carpal tunnel syndrome. In an attempt to reduce the inflammation and pressure, the usual recommendation for treatment is to cut the transverse carpal ligament. Unfortunately, this creates a permanent disability for the patients. Other treatments which are sometimes used but may not be fully effective include: cortisone injections, physical therapy, splinting and anti-inflammatory drugs. All of these treatments are based on reducing swelling. It has been our experience at the Milwaukee Pain Clinic and Metabolic Research Center that these methods have not produced satisfactory results.
Function of Ligaments
Ligaments have two functions: 1) They connect bones to bones and 2) They stabilize all joints and limit bones' range of motion. (See Illustration #1) As this illustration shows, there are many ligaments on the back of the wrist and the hand. In fact, the bones are barely visible through the many ligaments which hold all the bones together and stabilize the wrist.
Normal Stabilizing Wrist Ligaments
An Alternative Cause of Carpal Tunnel Syndrome
Analyzing the problem from a slightly different perspective, we start with the observation that when a person engages in repeated grasping or turning activities over time, the ligaments tend to stretch out or tear off where they attach to the bone. These repetitive activities cause swelling and injury. Since ligaments function to support and stabilize joints, it is likely that any weak joint also has weakened or torn ligaments. Tendons, like ligaments, also attach to the bone and may al so become stretched and torn in repetitive turning or grasping activities. Physiologic etiologies of median nerve compression require physiologic correction.
Discs, tendons and ligaments are made of fibrous protein and they lack a good blood supply. In fact, the major reason why ligament and tendon joint and disc problems do not heal well is because of their relative lack of blood supply.
Classic Symptoms of Weak Ligaments
Ligaments and tendons are very tough and very strong. When they become damaged they tend to become torn where the ligament or tendon attaches to the bone. (See Illustration #2) In our clinical practice we have found that there are a number of indicators which are suggestive of ligament or tendon damage. The first indicator is swelling on the back or dorsum of the hand and pain on the back of the wrist. These areas are distant from the bone-encased carpal tunnel and transverse carpal ligament which is on the palm side of the hand. The pain is usually located over the radial-carpal ligament (thumb side of the wrist), the ulnar-carpal ligament (little finger side of the wrist), and on the edges of the other wrist bones on the back of the wrist. All of these areas are remote from the carpal tunnel area as they are on the sides and the back of the wrist.
Torn & Relaxed Ligaments Resulting in Weakness & Instability
Another indicator of ligament or tendon weakness is grasp strength. Patients report they often drop things when doing aggressive activity and that they fatigue quickly. We have found with testing that often these patients have only 20% their normal strength. Ligaments and tendons play major roles in strength. Nerve problems can cause weakness and this fact complicates diagnosis.
In severe cases, other indicators include: clicking, popping or grinding in the wrist. This can be detected in less overt phases by putting the patient's wrist through its range of motion while placing the examiner's palm over the back of the wrist. Any slight popping, snapping or grinding indicates weakness and instability of the ligaments and tendons involved.
Another finding suggesting ligament weakness and instability is that the patient's symptoms are helped if a brace is used. The reason symptoms are relieved here is because the brace is doing the work that the ligaments should be doing; that is, giving strength and stability to the joints. When choosing a brace, use the type that is supportive of the entire wrist, not a wrist strap. The proper brace also has a metal support which extends into the palm. There are velcro straps which fit the 8 to 9 inch support snugly around the wrist and hand. The support leaves the thumb and fingers free and it is worn 24 hours a day. Many of these people have severe pain during the night. If the individual notices that the brace has helped, this is further evidence suggesting ligament weakness and instability. It should also be noted that a brace may help a carpal tunnel case in which there is swelling in the carpal tunnel.
An Alternative Treatment for Carpal Tunnel and Other Joints Which Have Not Improved with Conventional Methods
If conventional methods such as anti-inflammatory medicines, cortisone injections, physical therapy and surgery have not helped the problem, it is probable that there is some other factor which is the cause of the problem, that has not been addressed. Ligament and tendon instability have been shown to be the frequently unsuspected cause. Studies have shown that these ligaments and tendons can be permanently strengthened with a nonsurgical tendon, ligament and joint reconstructive injection method. (See Illustration #3) Published scientific studies conducted by the University of Iowa have shown that the injection of sodium morrhuate into the affected area increases ligament and tendon size by 20%-40% and increases ligament and tendon strength by 35%-40%. Dr. Harold Walmer, an osteopathic physician from Elizabethtown, Pennsylvania and co-scientist of the University of Iowa study, further emphasizes that this 35%-40%[ 2, 3] increase in size is compared to normal ligaments. Accordingly, the actual increase in an injured ligament or tendon could be much greater than 100%. (See Illustration #4) Sodium morrhuate is a natural FDA approved product which comes from purified cod liver oil. Sodium morrhuate and other proliferating natural substances work by causing an irritating stimulation to the weakened area. This process has been shown to cause fibroblasts, which are healing cells, to migrate to the weakened area and to lay down collagen which is strong protein tissue which mends the precise weakened areas.
Ligaments treated with reconstruction therapy obtain strength & structure up to 40% above normal
Two-Dimensional bar graph shows the potential of strength & structural to be greater than 100%
The main effect of this therapy is increased strength of the wrist or treated joint. With increased strength comes increased endurance. If the patient previously had any popping, snapping or grinding of the joint, this should also decrease as treatment progresses.
The therapy has undergone the most rigorous test-a double blind human study. Dr. Robert Klein, Dr. Thomas Derman and others at the Sansum Medical Clinic in Santa Barbara, California did a study using 81 low-back patients who had suffered from their problem for 10 or more years continuously. They also had failed to obtain relief after rest, exercise, physical therapy, chiropractic adjustments, osteopathic manipulations, acupuncture, medication, surgery and other modalities. Low back pain is considered the #1 cause of disability in the United States in patients under 45 years of age.
The patients in this study were divided into two groups. One group received injections of anesthetic, normal saline and sham manipulations. The second group received injections of anesthetic, phenol, dextrose and glycerine along with manipulations. Neither the administering physicians nor the patients knew which solution was received. Each patient was treated 6 times and then evaluated. The results indicated that the group that had received the anesthetic, phenol and dextrose responded with 88% marked to moderate improvement in their chronic back pain. This study was reported in the prestigious medical journal, The Lancet on July 18, 1987. This study is particularly impressive as its methodology was an improvement on a study previously published by surgeon George Stewart Hackett in the Journal of the American Medical Association in 1958 which reported that 82% of 1600 chronic unstable low back patients responded with marked to moderate improvement as determined by independent examinat ion some 2-12 years after the completion of the therapy. Dr. Hackett injected rabbit tendons 3x with reconstructive solutions. These studies demonstrate an increased weight and size of the treated tendon by 35-40% above the normal tendon.[ 4]
On December 28, 1988 Cable News Network (CNN) aired a story showing that surgeons were trimming frayed ligaments and using an electric burr to clean up the joint areas after an injury for patients with chronic joint pain. The report stated that it was not known why this method worked but that it seemed to work for people not helped by other methods.
Osteopathic and biological physicians know that the burring produces a mechanical irritation similar to the irritation of non-surgical tendon, ligament and joint reconstruction injection therapy which stimulates the body to produce new tissue. Marked improvement has been obtained with non-surgical tendon, ligament and joint therapy in cases of arthritic chronic joint, tendon and ligament problems, regardless of the severity and duration of the problem. Chronic whiplash, migraines, unstable weak knees and ankles and failed surgeries of the disc, tendons and ligaments, have been successfully treated with this therapy.
Jean Bailey, 46, was referred to the Clinic by her chiropractor, Dr. J. Odvarka of Bettendorf, Iowa. She was having pain in both hands and wrists. She couldn't grasp objects without pain. She couldn't sleep at night because of the pain in her thumb, fingers and wrist. Jean was told she had carpal tunnel syndrome and that she should try cortisone injections, which she did. She was then told to have surgery, which she refused because she knew other people at work at her assembly job who were not helped or who were even worse after surgery. Jean remarked that 'everything was out of control since she had been disabled with the pain in her wrist and hands.'
Examination at the Milwaukee Pain Clinic and Metabolic Research Center revealed Jean's hand grasp strength had decreased by 70% in both the right and the left hand. There was also a slight grinding and popping detected when she was examined for range of motion of her wrists. She was treated by injection into the precise areas of the wrist ligaments which attach to the bone. This treatment produces a marked increase in strength on repeat grasp testing. The popping and grinding also decreased, she experienced more endurance and relief from her pain, and she is able to work again.
James Hamm, 39, a production worker for Chrysler Corporation in Kenosha, Wisconsin endured agony of both wrists, elbows and pain in his shoulder. His job consisted of using air wrenches most of the time. He was referred to the clinic by his physician when repeated cortisone injections, rest, physical therapy and medications failed to relieve his pain and weakness. Precise injections of sodium morrhuate into the weakened and torn ligaments of his wrist, elbows and shoulders allowed him to return to his regular work without any rehabilitation training or further disability. In severe cases it is sometimes necessary to inject the joint, ligaments and tendons of the neck as well as the shoulder, elbow and wrist to return the patient to work, because repeated motion and vibrations can stretch and wear the tendons and ligaments up through the arm and into the shoulder and up the neck.
It was previously thought that reconstruction therapy caused a loss of range of motion. An increased range of motion was found by objective measurement in lower back treated portions in a study report in the July 1989, Journal of Neurological and Orthopaedic Medicine and Surgery by Drs. Klein, Dorman and Johnson. The same study reported the first histologic documentation of ligament proliferation in human subjects in response to a program of proliferant injections.
It is emphasized that the main effect of the therapy is increased strength and endurance. When the weak joints, tendons and ligaments are strengthened the pain is eliminated as the main side effect. Since new tissue is produced by the controlled irritation process, the therapy is considered permanent.
It is noted that there is almost always a significant time lag between a new discovery and its general usage. For example, it took 83 years for deep freezing, 38 years for the steam ship, 37 years for reinforced concrete, 26 years for radio, 34 years for television, 21 years for the electronic calculator, 10 years for semiconductors and 9 years for plastic fibers to be generally adopted.
Availability of Therapy
Reconstructive injection therapy is limited due to the fact that the substances used are not patented. This gives pharmaceutical companies little incentive to promote usage. The art of diagnosis and injection methods are taught in classroom and workshop formats by the American Academy of Neurological and Orthopaedic Surgeons, the American Association of Orthopaedic Medicine, the Canadian Association of Orthopaedic Medicine, the British Association of Orthopaedic Medicine and the American Osteopathic Academy of Sclerotherapy. Preceptorships are given by the author at the Milwaukee Pain Clinic and Metabolic Research Center. At present an American Board of Reconstruction Therapy is being formed under the auspices of the American Academy of Neurological and Orthopaedic Surgeons.
William J. Faber, D.O. Milwaukee Pain Clinic 6529 W. Fond du Lac Ave. Milwaukee, WI 53218
1. M.J. Onley, R.G. Klein, T.A. Dorman, B.C. Eek & L.J. Johnson, A new Approach to the Treatment of Chronic Low Back Pain. The Lancet, July 18, 1987.
2. Y. K Liu, Charles M. Tipton, Ronald D. Matthes, Toby G. Bedford, Jerry A. Maynard & Harold C. Walmer, An In Situ Study of the Influence of Sclerosing Solution in Rabbit Medical Collaterial Ligaments and Its Junction Strength. Connective Tissue Research, 1983. Vol. 11, pp. 95-102. Gordon & Breach, Science Publishers, Inc.
3. J.A. Maynard, V.A. Pedrini, A. Pedrini-Mille, B. Romanus & F. Ohlerking, Morphological and Biochemical Effects of Sodium Morrhuate on Tendon. Journal of Orthopaedic Research. 3:236-248, Raven Press, New York, 1985.
4. Hackett, M.D., George Stewart, Ligament and Tendon Relaxation Treated by Prolotherapy. Charles C. Thomas, Springfield, IL. 1958.
5. Klein, R.G., Dorman, T.A., Johnson, C.E., Proliferant Injections for Low Back Pain & Histologic Changes of Injected Ligaments & Objective Measurements of Lumbar Spine Mobility Before and After Treatment. The Journal of Neurological and Orthopaedic Medicine and Surgery. Vol. 10., Issue 2, July 1989, Las Vegas.
6. Faber, W.J., Walker, M., Pain, Pain Go Away. Ishi Press International, Mountainview, CA. 1990.
By William J. Faber