Carpal Tunnel Syndrome: A New Way of Thinking
CARPAL TUNNEL SYNDROME: A New Way of Thinking
I recently attended a great seminar on The Management of Common Conditions of the Upper Extremity put on by LACC. Paul Hooper, John Saringe, and Gary Schultz each made excellent presentations -- the best seminar I've attended in my 15 years of obligatory weekend learning.
A great deal of time was spent on Carpal Tunnel Syndrome, or more accurately, the management of symptoms of the wrist and hand. Paul Hooper covered the topic thoroughly and magnanimously admitted what we all know from practice -- very seldom is carpal tunnel syndrome cured -- we just manage the cases and give as much relief as possible.
The symptoms of CTS very seldom go away. Well, maybe for a while, but they seem to recur over and over again in those increasing numbers of sufferers. Symptoms usually appear on one side, the dominant hand, then start showing up on the other side in many cases. Bilateral symptoms are not uncommon.
Etiology was discussed briefly and included the following:
The latter was included because an increased incidence of CTS symptoms has been noted in diabetics.
Technically, CTS is a condition caused by impingement on the median nerve in the wrist, either by pressure or entrapment. But as chiropractors, we know that paresthesias of the hand can be caused by impingement at any level along the route of the nerves to the hands. Thus, Dr. Hooper pointed out many cases may be due to neck problems, shoulder problems, or elbow problems. The list of differential diagnoses included the following:
- carpal tunnel syndrome
- cervical radiculopathy
- cervicobrachial syndrome (same thing to me)
- pronator teres syndrome.
- ulnar neuropathy
- anterior interosseous syndrome
- double crush syndrome
- thoracic outlet syndrome
As chiropractors, we are thorough and consider impingement at every level and often treat at every level with adjustments and physical therapy. This is a good idea. I mean after all, our treatment will not cause irreversible damage as Dr. Hooper pointed this out, and made the differentiation between our approach and the medical approach. When we as chiropractors get poor results in cases of CTS (which is often) we refer to hand specialists. These specialists stand poised with a knife, although they usually try anti-inflammatories, physical therapy, and wrist braces before they cut. But they usually get around to surgery, trying some sort of release technique to free up the median nerve. Results are poor.
Surgeons also consider impingement at different levels, and they may try to remove the first rib when they suspect thoracic outlet syndrome after a failed CTS surgery.
All of us are thrashing about, and not very effectively. Whether it's surgery, physical therapy, acupuncture, chiropractic, medication, disability, or braces, the results are usually palliative at best, and usually provide only temporary relief.
Let's face it, We don't really know what causes CTS. Ask five doctors to evaluate a CTS case, and you will get five different ideas about where the impingement is occurring. It is very seldom obvious. If we knew the cause, we could eliminate it, and therefore the symptoms. Right?
THE CAUSE OF CARPAL TUNNEL SYNDROME
Let's all slow down and do a little investigation into the cause of CTS and maybe take a new approach. The notion that one practitioner is going to be a better technician using the same methods is just not true. It's the methods that limit the response. Let's all refer to the PDR and let's talk about drugs. I randomly picked three drugs to illustrate my point. Please bear with me.
Let's talk about Synthroid, taken by many of our patients for suspected thyroid problems. My book is a little older, a 1995 model, but it will suffice. If you will, please skip past the picture of the chemical structure, the indications, the contraindications, and all that other stuff until you get to adverse reactions. Let me quote for Synthroid: "Adverse reactions consists of mild, transient pain, paresthesias, bleeding, and transient dermatitis." It goes on.
Let's take a look at adverse reactions to Prinivil, a drug for hypertension. "Nervous System/Psychiatric: Stroke, ataxia, memory impairment, tremor, peripheral neuropathy (e.g.dyesthesias), spasm, confusion, somnolence, hypersomnia, irritability, and nervousness."
Adverse reactions to Dilantin (phenytoin), a drug used for seizures: "A predominantly sensory peripheral polyneuropathy has been observed in patients receiving long term phenytoin therapy."
One more, Calan, another drug for hypertension. Adverse reactions: "Nervous system: cerebrovascular accident, confusion, equilibrium disorders, insomnia, muscle cramps, paresthesia, psychotic symptoms, shakiness, somnolence." Symptoms that look like CTS are often caused by drugs. If you looked up every drug in the PDR, you would come up with thousands more that cause similar symptoms. You might also notice other things we treat, like headaches, back pain, joint pain, even lumago(?).
I know, at first you jumped with excitement. This is new and different. Then you started going quickly through your cases of CTS in your head, most of them women, most in their thirties. Then your shoulders gradually slumped as you realized that few if any of them are taking these medications. In fact, your worst cases are taking NO medication.
Ah, hah. Don't stop reading just yet. Those adverse reactions were chosen at random merely to illustrate a point. If a paresthesia is due to medication, where is the impingement? Where is the nerve being pressed, and what is the mechanism where that can happen chemically?
These paresthesias are not due to physical impingement. They are due to chemical irritation of the nervous system. And you know what else? Most cases of CTS are due to chemical nerve irritation, not physical impingement, or pressure, or entrapment. That's why surgery and manipulation don't work so good.
When you think of the cases of CTS you are treating, don't you notice that many of them have a very mild or nonexistent history of trauma or physical stress? OK, they may type on a keyboard once in a while, or maybe all day. They use their hands, but who doesn't? How many of them operate jackhammers, or have any kind of significant traumatic history that wasn't made up, or conflagrated, or focused on because both the doctor and the patient think the cause is purely physical?
But many of you know that symptoms of CTS are definitely aggravated by physical activity. That's because any disease process or pain complex is due to the accumulation of physical, mental, and chemical stress. Rest will help, but usually won't solve cases of CTS unless the chemical irritant(s) is eliminated. Then, most patients will find that physical stress in the absence of chemical stressors will not cause symptoms.
If you don't think the nervous system is affected by chemicals, then go back in your memories to your college days, or drink a six pack of beer then get one of those ortho/neuro exams performed by Highway Patrol officers.
I looked to the PDR for support, for proof actually, after I already discovered that most cases of peripheral neuropathy, or paresthesias, or CTS are due to chemical stress, not physical stress. Very few of the cases I have seen resolved were due to medication. Most are cases of chemical reactions to specific substances in the diet.
The following is the list of the most common causes of the symptoms we have come to call Carpal Tunnel Syndrome. They are listed in order. You can place all of them before physical nerve entrapment. Some people react to only one, others to several.
1. Casein. This is the main protein found in milk and dairy foods, and by far the most common cause of CTS. The mechanism is allergy, and allergies are not dose dependent, so all sources of casein must be eliminated. This includes all those goodies that make up the Standard American Diet, and are hugely responsible for Standard American Health: whole milk, skim milk, low fat milk, non-fat milk, butter milk, cheese, fake cheese, cottage cheese, cream cheese, sour cream, ice cream, ice milk, sherbet, yogurt, ranch dressing, bleu cheese, butter, pizza, and on and on. And foods that are made with milk, like pancakes, biscuits and gravy, mashed potatoes, omelets, protein shakes, etc., etc.
Some dairy foods are more powerful than others. The most powerful by far is chocolate (do you think this is fun for me?), even chocolate that contains no milk, like cocoa, oreos, chocolate flavoring, cappuccino, mocha coffee, etc. After chocolate is ice cream, then sour cream, then parmesan cheese, then cream cheese.
Many non-dairy foods contain some form of caseinate. This will also set off a reaction, so coffee creamers, Cool Whip, IMO, and many soy milks must also be avoided.
2. Monosodium glutamate (MSG). This flavor enhancer is widely used (more than you think) and is designed to irritate nerves, namely, the taste buds. MSG is found in almost every restaurant, especially in soups, especially in oriental foods, in most sauces (BBQ sauce, teriaki, soy), in packaged foods like TV dinners, Rice-A-Roni, rice pilaf, many spices (Accent is pure MSG), snack foods like flavored chips, and in processed meats like salami, bologna, pastrami (all deli meats), and canned tuna.
MSG is the salt of glutamic acid, and is produced by hydrolyzing food proteins, although it occurs naturally in soy sauce and seaweed. It is often disguised on labels as hydrolyzed protein (any kind, even casein), natural flavors, flavorings, yeast extract, autolyzed yeast, yeast extract, and protein isolate.
3. Aspartame. This chemical is similar in structure to MSG and is used today in most diet foods, sugar free goods, most diet sodas, and Equal.
4. Gluten. Gluten is wheat protein and can cause nerve irritation although it is not nearly as common as those listed above. Avoiding gluten makes for a very restricted diet, avoiding all breads, cakes, cookie, crackers, and pasta. Those who are gluten intolerant usually are also allergic to milk protein.
This is not information most patients and doctors want to hear, but it is true. Symptoms of CTS will abate, or be much improved within 30 days of avoiding the chemical substance responsible for the nerve irritation.
The medical profession will continue to consider poison pharmaceuticals and useless surgery. Many chiropractors will insist on using only manipulation. But eventually, one profession or the other is going to come to the realization that the diet causes most disease. I've seen an ad for years that claims "disease and death begins in the colon." That's close. Try the other end.
We are licensed to give nutritional counseling, and we are trained.
Let's do it now for the sake of those who suffer.
The American Chiropractor Magazine, Inc.
By Daniel A. Twogood