Osteopathy For Carpal Tunnel Syndrome

Image credit: By DoPhotoShop - http://dophotoshop.com/carpal-tunnel-exercises.php, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=14614865

Image credit: By DoPhotoShop – http://dophotoshop.com/carpal-tunnel-exercises.php, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=14614865

Carpal tunnel syndrome is a common presentation, but is often poorly managed. Osteopathy can provide a conservative option to treat carpal tunnel syndrome.

Carpal tunnel syndrome is a fairly common condition that affects women slightly more than men, with numbers ranging from 1-7% of the population affected. (1)

It is described as “a painful disorder of the hand caused by pressure on nerves that run through the wrist. Symptoms include numbness, pins and needles, and pain (particularly at night).” (2)

It usually presents with the following symptoms (3):

  • paresthesia, dull, aching pain, or discomfort in the hand associated with weakness or clumsiness;
  • fluctuating level of symptoms with exacerbation at night (nocturnal numbness), worsened by strenuous hand use or activities with maintained posture (driving);
  • and partial relief of symptoms by changing hand posture or shaking the hand.

Diagnosis or description?

Generally speaking, any condition that has the word “syndrome” in its name is not a diagnosis, but rather a collection of clinical findings.

In the case of carpal tunnel syndrome, it is considered a clinical diagnosis, but, whilst the symptoms can be similar from person to person, the clinical findings (and thus underlying causes) can be quite different, based on a variety of different factors.

Some of these factors include:

  • Individual anatomical differences (wrist space, nerve length, a cervical rib etc)
  • Lifestyle and occupational activities (assembly line workers tend to have a higher incidence of carpal tunnel syndrome than other occupations – NINDS)
  • Pregnancy – pregnant women have a higher incidence
  • Health status – diabetes, hypothyroidism and obesity are known risk factors (Frontiers)

To diagnose carpal tunnel syndrome a clinical examination is sufficient, though in more severe cases, nerve conduction tests are recommended.

When you consider that any combination of factors can be present, an individualised approach to management becomes critical.

General Recommendations

The general medical recommendations (1, 4, 5) to treat carpal tunnel are (in order):

  • Rest. Rest is important, but it is often futile if there are other issues involved, because as soon as you stop resting, symptoms flare up again.
  • Splinting, particularly at night. Splinting can be useful, but again, it isn’t because of a “lack of splinting” that you develop the condition in the first place. This means, that without addressing the other factors, splinting is just another form of rest, and symptoms will likely return once splinting has stopped.
  • Physiotherapy. Hand, wrist and arm exercises can be useful in helping reduce symptoms and address causative factors. Exercises targeted at mobilising the nervous tissue, can be particularly helpful here. Whilst different professions, osteopaths can do most of what physiotherapists can do and vice versa, and what matters most is that the professional in question is up to date in their knowledge and provides an individualised treatment approach.
  • Diuretics to reduce fluid. Diuretics can provide a short term reduction in fluid, but again, we need to work out why the fluid was accumulating in the first place. If, for example, there is lymphatic congestion, the diuretics will only have a short term effect, often with the risk of side effects. Another common cause of congestion is hypothyroidism, which needs to be medicated properly, so identifying the cause of the congestion is as important as reducing the fluid with diuretics.
  • Cortisone. Cortisone can reduce inflammation locally, with the potential risk of nerve injury resulting in worse pain. The benefits do not outweigh the risks, in my opinion, considering the alternatives available. If you do decide to have a cortisone injection, it’s best to have it performed by a surgeon who performs it often, as their skills will be higher, reducing the risk of adverse effects.
  • Surgery. Surgery is indicated in severe cases, but is not always successful (like any treatment). It has the risk of nerve and/or artery damage, with the benefit of increasing the space under the transverse carpal ligament, which is often a cause of symptoms. The success rate of surgery for carpal tunnel is generally higher at 12 months than conservative approaches, when considering nerve conduction studies, but due to the risks involved, the recommendation is to initially treat conservatively, and only explore surgery if there is not the desired improvement.

(My) Osteopathic Approach

To understand my osteopathic approach to treating carpal tunnel syndrome (and any condition really), you have to have a grasp of complex systems and emergent properties.

Put as simply as possible:

This means that something like pain, or symptoms arising from the nervous system are not predictable based on statistical or experiential averages, and any linear causality we deduce, is false logic.

So, when it comes to treatment, we have to have an understanding of normal physiology, then use our clinical skills to find the “abnormal” or “dysfunctional” or “disturbances to normal”.

We can then apply an intervention that results in a change (remember, this change is unpredictable), monitor the change (see if the abnormal has become normal) and then reevaluate the approach.

In essence, it is a trial and error approach, but an educated one.

Measure Twice, Don’t Cut

It’s important to measure the effects of treatments somehow, but, this can be hard, because clinical findings vary for the same condition, and the same clinical findings will not always result in symptoms, even in the same patient.

Because of this difficulty in measuring clinical findings and symptoms, I try to use objective outcome measures. These are simple, validated (by research) questionnaires, like the Boston Carpal Tunnel Syndrome Questionnaire, which provide a measure of the disability associated with a certain condition; and they can be very helpful to use at the beginning, mid-point and end of treatment process to gauge efficacy.

As mentioned earlier, nerve conduction tests are valuable in certain cases, but are invasive and costly from an economic point of view, so they are not always practical.

Treat The Whole, Not The Cause

As I described in Osteopathy For Low Back Pain, there are general, or systemic effects from osteopathic treatment, as well as local.

When treating a person with carpal tunnel syndrome, as opposed to treating carpal tunnel syndrome as a condition, these general effects can be important in improving overall sense of wellbeing as well as positively affecting the body’s physiological functioning.

Sense of wellbeing is often overlooked in outcomes based medicine, but, with outcomes being equal, the process that produces a more pleasant/less unpleasant experience for the patient is superior.

nerves_of_the_left_upper_extremityIn addition to the general aspects of an osteopathic manual treatment, with carpal tunnel syndrome, a focus on the structures related to the median nerve starting from it’s origin in the brachial plexus as it arises from the C5-T1 nerve roots, all the way to it’s end point in the hand.

It is surprising how many people I see who have consulted with their GP and perhaps a rehabilitation professional (occupational therapist, physiotherapist, hand therapist) who have only had interventions directed at the wrist and hand.

Simple anatomy suggests that this will not be adequate.

Given the nature of nerves, symptoms will appear distal to (below) any site of adverse tension/compression. Considering the hand is the site of carpal tunnel syndrome symptoms, my preference is to work up from the hand and wrist towards the neck and thorax.

Common areas of dysfunction include:

  • Transverse carpal ligament (this is what surgeons cut)
  • Carpal (wrist) bones
  • Radius and ulna (forearm bones and their joints)
  • Interosseus membrane of forearm (connection between radius and ulna)
  • Elbow flexor muscles and associated connective tissues
  • Pectoralis minor
  • Upper ribs (especially the 1st rib) and clavicle
  • Scalenes (and other neck muscles)
  • Cervical spine (neck) and thoracic spine and rib cage

Unless all these areas are considered and any dysfunction addressed, I wouldn’t consider the examination process thorough enough.

Neurodynamics must be considered

One of the issues with traditional approach to carpal tunnel syndrome, is that the median nerve itself is not considered as a primary cause of the symptoms, but rather a secondary “victim” to other changes.

Neurodynamics considers 3 aspects (Shacklock):

  1. The mechanical interface of the nerve and body tissue (joint, ligament, muscle etc)
  2. The neural tissue itself
  3. The innervated tissues

Abnormal changes at any of these aspects can alter neurodynamics (the function of nerves), leading to symptoms.

Techniques Are Secondary

Lot’s of people want to know what technique will work best, whether it is a manual technique delivered by an osteopath, or an exercise to self manage. The technique doesn’t matter as much as the reasoning behind the technique and how the technique is executed.

So if someone reasons that muscular tension in the neck muscles is affecting the median nerve, a range of techniques to reduce said tension will be helpful. These can be active or passive and are guided by patient and practitioner experience and preference, as well as a risk to benefit analysis (when known).

This technique needs to be delivered or performed in a mindful manner, with attention being paid to the experience of the technique, as well as the response, by all parties involved (patient and practitioner).

By engaging patients in the process, the treatment automatically becomes more “active”, which we know produces superior results to passive treatments in the long term (BMP).

Conclusions: Putting It Altogether

 

Carpal tunnel syndrome has two components – the symptoms experienced (pain, numbness and tingling etc) and the reduced nerve conduction, which is not always perceptible.

Osteopaths have a role to play in reducing the symptoms (6), and research performed on other manual therapies supports this (7).

However, it must be considered that there is no set formula for a condition like carpal tunnel syndrome, and that each person will have their own “physical story” explaining their condition, and it is this story that a practitioner must somehow read, understand and interact with.

So when you are seeking treatment for carpal tunnel syndrome, you want to find a practitioner who considers everything, not just what is happening at the wrist, not just what is happening “in your body”, but everything.

It sounds cliche, but that is what a truly holistic approach entails.

 

Nick Efthimiou Osteopath

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

 



 

 

References

(1) Primary Care Management of Carpal Tunnel Syndrome

(2) Better Health Channel – Carpal Tunnel Syndrome

(3) Carpal Tunnel Syndrome – Primary Care and Occupational Factors

(4) Conservative Interventions for Carpal Tunnel Syndrome

(5) Is surgical intervention more effective than non-surgical treatment for carpal tunnel syndrome: a systematic review

(6) Effectiveness of Osteopathic Manipulative Treatment for Carpal Tunnel Syndrome: A Pilot Project

(7) A Pilot Study Comparing Two Manual Therapy Interventions for Carpal Tunnel Syndrome

(8) Median Nerve Image

Does Sitting Cause Low Back Pain?

Sitting And Low Back Pain

Sitting is the new smoking. – everyone

You’ve heard it. You’ve read it. Somewhere in your brain is the meme that sitting is the new smoking.

Yes, sitting for long periods without moving is unhealthy, mostly from a metabolic point of view, but does sitting cause low back pain?

In reality, like all things related to pain, it’s complex, and as a result, the research seems to be mixed, which is a far cry from what you’ll read in most health articles posted online, in newspapers and magazines.

What Does The Popular Media Say?

It’s really common for articles in the popular media, both online and offline, to say that sitting causes low back pain. (1,2)

Most say that the incidence of low back pain has increased because of increased sitting time or via mal-adaptive processes (like muscle shortening) as a consequence of sitting.

You will read about how sitting shortens hip flexors and hamstrings, about how sitting compresses the spine and the discs and about how sitting weakens “the core”.

Because these mechanisms sound plausible, and because they are repeated so often, they are gradually accepted as fact, without much further questioning.

Unfortunately, what makes sense in theory doesn’t always pan out to work in the real world, which is why we use the scientific method to try and determine cause and effect.

This is important for two reasons:

  1. If we determine that sitting causes or doesn’t cause low back pain, then we can act on this information accordingly.
  2. If we determine a causal relationship between sitting and low back pain, we can then look at why this might be happening, in order to better treat it.

What Does The Research Say?

When we look at the research around sitting and low back pain, the results are mixed.

One study (3) took a group in 1993 and followed up at 5 year intervals until 2012. They looked at mental health, metabolic health and musculoskeletal health. They found no association with occupational sitting and low back pain.

Another study (4) I looked at objectively measured sitting time as a risk factor for low back pain. This is important, because most studies rely on self-reported data, which is typically inaccurate. The authors found that total sitting time (most studies just measure occupational sitting time) was associated with low back pain intensity, when other factors were controlled for. This means that the more these people sat, the more intense low back pain they experienced.

The third study (5) I looked at wasn’t a study, it was a review. A review is when researchers look at all the studies on a certain topic that meet certain criteria, and then compile their results.

Aside: a meta-review is when researchers review all the reviews on a topic to get an idea of what “works”. This is regarded as the best form of research evidence, because it is more robust and has more statistical power (is more likely to be correct).

In this review the authors reached the following conclusions:

Although occupational physical activities are suspected of causing LBP, findings from the eight SR reports did not support this hypothesis. This may be related to insufficient or poor quality scientific literature, as well as the difficulty of establishing causation of LBP. These population-level findings do not preclude the possibility that individuals may attribute their LBP to specific occupational physical activities.

So as you can see, from my small sample, one showed a link, another showed no link and the review found no link, but also acknowledged potential issues as to why this is so.

So, Does Sitting Cause Low Back Pain?

As you can see, the results were not conclusive. Even if increased sitting time is associated with low back pain, it doesn’t mean it causes low back pain.

This is because, pain is emergent, not dependent.

An emergent property is a property which a collection or complex system has, but which the individual members do not have. A failure to realize that a property is emergent, or supervenient, leads to the fallacy of division.

What this means, is that pain arises based on many factors, that are unpredictable, so to try and isolate one variable, like sitting, as the cause, is impossible.

No one thing causes pain.

A “More” Plausible Explanation?

If we look at why somebody might experience pain after sitting, we have to ask:

Was it the sitting, or something the sitting did?

Do people who experience low back pain from sitting also experience low back pain from other activities?

What about positions that replicate sitting, but aren’t sitting?

If they do, then what do these activities have in common?

Finally, is there ways they can sit that don’t cause them pain?

Most of the time, we will find that sitting is not the sole cause of low back pain, and when it is apparently so, it’s likely that there are still other factors at play.

One way to explain why we get pain in certain positions, is to understand the sensitivity of peripheral nerves.

When we occupy any position, particularly when pressure on the body is involved (sitting, lying etc), there is a compression of body tissues taking place, including the peripheral nerves.

When we apply pressure to peripheral nerves, they deform.

This deformation causes altered neural blood flow – rabbit models show a reduction of up to 70% of their blood flow when a strain of only 8.8% is applied.(6)

This could feasibly be a driver of nociception (bearing in mind that pain is produced by the brain, there are no “pain signals”) which could result in a pain experience.

So instead of thinking that sitting causes low back pain, it is probably better to look at the function of your body as to why you don’t have the capacity to sit for extended periods, and address those issues.

Conclusions

Just because sitting doesn’t necessarily cause low back pain, doesn’t make it harmless. Sitting has many pronounced negative effects on our metabolic functions, and movement has many pronounced benefits, including reduced incidences of pain (7).

Additionally, if you understand that no one thing causes pain, you will be in a much better position to deal with pain when it happens.

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 



 

References

(1) Heal your lower back pain with these 5 yoga poses

(2) Proper sitting

(3) Occupation sitting and cardiometabolic, mental and musculoskeletal health

(4) Sitting time (measured) and low back pain

(5) Occupational physical activity and low back pain

(6) Structure and biomechanics of nerves

(7) Physical activity and chronic pain (in mice)