CARPAL TUNNEL Syndrome

Chances are your checker at the grocery wears a big, clunky wrist splint. If her arm is entombed in a Velcro-fastened binding extending from fingers to elbow, she's got carpal tunnel syndrome. Not exactly a velvet evening glove, but these wrist wraps are the fashion statement of the twenty first century.

Carpal tunnel syndrome (CTS) is a common disabling condition. Most often associated with computer use, it can strike just about anyone who performs repetitive hand motions. CTS afflicts women more often than men. Pregnancy, rheumatoid arthritis and diabetes are risk factors.

This crippler is caused by compression of the median nerve, a major nerve supplying the arm and hand. On its way through the wrist, the nerve navigates through a passage in the wrist called the carpal tunnel. This nerve generates sensation and movement in the hand.

CTS is the most common type of repetitive stress injury. Continuous, repetitive wrist motion may irritate the ligaments and tendons encased in the tunnel, causing these structures to swell, squeezing the median nerve. Tingling and numbness in the thumb, index finger, middle finger and half of the ring finger ensues. The individual's hand will feel as if it has "gone to sleep." The pain and discomfort of CTS is so severe that it often wakes people in the night. It can even eventually make it hard to grasp small objects.

Eventually, the associated muscles of the hand may begin to atrophy (grow noticeably smaller), particularly the thumb flesh. Without treatment, CTS may eventually manifest as permanent weakness, loss of sensation, or even thumb and finger paralysis.

CTS is a signal that your body is experiencing more strain than it was designed to handle. Activities that cause a person to repeatedly bend the wrist inward toward the forearm can increase the risk of CTS. Jobs that call for repeated strong wrist motions carry a comparatively high risk of CTS. Repetitive motion injuries are more frequent among office workers who do a lot of typing, those working at computers (keyboard and mouse) or cash registers, factory machine operators, and various musicians.

Job injuries from repetitive stress, heavy lifting and related conditions befall about 1 million workers each year and cost the nation $54 billion, according to a National Academy of Sciences report, Musculoskeletal Disorders and the Workplace: Low Back and Upper Extremities, presented to Congress in January of 2001.[ 1]

CTS is a noteworthy cause of missed workdays due to pain, causing an estimated 460,000 employee work-related injuries a year.[ 2] Since most occurrences of CTS are job related, paying attention to proper ergonomics is essential (-perhaps repositioning the computer keyboard or taking more breaks).

The first step in conventional CTS treatment is splints, which support the wrist and prevent it from flexing inward, exaggerating nerve compression. Some people wear such splints at night, while others need to wear the splints all day, especially while working.

Nonsteroidal anti-inflammatory drugs are used to decrease pain and swelling. In advanced CTS, steroids are injected into the wrist. The most serious cases of CTS may require surgery, cutting the ligament that crosses the wrist, to decrease the nerve compression. If surgery becomes necessary, physiotherapy is essential for speeding recovery. In one setting, a policy of initiating physical therapy the day after surgery reduced sick leave costs by 58 percent. A medical group investigation found that each single session of hand therapy cost $45, but reduced lost work time by 8.6 days.[ 3]

More than two decades ago, investigators noticed that people with CTS seemed to be deficient in vitamin B6, leading to pervasive use of B6 as a CTS remedy. Some more recent studies have affirmed this connection.[ 4] But another extensive study from 1997 suggests that CTS among active industrial workers is unrelated to vitamin B6 status.[ 5]

While many studies have been performed on this treatment, experts disagree on the effectiveness. In a 12-year study conducted in Louisville, Kentucky, Morton Kasdan, M.D., found that 68 percent of his 494 carpal tunnel syndrome patients improved while taking daily B6.[ 6]

B6 does seem to lower pain level.[ 7] In a 1993 experiment, pain scores reduced. That study suggests that vitamin B6 deficiency may not be a cause of carpal tunnel syndrome, in spite of the observed therapeutic effect.[ 8] A typical recommended dose of vitamin B6 for CTS is 200 mg twice daily.

Researchers determined that CTS could improve with osteopathic manipulation and weight loading.[ 9] This combination gave additional benefit because both treatments lengthen the ligament. A stretching exercise for self-manipulation of the ligament can also help.

A National Institute of Health (NIH) panel reported that traditional acupuncture might be a useful treatment for carpal tunnel syndrome.[ 10] Studies have shown that both laser acupuncture and microamp transcutaneous electrical nerve stimulation (TENS) can greatly reduce the pain associated with carpal tunnel syndrome. In one investigation, which also included Chinese herbal medicines, deep acupuncture (including needles), moxibustion, and omega-3 fish oil capsules, more than 90% of the subjects reported no pain or pain that had been reduced by more than half. All patients were able to return to work and most patients remained stable for up to two years.[ 11]

Yoga has shown benefit for CTS in several studies.[ 12] In one preliminary study, published in the Journal of the American Medial Association in 1998, a yoga-based regimen was more successful than wrist splinting in relieving some symptoms and signs of carpal tunnel syndrome.[ 13]

Willow bark (Salix alba and other species)
Willow is the main traditional pain reliever of European herbalism. It contains salicin and other related compounds (salicylates), which are the herbal predecessors of aspirin.[ 14] Plant salicylates relieve pain, reduce fever and curb inflammation. The American Herbal Pharmacopoeia says, "in modern herbal therapy, willow is predominantly used as an anti-inflammatory for symptomatic relief of gouty arthritis and as an analgesic for mild neuralgic pains, toothaches and headaches."[ 15]

An Israeli blinded study from 2000 substantiated this benefit. The 191 pain sufferers took a willow extract, standardized to contain either 120 mg or 240 mg of salicin, per day. The herb turned out to be a great deal more effective than a placebo in this trial, with the higher dose being considerably more effective. In the high-dose group, the response was apparent after only 1 week of treatment.[ 16]

Use a tea brewed from up to 1 oz., dry weight, of the raw herb, per day, or an extract containing 240 mg total salicin per day. Use willow for as long as necessary.

Saint Johnswort flowering tops (Hypericum perforatum)
These days, Saint Johnswort flowers are frequently used for mild to moderate depression. It is an ancient medicine, though, and has been used for hundreds of years in Europe. European and North American herbalists use the herb to treat mild painful conditions including arthritis and muscle inflammation.[ 17] St. Johnswort helps nerves recover when they are damaged, inflamed or strained, says Jill Stansbury, N.D., of National College of Naturopathic Medicine. The relaxing herb is used to heal nerve pain and tingling, she says.[ 18]

The usual dose is 2-5 g of raw herb, 10-15 ml of tincture, or 900 mg of standardized extract (0.3% hypericin), per day.

Turmeric root (Curcuma longa)
Turmeric, which we know as a curry spice, is a mainstay in Ayurvedic herbal medicine, where it is widely used to benefit the musculoskeletal system.

Curcumin, the pigment that gives this herb its characteristic yellow color, is an anti-inflammatory agent comparable to cortisone and phenylbutazone,[ 19][ 20][ 21] the standard anti-inflammatory drugs. Curcumin is nonsteroidal, so it has none of the destructive side effects of steroid anti-inflammatories.[ 22]

Curcumin also treats pain directly. Like cayenne, it depletes substance P, the pain receptor neurotransmitter, in the nerve endings.[ 23] Research shows that curcumin and related compounds suppress pain through a mechanism similar to many drugs (COX-I and COX-II enzymes).[ 24]

Turmeric is a mild herb. For acute wrist inflammation, the dose can be as high as one ounce (4 Tbs.) per day. Stir the powder into water and swallow, or make it into a paste with honey or a bite of oatmeal.

For continuing health benefit, use 1 gram per day as a spice, or in capsules. Standardized extract is available. The dose is 1500 mg of total curcumin content per day.

Pineapple fruit contains a proteolytic (protein-dissolving) enzyme, bromelain, which is often recommended for CTS. As a supplement, bromelain is usually derived from the stem of the plant, and is a mixture of several proteases that enhance muscle relaxation, inhibition of blood platelet aggregation and improved wound healing.[ 25]

Naturopathic physicians suggest taking 250 to 1,500 milligrams of pure bromelain a day, between meals, to treat inflammatory conditions such as CTS. Of course, you can use the fruit liberally in your diet.

Topical Treatment
According to traditional herbalists, applying comfrey externally can relieve pain, swelling and inflammation. Use a poultice or commercially prepared cream.

In my personal experience, ginger works well. Slice the fresh roots lengthwise in thin, flat strips. Wrap the wrist with the strips, cover with a bandage and leave overnight. Norma Pasekoff Weinberg, in Natural and Herbal Remedies for Carpal Tunnel Syndrome (Storey Books, Pownal Vermont, 2000), recommends a compress made from cooked, fresh grated ginger.

Europeans know Saint Johnswort as an external remedy, which is where it really excels. Yellow Saint Johnswort flowers contain red pigments, so the oil is a beautiful deep red. Prepared as an oily preparation, such as an ointment, it is one of the most popular European remedies for muscle pain, confirmed by Commission E.[ 26] Weinberg also extols the virtues of the oil in her book.

With our world become ever more dependent on the computer, we are going to see nothing but more CTS. If you're one of the unlucky victims, perhaps natural medicine is for you.

Avoid carpal tunnel
The American College of Occupational and Environmental Medicine offers the following ergonomic tips:[ 27]

Provide job rotation and rest breaks.
Monitor line speed and machine use.
Develop an ergonomics committee to review workstation design, perform job cycle analysis and measure outcomes.
Design workstations to minimize reaching, properly support the back, upper and lower extremities and provide adjustable height, space and seating.
Engineer pneumatic hand tools to reduce vibration.

Provide mechanical lifting support.
Provide ergonomically correct tools to keep wrist in neutral/straight position and minimize vibration, pinch grip, torque and forceful hand exertion.
1 Sherman, Neil, Report: Workplace Injuries Can Be Cut http://www.healthscout.com/cgibin/WebObjects/Af.woa/wa/article?ap=1%26 ;id=107458

2 Weinstein, Bob, Ouch! Ergonomic Rules Hurt, Fortune Small Business, http://www.fsb.com/fortunesb/articles/0%2C2227%2C1153%2C00.html

3 Anderson, David RSI can strain the bottom line. Business & Health Jan, 1998 http://www.findarticles.com/cf0/m0903/n1v16/20435085/print.jhtml

4 Keniston RC, Nathan PA, Leklem JE, Lockwood RS. Vitamin B6, vitamin C, and carpal tunnel syndrome. A cross-sectional study of 441 adults. J Occup Environ Med 1997 Oct;39(10): 949-59 Comment in: J Occup Environ Med. 1998 Apr; 40 (4):305-9

5 Franzblau A, Rock CL, Werner RA, Albers JW, Kelly MP, Johnston EC. The relationship of vitamin B6 status to median nerve function and carpal tunnel syndrome among active industrial workers. J Occup Environ Med 1996 May;38(5):485-91 Comment in: J Occup Environ Med. 1996 Oct;38(10):959-60; discussion 960-1, J Occup Environ Med. 1996 Oct;38(10):959; discussion 960-1

6 Kasdan ML, Janes C. Carpal tunnel syndrome and vitamin B6. Plast Reconstr Surg 1987 Mar;79(3):456-62

7 Feuerstein M, Burrell LM, Miller VI, Lincoln A, Huang GD, Berger R. Clinical management of carpa tunnel syndrome: a 12-year review of outcomes. Am J Ind Med 1999 Mar;35(3): 232-45 Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.

8 Bernstein AL, Dinesen JS. Brief communication: effect of pharmacologic doses of vitamin B6 on carpal tunnel syndrome, electroencephalographic results, and pain. J Am Coll Nutr 1993 Feb;12(1):73-6 Department of Neurology, Kaiser Permanente Medical Center, Hayward, CA 94545.

9 Sucher BM, Hinrichs RN. Manipulative treatment of carpal tunnel syndrome: biomechanical and osteopathic intervention to increase the length of the transverse carpal ligament. J Am Osteopath Assoc 1998 Dec; 98(12):679-86 Comment in: J Am Osteopath Assoc. 1998 Dec;98(12):662

10 Acupuncture. NIH Consens Statement 1997 Nov 3-5;15(5):1-34

11 Branco K, Naeser MA. Carpal tunnel syndrome: clinical outcome after low-level laser acupuncture, microamps transcutaneous electrical nerve stimulation, and other alternative therapies — an open protocol study. J Altern Complement Med 1999 Feb;5(1):5-26 Acupuncture Healthcare Services, Westport, Massachusetts, USA.

12 Garfinkel M, Schumacher HR Jr. Yoga. Rheum Dis Clin North Am 2000 Feb;26(1):125-32, xBKS Iyengar Yoga Studio of Philadelphia, Pennsylvania, USA.

13 Garfinkel MS, Singhal A, Katz WA, Allan DA, Reshetar R, Schumacher HR Jr. Yoga-based intervention for carpal tunnel syndrome: a randomized trial. JAMA 1998 Nov 11; 280 (18): 1601-3Comment in: JAMA 1999 Jun 9;281(22):2087; discussion 2088-9

14 Willow Bark Monograph, European Scientific Cooperative on Phytotherapy Monographs, Exeter, UK, 1997

15 Willow Bark Monograph, American Herbal Pharmacopoeia, Santa Cruz, California, 1999.

16 Chrubasik S, Eisenberg E, Balan E, Weinberger T, Luzzati R, Conradt C Treatment of low back pain exacerbations with willow bark extract: a randomized double-blind study. Am J Med 2000 Jul;109(1):9-14

17 Mills, Simon, and Bone, Kerry, Principles and Practice of Phytotherapy, Churchill Livingstone, London, 2000

18 Carpal Tunnel Syndrome http://www.mothernature.com/library/books/natmed/carpal%5ftunnel%5f syndrome.asp

19 Srimal RC, Dhawan BN Pharmacology of diferuloyl methane (curcumin), a non-steroidal anti-inflammatory agent. J Pharm Pharmacol 1973 Jun;25(6):447-52

20 Mukhopadhyay A, Basu N, Ghatak N, Gujral PK Antiinflammatory and irritant activities of curcumin analogues in rats. Agents Actions 1982 Oct;12(4):508-15

21 Ghatak N, Basu N Sodium curcuminate as an effective antiinflammatory agent. Indian J Exp Biol 1972 May;10(3):235-6

22 Murray, Michael, and Pizzorno, Joseph, Encyclopedia of Natural Medicine, Prima, Rocklin, California, 1998.

23 Patacchini R, Maggi CA, Meli A Capsaicin-like activity of some natural pungent substances on peripheral endings of visceral primary afferents. Naunyn Schmiedebergs Arch Pharmacol 1990 Jul;342(1):72-7

24 Ramsewak RS, DeWitt DL, Nair MG Cytotoxicity, antioxidant and anti-inflammatory activities of curcumins I-III from Curcuma longa. Phytomedicine 2000 Jul;7(4):303-8

25 Metzig C, Grabowska E, Eckert K, Rehse K, Maurer HR. Bromelain proteases reduce human platelet aggregation in vitro, adhesion to bovine endothelial cells and thrombus formation in rat vessels in vivo. In Vivo 1999 Jan-Feb;13(1):7-12

26 Blumenthal, Mark, The Complete Commission E Monographs, The American Botanical Council, Austin, Texas, 1998

27 http://www.acoem.org/wood spring 2004

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By Karta Purkh Singh Khalsa, C.D.-N., A.H.G.

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