International Forum on New
Science, Fort Collins, Colorado USA, September 13-17, 1995
A NONSURGICAL APPROACH TO
CARPAL TUNNEL SYNDROME
The widespread use of computers
and the evolution of technology have caused carpal tunnel
syndrome and other repetitive strain injuries (RSI’s) to
become the affliction of the 90’s - and possibly the next
century. Carpal tunnel syndrome has even been called the
"technological disease" of the ‘90’s.
However, carpal tunnel syndrome is not a disease - it is a
musculoskeletal disorder brought on by overworked muscles.
RSI’s are already at epidemic stages, with more and more
people diagnosed every month. The terms carpal tunnel syndrome,
cumulative trauma disorders, ergonomic disorders, repetitive
strain injuries and repetitive motion injuries all refer to the
same disorder of the wrist and hand. They are use interchangeably
throughout the article depending on the source of the
information.
In 1990, repetitive strain
injuries were beginning to be recognized as an injury due to the
increased use of computers. As a sports massage therapist, many
of my clients had occupations and performed in sports that
required them to repeat movements repetitively. I was already
teaching a self-care program to my clients and decided to publish
this method in a book titled, Carpal Tunnel Syndrome, Prevention
and Treatment, A Non Surgical Approach to set the record straight
about this disorder. The following article and case studies are
my clinical findings and experience working one on one with
varies individuals, and varied occupations.
CONSIDER THESE STATISTICS:
*Repetitive strain injuries rose
from zero cases in 1982 to 300,000 cases in 1994. Bureau of Labor
Statistics. Published in Time Magazine, June 26, 1995 issue.
*In 1992, ergonomic disorders
accounted for 56% of the illnesses reported to the Occupational
Safety and Health Administration (OSHA). This is double 1984
levels.
*OSHA estimates that by the year
2000, cumulative trauma disorders will account for 50 cents of
each dollar employers spend on medical care. *A study by the
Labor Department said 3.2 million cases of repetitive motion
injuries in 1989 were serious enough to take time away from jobs,
adding up to 57 million lost workdays.
*In 1992, the Bureau of Labor
Statistics recorded 280,00 cases out of 1 million injuries were
CTD’s of the upper extremities, wrists, shoulders and
elbows.
*The American Academy of
Orthopedic Surgeons estimates cumulative trauma disorders (CTD)
cost $27 billion annually in medical treatment and lost income.
*Each worker compensation claim
for repetitive stress injuries can cost up to $20,000 - $100,000.
Consumer Watch Report, PC World, May 1993.
*Additional cost factors: A
surgery for carpal tunnel syndrome with all the factors involved
can run anywhere from $20,000 to $100,000.
*The use of alternative therapies;
chiropractic, massage therapy and acupuncture will run
approximately $6,000.00 a year for preventative maintenance
therapies. Based on a survey of Chiropractic, massage therapy,
and Acupuncture costs around the country: Average visit: $50.00.
1993 by Sports Touch® International.
This is a world wide epidemic.
People involved in all types of occupations - fisherman, farmers,
spinners, carpenters, mechanics, glass blowers, grocery clerks,
bakers, dispatchers, needlepoint, cyclists, students, meat
cutters, chefs, secretaries, homemakers, massage therapists,
court reporters, musicians and medical transcriptionists, among
many others - experience repetitive stress injuries such as
carpal tunnel syndrome. Why? Because they use the muscles of
their arms and hands.
The solution to carpal tunnel
syndrome need not be limited to expensive, sophisticated surgical
techniques; rather, a solution can be found in body maintenance.
Simple massage therapy in combination with structural realignment
and self-care techniques can be an answer to alleviating the pain
and distress already being suffered by thousands. Along with
regular strengthening and stretching exercises and a sound
nutritional program, the body can remain productive and useful
for a long time.
Carpal tunnel treatment has become
the surgery of the decade, despite its expense and the lack of a
guarantee of post-surgical improvement. In fact, according to Dr.
Fred Meyer, MD, orthopedic surgeon with Hand Surgery Associates
in Phoenix, Arizona, who was quoted in a January 1994 DataHand®
press release, "the surgical success rate for CTS is only
54-56 percent, and additional surgeries are required in about 10
percent of the cases." And according to some reports the
procedure results in, at best, a minimum of a two-to
six-months’ loss of use of the hand(s) involved.
Surgical procedures include the
possibilities of cutting the volar carpal ligament and flexor
retinaculum, (which takes pressure off the median nerve at the
wrist), laser surgery, cutting the supinator or pronator muscles
at the elbow joint, and possible shoulder surgery if the pain
keeps moving upward. The surgery is suppose to alleviate the
pressure on the nerve; however, for many these surgical
techniques are only a temporary fix . The physician may be
treating the symptoms, but not the cause.
Carpal tunnel syndrome is an
entrapment and compression of the median nerve due to structural
and postural misalignment. It is brought on by the over-worked,
over-strained muscles of the arms and hands, resulting in a loss
of nerve conductivity and possibly leading to a muscle strength
problem. Persons who perform continuous repetitive movements are
at high risk to develop carpal tunnel syndrome.
A median nerve entrapment can
develop anywhere along the vertebral joints in the neck through
the shoulder joint, descending to the elbow and ending, finally,
with distortion and pain in the wrist and hand.
Using assessment techniques such
as applied kinesiology or muscle monitoring, the evaluation of
how the nervous system controls muscle function; a dynamometer,
which quantifies and measures grip strength; the Tinel's test, by
manually tapping the volar ligament over the median nerve to
elicit a pain response; and Phalen's test, which is extreme hyper
extension and hyper flexion of the wrist joint. I discovered that
the vast majority of my clients over the past year and a half,
had diffident symptoms of repetitive strain injury and had been
diagnosed with carpal tunnel syndrome. Most had tendinitis at the
wrist and elbow, and nerve entrapment through the medial side of
the elbow joint where the pronator teres originates, running
downward to the wrist. Anyone who has had a whiplash and has not
received proper care could be a candidate for recurring symptoms.
These individuals were from varied backgrounds, represented a
wide range of occupations, and lifestyles, ages, and participated
in many different types of sports. What they all had in common,
however, was use of their hands and muscle weakness.
THE CAUSE OF CARPAL TUNNEL
SYNDROME
The primary cause of carpal tunnel
syndrome is the biomechanical problem of structural and muscular
failure that leads to a decrease in nerve transmission to the
hand. The body is not a robot. Consistent repetitive movements
will cause mechanical exhaustion of the body’s muscles, the
consequence being loss of muscle strength.
Constant repetition of a specific
motion, whether it be micro- movements - such as using a
keyboard, isometric contractions - holding a pencil too tight or
playing a musical instrument, among other activities, can cause
the muscles of the forearm to become tight, sore, and fatigued.
Trigger points, hyper-sensitive areas in a muscle that are tender
to the touch and have a specified referral area of pain, will
activate and set off a pain-spasm cycle when muscles start to
tire from physical overuse and abuse. When this occurs, the
tightness of the tendons and muscles increases stress on the
elbow joint when it is held in one position, such as gripping a
knife to chop vegetables; when there is direct weight on the
joint, such as holding a child; or when constant repetitive
motion is maintained for many hours, such as typing for several
hours.
When the forearm muscles become
tight, the tendons begin to pull on the elbow joint. This
increased pressure of the tendons on the elbow joint causes a
misalignment of the elbow joint, which in turn moves apart the
radius and ulna bones at the wrist joint. The transverse carpal
ligament becomes stretched, thus applying pressure on the median
nerve. The results are a decrease in nerve transmission and a
weakening of the muscles in the hands.
The most vulnerable joint in the
pathway of the median nerve is the elbow joint. It is the most
difficult to protect and the most often ignored. This joint is
responsible for supination and pronation, along with flexion and
extension. Any direct stress applied to the muscles that surround
the elbow joint (biceps, triceps, supinator, pronator teres,
pronator quadratus, brachioradialis, brachialis, flexors and
extensors of the forearm) can eventually cause carpal tunnel
syndrome along with radial tunnel syndrome, distal ulnar
neuropathy, pronator syndrome, and cubital tunnel syndrome.
Incorrect posture plays a pivotal
role in maintaining nerve integrity. Postures such as habitual
forward and backward neck bending, that cause continual
irritation of the nerve roots in the cervical vertebrae, can
cause pain in the neck, shoulders, arms and hands, and can lead
to cervical radialopathy and thoracic outlet syndrome with
symptoms of tendinitis, numbness and tingling in the hand. A
necessary part of proper body mechanics is the installation of
correct ergonomic equipment to support the body’s frame.
Recognizing there are three
factors for a solution to this disorder is necessary. They are:
1). Safe ergonomic equipment at the workstation or worksite, 2).
Learning correct body mechanics and posture as the body
interfaces with the equipment, and 3). Body maintenance - regular
preventive therapy to ensure the body’s structural
foundation and muscles are aligned, free of tension and pain All
three in combination can help prevent repetitive strain injuries.
DETECTING STRUCTURAL AND
MUSCULAR IMBALANCE
A method of evaluating nerve
integrity is a system called Applied kinesiology, which is used
by chiropractors and health kinesiologists to evaluate
structural, muscular, chemical and mental aspects of the body. It
employs muscle testing with other standard methods of diagnosis,
including nutrition, manipulation, acupressure, exercise and
education, to restore balance and maintain well being throughout
life. When used on a regular basis, this method of assessment can
prevent injury and deterioration of the body. It is a unique tool
used in the healing arts to accentuate healing and recovery.
In my practice I use muscle
monitoring techniques along with a dynamometer, a mechanical
device to quantify and measure grip strength, the Tinel's test,
manually tapping the volar ligament over the median nerve to
elicit a pain response, Phalen's test, extreme hyper extension and
hyper flexion of the wrist joint for a pain response or changes
in sensation, range of motion of the arms, wrists and fingers,
palpation of the soft tissue, along with other neurological
tests. These are quantitative tests. I use a subjective test, the
fist squeeze, to allow the individual to determine there own grip
strength. This in turn will allow them to feel the subtle changes
in their body as they perform corrective techniques. The
assessments will determine if there is structural misalignment,
bilateral muscle weakness and loss of nerve conductivity.
Symptoms of carpal
tunnel syndrome
- Increased occurrence of
dropping objects.
- Loss of the sense of
touch.
- Tingling and numbness in
the fingers and hand.
- Loss of grip strength in
the hand.
- Pain in the shoulder
while sleeping.
- Pain in the elbow area.
- Pain in the wrist area.
- Burning in the wrist
area.
- Tendinitis in the
elbow/wrist joint.
Symptoms such as those listed
above are cumulative. They did not develop over night. The body
is not a ROBOT. No two secretaries performing the same job will
develop symptoms at the same rate or at all.
As with any medical condition,
anyone who believes they suffer from carpal tunnel syndrome
should, consult with their physician. In addition, they should
have as much information from as many sources as possible.
SELF-EXAMINATION
Using applied kinesiology and with
a partner, muscle test the strength of the muscles of the thumb
and little finger. This determines grip and structural alignment.
This test is done at the lower
joint where the fingers attach to the hand:
Thumb: metacarpal attaches to the
trapezium; the little finger:
metacarpal attaches to the hamate
bone.
Step 1. Place the pads of your
thumb and little finger together, palm side up, and have a friend
try to pull the thumb and little finger apart. Testee: Hold the
fingers together as tight as you can.
Step 2. Place the pads of your
thumb and little finger together, palm side down, and have a
friend try to pull the thumb and little finger apart. Testee:
Hold the fingers together as tight as you can.
If your fingers move apart easily,
this may be an indication you have a structural misalignment and
a loss of nerve conductivity into the hands for muscle strength.
Once you have determined you have
a loss of grip strength, subjectively assess what you feel is
your grip strength. To do that, squeeze your fists together as
tight as you can. Pick a number between 0-10, 10 being the most
strong, you determine how strong you think you are. Then you can
begin The Montgomery Method of corrective techniques that will
lead to a structural realignment of the elbow and wrist joints
and reinstate nerve conductivity for grip strength.
The development of The Montgomery
Method began in 1992. Repetitive strain of the muscles was a
common occurrence with the athletes I was working with. When
repetitive strain injuries started to surface due to the increase
in computer usage, the statistics for worker compensation claims
also started to climb. No one was prepared for the constant micro
movements required by the forearms flexors and extensors. Even
though these injuries have been mentioned within the meat packing
industry and other trades, it was not until the use of computers
in the advancing technological world started to effect millions
of users. One by one anyone who uses a computer, may be at risk
of developing repetitive strain injury if the proper education
and preventative medical care is not provided.
CLINICAL RESULTS
In a study of 15 men and 32 women,
I was testing the hypothesis that if you taught a specific method
and process of self care techniques, would the results indicate
significant change in grip strength. Each was taught a specific
process of self care called The Montgomery Method.
The Montgomery Method consists
of ten steps to correct the elbow and wrist alignment. They are:
Begin first with the alignment of
the posture. Sit up straight, shoulders back and down. Muscle
test to determine loss of nerve conductivity.
1. Grip Strength Assessment of
the Hand - Perceived.
2. Neck Massage.
3. Forward Arm Extension.
4. Lateral Arm Extension.
5. Wrist Stretching.
6. Wrist Pull.
7. Wrist Squeeze.
8. Finger Pull
9. Shoulder, Chest and Elbow
Stretch
10. Upper Back Stretch.
Repeat #9.
Repeat Muscle test and perceived
grip strength.
I based my findings on three
factors.
1. Perceived grip strength
1-10, ten being the maximum perceived grip.
Pre and post corrections using
The Montgomery Method.
2. Perceived pain level. 1-10,
ten being the maximum pain level perceived.
Pre and post massage.
3. One massage therapy session
directed to the upper body, focusing on the arms. Specific
strokes used were cross fiber, broad cross fiber and flushing
strokes.
STATISTICAL FINDINGS
FOR WOMEN:
Total Massage sessions: =1.81 +
.86
Pre to post pain factor =7.76 + 1
to 4.29 + 1.4 p<0.001
Pre to post grip test R =7.22 +
1.8 to 8.61 + 1.5 p<0.001
Pre to post grip test L =6.83 +
1.9 to 8.20 + 1.5 p<0.001
FOR MEN
Total Massage sessions =1.86 +
.7
Pre to post pain factor =7.45 +
2.2 to 3.55 + 1.7 p<0.001
Pre to post grip test R =6.00 +
2.0 to 7.93 + 1.6 p<0.001
Pre to post grip test L =6.24 +
2.4 to 8.25 + 1.5 p<0.001
These are highly significant at
the alpha level of 0.05 using a "T" test. These changes
achieved by the participants of The Montgomery Method self care
corrections indicate an effective way of dealing with carpal
tunnel syndrome outside of today’s traditional medical
program of rest, drugs and last, surgery, if all else fails.
RECOMMENDATIONS FOR BODY
MAINTENANCE
Even if carpal tunnel syndrome or
any other repetitive strain disorder of the hand, is present, the
solution in most cases, is to care for the muscles and alignment
of the skeletal structure. Following a daily program of body
maintenance, consisting of self-corrective techniques, warm-up
exercises and stretches, self-massage, performed before beginning
the day, during the workday and after work, will help to prevent
repetitive strain of the muscles and avoid structural
misalignments.
The care and maintenance of the
body is the most important thing that can be done to preserve its
function and health. The following is a list of self-care
techniques that can be performed to prevent repetitive strain
injuries:
*The Montgomery Method - An
Twelve Step Self-Corrective Technique.
*Self-massage the forearms and
hands.
*Acupressure for increased energy
to the hands. *Stimulation of neurolymphatic reflex points (The
Chapman Reflexes) to flush the muscles of soreness and pain.
*Stretching and range of motion
exercises for the hands, shoulders and neck.
*Strengthening exercises using one
to two pound weights for the arms and hands. *Receiving
therapeutic massage regularly, concentrating on the upper body
and arms. Once a week is best; however, twice monthly is
adequate. *Chiropractic with applied kinesiology testing or
osteopathic visits as needed, for structural stability and muscle
balance. *Acupuncture to revitalize the body’s vital energy.
In 1992, I started the development
of The Montgomery Method and today it is a twelve step protocol
for the alignment of the elbow and wrist joint. It involves total
self-care along with recommendations for maintenance therapies
needed to help maintain the functional aspect of the body.
Once again, I want to reiterate,
there is NO Cure for carpal tunnel syndrome or any other
repetitive strain injury, Only Body Maintenance. Carpal Tunnel
Syndrome is not a disease. That implies there is a cure or not a
cure. By using alternative therapies, a person can remain
productive in any occupation where it demands more use of the
hands. Our bodies only break down through misuse and abuse. We
expect it to withstand everything we put it through. There are
now over 30 million users on the Internet. A lot of computer users
will need muscle therapy if they are to remain productive and useful. By educating people about alternative therapies it will
eliminate the fear that has been created out of lack of education
regarding repetitive strain injuries.
