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12 Articles in Volume 11, Issue #1
Simultaneous Use of Stimulants 
and Opioids
Therapy for Management of Childbirth Perineal Tears and Post-Partum Pain
Measuring Clinical Outcomes of Chronic Pain Patients
Real-Time Functional Magnetic Resonance Imaging in Pain Management
A Non-Surgical Treatment for Carpal Tunnel Syndrome
Fibromyalgia, Chronic Widespread Pain, and the Fallacy of Pain from Nowhere
Sonoanatomy and Injection Technique of the Iliolumbar Ligament
Back Surgery That Does Not Relieve Pain
The Immune System and Headache
Diversity in Pharmacologic Treatment of Pain
Memantine for Migraine and Tension-Type Headache Prophylaxis
Pain Management in Inflammatory Arthritis

A Non-Surgical Treatment for Carpal Tunnel Syndrome

Stretching the anatomical structures of the hand, over time, may reduce the pain of severe carpal tunnel syndrome and avoid surgery.

Carpal tunnel syndrome (CTS) is one of the most prevalent causes for pain, numbness and weakness of the hand. It is usually treated with rest, anti-inflammatory agents, exercise, corticoid injections, and surgery to relieve ligament pressure. This regimen, however, is not always successful. Described here is a stretching technique and procedure which I invented and believe is a significant advance for treatment of patients who have failed standard measures and desire to avoid surgery.


Epidemiology


This condition is most commonly associated with intensive usage of the hand. 1-3 It occurs as a result of both recreational and work-related activities. Employment that requires repetitive grasping of the hand and involves the thenar and hypothenar muscle groups appears to be a major causative factor in its development. Jobs involving repetitive use of shears, pliers, butchering equipment, screw drivers, etc. have fairly high incidences of CTS. There are causes not associated with overuse, such as some immunologic disorders—including hypothyroidism—that have been associated with CTS. This condition affects both male and female but occurs with greater frequency in females. Symptoms range from night pain with numbness to daily pain, weakness, numbness, paresthesis and tactile difficulties of the affected hand. These symptoms can range from mild to quite severe and can compromise the patient’s ability to continue to do specific daily or work-related activities. The duration of symptoms has a direct effect on treatment results. The longer the symptoms persist, the more difficult and resistant the condition is to treatment due to the pathophysiological changes that occur in CTS. 


According to the National Institute of Neurological Disorders and Strokes, the cost of medical and industrial treatment of CTS from the initial stage through surgery, ranges between $25,000 to $40,000 per case. 1,2 Not included is industry’s cost to retrain personnel to replace the injured worker, compensation liability cost, litigation and settlement expenses.


Current Treatment Approaches


Currently, the initial standard treatment for early diagnosis of CTS involves some type of non-steroidal anti-inflammatory drug (NSAID), a stock immobilizer, physical therapy and rest to the hand. If the patient does not respond to this treatment, further intervention may include cortisone injections juxtapositioned to the median nerve and possibly an electromyogram to confirm the clinical diagnosis. If after several weeks or a month there is no clinical improvement, the patient is referred for a surgical consultation and likely surgical intervention. 


Surgical intervention can be performed by either open surgical release or by arthroscopic release. Both procedures result in the transaction of the conjoined tendon of the thenar and hypothenar muscles with subsequent bleeding and decompression of the median nerve. Following this procedure there is healing and perhaps scarring of the severed tissues. The post surgical scarring can again produce compression of the subjacent median nerve thus causing return of CTS symptoms. According to national statistics, approximately 85% of surgeries are successful with 15% failure to relieve the patients CTS symptoms. 1,2

Pathophysiology of CTS


The standard belief is that CTS is caused by compression in the area of the transverse carpal ligament with swelling of the flexor tendons causing compression of the median nerve. Observations of CTS patients at surgery reveals, however, that this explanation is only partially correct—at least in those patients who require surgery because they failed conservative measures. During CTS surgery, the author and others have observed that some, if not the majority, of offending pathology is distal to the transverse ligament and distal to the aponeurotic tendon of the thenar and hypothenar muscles. 3 The pathological changes observed are swelling and a discolored, injected median nerve caused by venous congestion within the nerve. Upon transection of the aponeurotic tendon, venous congestion within the nerve appeared to improve. It appears that the tendon is acting as a tourniquet, restricting the venous blood flow within the median nerve. These observed anatomical abnormalities caused me to theorize that the etiological cause for CTS, in at least some cases, was not necessarily found within the transverse ligament but was, instead, due to muscular hypertrophy of the thenar and hypothenar muscle groups which increased tension on the aponeurotic tendon. Therefore, this tightness or contraction of the tendon causes a compression of the median nerve and restricts the venous blood flow within the nerve. This produces swelling and toxicity of that structure and causes the typical symptoms of CTS. Given these anatomical findings, I formerly believed and am now convinced that devices that stretch the anatomical structures of the hand help relieve and possibly even eliminate the pain and symptoms of CTS.


Initial Clinical Effort


To test my theory, I initially identified 10 patients who had a bona fide CTS diagnosis in which other medical causes for peripheral hand neuropathy had been ruled out. Patients presented with negative x-rays for bone and soft tissue pathology and had a positive nerve conduction test indicating compression of the median nerve in the area of the wrist. All participants had failed to respond to the usual conservative treatments of NSAIDs, physical therapy, stock hand brace, cortisone injections and rest.


Initially, a thermoplastic material was used for an orthotic individually designed for each patient and intended to stretch the anatomic structures of the hand. A tracing of the patient’s hand was made on a thermoplastic sheet, with the 1st and 5th digits spread into maximum abduction and the hand-wrist relationship in a neutral position to remove the ulnar deviation. The thermoplastic design was cut from the sheet and softened in a hot water bath. The patient’s hand and wrist was wrapped with a light layer of common webril and the softened thermoplastic was molded to the patient’s hand and wrist while keeping the abduction to the 1st and 5th digits and placing the hand and wrist at maximum extension. This was then secured with a snug ace wrap. After a few minutes, the wrap was removed and the thermoplastic allowed to further harden. Velcro strapping was used to secure the application of the orthotic to the patient (see figures at left).


Patients were advised to wear the device as much as possible but certainly wear the device at night while sleeping. This allowed a stretching of tissue for prolonged periods of time. No medications or other treatments were prescribed.


Results, Observations, and Further Testing

The initial 10 patients accepted the stretching device quite well and, over a six week period, reported improvements in night and day pain, numbness, weakness and paresthesias. Since the pilot study, I have now treated 153 cases. All but 10 have reported symptomatic improvements.


All patients continued with their normal employment. All wore the device for at least 4 to 6 hours per night, with an average of 5 hours per night. After six weeks, some cases continued with numbness but to a lesser degree than initially. Other CTS symptoms of pain, weakness, parethesia, and tactile difficulty were essentially abated. Approximately one third of the patients continue to wear the orthotic for several nights—periodically, when the CTS symptoms return—to secure relief and use it on an “as needed basis.”


Discussion

Stretching of painful, scarred, and contracted tissues is a long-practiced remedy. In this instance, overuse of the hand and wrist apparently leads to scarring and contraction of tendons with resulting venous congestion and inflammation. The device I have developed appears to be therapeutic in those patients who have failed the basic non-surgical, conservative measures of anti-inflammatory drugs, stock braces, corticoid injections, and rest. The stretching device, employed in my hands for my patients, has eliminated almost all surgery. Although my device is now on the commercial market, the most important point to be made is that stretching of the hand, over a few weeks, may be therapeutic and obviate the necessity of surgery. Stretching of the 1st and 5th digit and maximum extension of the wrist—even though contrary to current thinking that the extension of the wrist may cause further compression of the median nerve—has produced positive clinical results in the majority of cases that I have treated so far. Stretching of the hand has not had any lasting, adverse effects to the median nerve or hand function. Although the stretching of muscle and tendon may cause muscle fatigue, stretching also activates the Golgi-tendon organ that subsequently causes a decrease in tendon tension and elongation of the muscle and tendon structure. This appears to be the physiologic reason for the positive results observed with stretching.


Summary


Stretching the anatomic structures of the hand, over time, may relieve symptoms of CTS. Physicians are encouraged to develop their own stretching devices or avail themselves of commercial products that are now on the market.



Disclaimer: Practical Pain Management desires to encourage and publish innovations and new creations as is the case with this author’s invention. We do not, however, endorse any product in this article or elsewhere in this publication. We will publish articles on new devices and instruments if we believe the scientific literature and rational thought make the device or instrument a potential, useful clinical tool. Physicians must individually judge each device on its own merits.


Last updated on: May 20, 2015
Continue Reading:
Diagnostic Ultrasound in Carpal Tunnel Syndrome: A Helpful Additional Tool
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