Abstract:
To describe and show the outcome of care with a patient that has carpal tunnel syndrome symptoms. A 32 year old female presented with a complaint of “bilateral hand numbness with pain.” When it was reported, the pain was in both hands, and the hands go numb in the morning upon waking up from sleeping. Carpal tunnel syndrome was diagnosed upon the positive findings with the orthopedic tests and examination findings. The patient was treated with chiropractic diversified adjustments to the wrists, hands, and cervical region. During the 6 week trial period, orthopedic tests were performed before and after the re-evaluation period to the wrists and cervical spine to evaluate the progress of the symptoms. Once the re-evaluation was complete, when inspecting the hands there was no longer inflammation in the wrists and hands, a decrease in the amount of pain overall, an increase in the range of motion of the wrists, and all of the orthopedic tests that were performed in the wrists and cervical region had negative findings. This case study does provide evidence that patients with carpal tunnel syndrome symptoms, can benefit from chiropractic adjustments. There needs to be further studies that are larger in size to support the research about chiropractic and carpal tunnel syndrome symptoms.
Introduction
Carpal Tunnel Syndrome is a compressive neuropathology that affects the median nerve, as the median nerve controls the distribution of feeling and movement on the palm-side of the hands. This nerve runs down the forearm and into the hands passing through the carpal tunnel on the palmar side of the wrist. This tunnel is formed by carpal bones, a strong band of ligaments, and connective tissue that is called the transverse carpal ligament. Carpal tunnel syndrome is caused by repetitive movement of the wrist, which could cause numbness and inflammation in the wrist. This inflammation puts pressure upon the median nerve and causes pain, tingling, and numbness within the median side of the hand within the thumb and first 3 fingers. Other causes could be from alcohol abuse, fractures, cysts of the wrists, infections, obesity, pregnancy, or arthritis.(2)
Based on multiple case studies, it was reported that a higher percentage of the white population has carpal tunnel syndrome. The incidence is about 1-3 /1000 people per year, and prevalence is about 50 out of 1000 people.(3) The people who are in jobs that use repetitive wrist actions more than the average person will be more likely to acquire this syndrome. The peak age is around 45-60 years old, and there is a ratio of about 3-10:1 when looking at a female: male ratio, as the highest percentage is women over the age of 30.(3)
When looking at the common treatments of carpal tunnel syndrome, physical therapy is commonly used to help with diet and exercise routines, such as stretching and strengthening the wrist. Also, when looking at a person’s occupation, it would be protocol to use a wrist splint, massaging the wrists, look at the ergonomic work place settings, and eventually giving the wrists a rest. When looking into the medical protocols, they consider steroid injections, NSAID’s, or eventually surgery if no other possibility has helped with the symptoms.
When looking at the healthcare costs in the U.S., a treatment that is not surgery could cost up to $300, a surgery could cost $7,000+ per hand without any health insurance.(5) Other sources state that this could be around $2,445 at an ambulatory center, around $5,354 in a hospital which includes a 2 day stay at the hospital, and Medicare states that it could cost around $8,185.(6) Although prices vary, the carpal tunnel institute states that the lowest price could be around $2,480 and the highest price could be around $3,100.(7) The damage that carpal tunnel does to the economy is about a $100 billion revenue that’s lost each year with consumers, insurance companies, large corporations and also private companies.(8)
Chiropractic is related to carpal tunnel due to the wrist bones, elbow, or upper cervical spine that could be out of place with the alignment. Manipulation of the carpal bones at the wrist, elbow, or upper cervical spine could be utilized to help in restoring motion and alignment of these bones. This manipulation or adjustment of the bones can relieve pressure on the area that the median nerve is passing through, as this will alleviate the stress upon the area and help the nerve and blood flow. The use of chiropractic care, exercises, and other types of physical therapies has been shown to have positive results improving function of the wrists, and helping decrease the pain, tingling and numbness that have occurred in the hands regarding the median nerve entrapment.(10)
Case Report
A 32 year old female presented with a complaint of “bilateral hand numbness with pain.” It was reported that the pain was in both hands and both hands go numb in the morning when waking up from sleeping at night, and when working as a bartender. The complaint started when the bartending occupation began 4 years ago, as this is when it was noticed that the bilateral pain and numbness was in the hands. It was reported that the pain is relieved with massaging the hands, and she described the pain as a burning pain in the hands. There has been no intervention with any doctor for the complaint of bilateral hand pain and numbness, and it was reported that the pain is a 9/10 on a visual analog scale.
Upon inspection of the posture, it was revealed that there was anterior head carriage with bilaterally anterior rolled shoulders, and both arms and hands had slight inflammation in the tissues. When doing orthopedic testing of the cervical region, there was a positive finding with right lateral flexion compression with tightness and pain along the left side of the cervical spine. Also when performing the shoulder depression test there were positive findings on both left and right sides for tightness and pain at the base of the neck bilaterally that went into each shoulder. Upon further testing of the upper extremities performing the Modified Adson’s test, there were positive findings on both left and right arms showing a decrease in amplitude of the radial arteries in both arms. Utilizing the orthopedic tests in the hands and performing both Phalen’s and Reverse Phalen’s, this indicated a positive finding for tightness and pain in the hands bilaterally.(11) While performing Tinel’s test of the wrists, also indicated a positive finding with pain at the wrists bilaterally.(12) Going through the exam with evaluating the range of motion in wrists, elbows, shoulders, and neck it was noticed that there was full range of motion bilaterally in each shoulder and elbow, but did show a decrease in flexion, extension, abduction and adduction of each wrist by 5-10 degrees visually, and a decrease in range of motion in the cervical spine with right and left lateral flexion by 10-15 degrees.
The clinical impression was aberrant posture due to an upper cross syndrome, thoracic outlet syndrome, carpal tunnel syndrome bilaterally, and possible subluxations of the carpal bones, distal radius, distal ulna, middle cervical spine and lower cervical spine.
Intervention:
The patient received chiropractic care using the Diversified protocols and chiropractic technique. The patient was put on a plan to be seen two times per week for 4 weeks, and one time per week for 2 weeks and then subjected to a re-evaluation. She received 10 adjustments to her cervical spine, 2 adjustments to the hip, and 4 adjustments to her wrists bilaterally over the 6 week period. During the first appointment she was experiencing bilateral hand pain and numbness that would wake her up at night. The initial treatment involved a hip adjustment on the right ilium, a cervical spinal adjustment to the fourth and fifth cervical vertebra, and an adjustment to the distal radius and distal ulna bilaterally. After the first adjustment the bilateral hand pain and numbness were not noticed as much during the first visit. On the next visits her pain level was decreasing on the VAS with regards to her hands bilaterally, but she did have some general tightness noticed in the upper thoracic area and lower part of the cervical spine with a decrease in range of motion in the cervical and thoracic spine. Once the adjustments were made in the lower cervical and upper thoracic spine the tightness in the lower cervical spine and upper thoracic area were gone, and she had full range of motion with the cervical spine and thoracic spine. The hand pain and numbness was steadily decreasing with duration and frequency. This was the first case that was presented in this fashion with the carpal tunnel syndrome that I was involved with, and also during the treatment plan the patient didn’t receive any outside medical treatment.
Outcome:
After the re-evaluation had been completed with the 6 week treatment plan utilizing the Diversified technique, the patient did report that the bilateral numbness and pain in the hands went from the starting 9/10 on the VAS down to a 0/10 on the VAS and was no longer noticed and wasn’t affecting her in any way in regards to pain for function. Also when inspecting the hands there was no longer inflammation in the wrists and hands, and all of the orthopedic tests that were performed like Phalen’s, Reverse Phalen’s, and Tinel’s tests all had negative findings in the wrists. The adjustments made to the cervical spine helped relieve the pressure on the nerves, which could have been labeled a “double crush” syndrome.(13) The cervical spinal musculature no longer had tightness or pain, which gave the patient more maneuverability within her cervical range of motion. The outcome measures that were utilized to help monitor the progression of the treatment provided over the 6 weeks of initial care was the General Pain Disability Index Questionnaire (GPDIQ) rating for pain and functionability. The GPDIQ score initially on the first visit was a 32/60, which affected her family / home responsibilities, recreation, social activity, occupation, general self-care, and life supporting activities. After the initial 6 weeks of the treatment plan the GPDIQ was now a 0/60, as she was fully functioning without pain in all of her activities, social functions, work, and within her daily life. Also with the cervical and hip adjustments the posture of the neck, back and pelvis improved dramatically, with not having anterior head carriage, bilateral anterior rolled forward shoulders, or pelvic un-leveling. The range of motion in the hands bilaterally went from showing a decrease in flexion, extension, abduction and adduction of each wrist by 5-10 degrees, to now having normal range of motion in the wrists bilaterally. With the adjustments on the wrists, cervical spine, thoracic spine, and hip, there was significant improvement in regards to pain, function and ability with the wrists and cervical spine, and normal range of motion with the wrists and cervical spine.
Discussion:
When looking over the initial exam findings and relating them to the pain that was felt by the patient, it is easy to look at this case and state the person has carpal tunnel syndrome. After doing an extensive exam, it was determined that the wrist bones, distal ulna, and distal radius were all fixated and out of alignment. Once the adjustments were made on the cervical spine, distal radius, distal ulna, and carpal bones, there was an immediate relief of pain and an increase in the range of motion of the wrists. When looking at the limited function and decreased range of motion, it was determined that the bones that make up the wrist and the bones that attach to the wrist from the arm were the reason for this pain, inflammation, and diminished function. After the adjustments was made over the treatment plan period, there was a direct correlation to the pain, decreased range of motion and diminished function in the wrists due to the carpal bones, distal ulna and distal radius being out of alignment. When the carpal bones, distal ulna and distal radius were adjusted back into the correct alignment, the pain decreased and the function improved to being able to have full range of motion in the wrists. Allowing the blood vessels and nerves to be relieved of pressure and alleviating any interruption of flow into the wrists and hands improves the circulation, decreases and removes the inflammation in the wrists and hands, increases the range of motion, enlarges the area of the carpal tunnel, and strengthens the muscles of the hand where the appearance of any atrophy wasn’t noticed anymore.(14)
In this study it was started through education of the daily activities that exacerbated the symptoms in the wrists and hands, and minimizing any repetition that would cause further damage and irritation. When looking at the severity of the pain, interruption in the daily activities with decreased functionability, and the duration of the complaint, it was determined that the treatment plan would be beneficial in alleviating her complaints. The overall goal of the management plan was to decrease the amount of pain she was in daily, increase the function in her wrists and hands, and decrease the inflammation that has occurred in the wrists and hands. After taking the history of the compliant and understanding the duration and cause, the treatment plan would be intensive at the beginning and based on improvement be altered accordingly.
A couple limitations were the size of the study, as it was one case with carpal tunnel syndrome symptoms, which the results based on the patient reporting was positive. Also another limitation was age of the patient, being middle 30’s is in the age range of people who get carpal tunnel syndrome, but a larger study with more diverse age range would be suggested to get the full evaluation of the carpal tunnel syndrome and effects with adjustment of the wrists. Another limitation was the placebo effect, due to the patient never having a chiropractic adjustment before, these results could be altered due to the positive feeling from coming in and getting general relief overall. With the limited number of case studies on adjustments to alleviate carpal tunnel syndrome, this case study does prove positive results and confirms some studies that increasing blood flow and alleviating additional stress on the wrists are beneficial in improving circulation and motion in the wrists and hands. (14)
Conclusion:
After evaluating the patient once the treatment plan was completed, there were substantially less symptoms that were currently ongoing. Looking at the adjustments that were administered for the symptoms that were presented, it is fair to say that in this case study the patient benefited from the adjustments not only to the cervical region, but also the hands and wrists. When the patient started the case study, there was a significant amount of pain and altered function with her hands and wrists bilaterally. After evaluating the alignment of the hands, wrists, and cervical area once the treatment plan was complete, there was evidence that showed a loss of symptoms and complaints that relates to the carpal tunnel syndrome, showing an increase in range of motion, function and daily living activities. When looking into other treatment options for carpal tunnel syndrome, there is a lot of effort put into surgery and other surgical procedures. This case study does shine some light on the possibility that adjustments to the hands, wrists, and cervical area would be beneficial for people with carpal tunnel like symptoms. With the economy loosing around $100 billion in revenue due to carpal tunnel problems yearly, this case study will help in allowing people to see that there are other alternatives to surgery that can help these individuals get back to living their life without having these carpal tunnel symptoms.(8) With the rate of about 1-3 /1000 people per year being affected by carpal tunnel symptoms, these people need to search out and find other alternatives for care first before going down the path of surgery. Moving forward after completing this case study, there needs to be more involvement with larger sample sizes to determine how beneficial chiropractic would be to everyday suffering of carpal tunnel symptoms.
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