There is a space between the bones of the wrist and the ligament that runs across the bottom of the palm, called the carpal tunnel. Through this tunnel courses a nerve called the median nerve, which supplies the thumb, index and middle fingers. In a healthy wrist, there is plenty of space in the tunnel for the nerve and blood vessels that travel through it, but with overuse (think keyboarding or hammering) the space gets reduced, and can cause irritation or even pinching on the median nerve. This can produce the common symptoms of pain, numbness and tingling, and eventually weakness and muscle wasting.
Carpal tunnel syndrome is a great example of the difference between looking at a condition from a holistic viewpoint versus a reductionist one. Many of us are familiar with the term holistic — it means looking at all aspects of health, or all the causes of a particular problem. Most are not familiar with it’s opposite, focusing on only one aspect of a health problem, called reductionism.
These different views apply to our understanding of carpal tunnel syndrome. The reductionist view is that the whole problem is at the wrist, and nothing but the wrist. The holistic view is that the pain in the hand is often the result of a regional problem, including the shoulder and neck, and can even be affected by posture and diet. I certainly prefer the holistic viewpoint; the long hours spent at a keyboard would stress the neck and shoulders along with the wrist. And even if these other areas are not inflamed enough to be painful, they can certainly contribute to the numbness and tingling at the wrist. There is a syndrome called the “double crush” where the nerve that travels from the neck to the hand is compressed both at the neck and the wrist; an article in the Orthopedic Clinics of North America journal covers this problem, stating that if treatment is focused only at the wrist, the results can be “less than optimal,” and that minor nerve irritation at the neck magnifies the effect of nerve compression at the wrist. Not every carpal tunnel patient has this pattern, but the majority do. The authors estimate about 75 percent of CTS patients are “double crush” patients, and only 25 percent are “pure” CTS. They recommend treating both areas for optimal results.
Remember, CTS involves only the median nerve, and therefore only the thumb, index and middle fingers. I see many patients who have been given the diagnosis of CTS who actually have pain and tingling throughout the whole hand, or up and down the arm. These are usually “double crush” cases; by definition, if the symptoms extend beyond those three fingers, it cannot be “pure” CTS.
The difficulty with the “double crush” syndrome is that even when the neck is contributing to the nerve irritation, there may be no neck pain at all. It takes some training to learn how to evaluate the area for these types of problems, or even to know to look for it in the first place. And the nerve does not actually have to be physically pinched, only irritated; this means that nerve conduction studies that only show a pinched nerve typically miss it.
Doctors of chiropractic and physical therapists tend to take a more holistic view of carpal tunnel syndrome, and will treat the whole region. It is not uncommon for the patient to get lifestyle and postural advice, as the typical forward head and shoulder posture adds stress to the whole system.
Acupuncture certainly takes a more holistic view; one approach uses points on the ankles, as well as the wrist itself, to treat CTS. I describe this approach as recruiting the whole body to heal the problem area, and it seems to work. There are even points in the ears that can be used. There are ear points for treating the whole body, including the ear itself.
It is all too common for patients to equate CTS with surgery. Most cases do not require surgery, or even shots — they can be handled well by conservative treatments. It is always better to try the less invasive and safer treatments before going under the knife. These more holistic treatments do not always work, of course, but it is certainly worth try.
Dr. Michael Noonan practices chiropractic, acupuncture and other wellness therapies in Old Town. He can be reached at firstname.lastname@example.org.