Carpal tunnel syndrome

What is happening with Carpal Tunnel Syndrome (CTS)…?
There is a new interest in CTS. Recent basic sciences advances are suggesting that the CTS diagnosis is in need of a deconstruction and there is a new impetus for better non-surgical and non pharmacological strategies such as movement and education.

Deconstruct?
Good clinicians already deconstruct – many of our readers will know that CTS is often not all about the carpal tunnel and its contents. While a CTS diagnosis could be a nerve problem at the wrist, it could also involve other parts of the median nerve (double crush), it could involve the central nervous system and it could also involve perturbed homeostatic systems such as the immune and autonomic systems. Overall, there are three new key research areas.

Is it in ‘the head’?
Well it could be!! Changes in the hand representation in the brain (Druschky et al., 2000; Napadow, 2006) occur in people who have a CTS. This is a very real change in synapses and it suggests that the symptoms may be influenced strongly by thoughts and feelings, both adversely and beneficially.

What has it got to do with the immune system?
Immune responses are a key part of many peripheral neuropathies (Thacker et al., 2007; Watkins et al., 2003) and may well be a part of the changes in the brain representations. Mick Thacker, one of our UK teachers and a prominent immune system researcher has a nice new definition of the immune system as “a system that can identify self from non-self”. It may well be that some of the things people do with their hands (eg excessive vibration, repetition) may signal the ‘self’ to construct that ‘that is not really me’ and an initially protective immune responses follows.

What about nerve mobilisation for CTS?
NOI has always had an interest in the management of this common neuropathic pain state. Syndrome deconstruction is an essential part of our teaching philosophy and nerve mobilisation techniques are taught in the Mobilisation of the Nervous System courses and the Upper Limb Clinical Applications course. In addition, our teachers have been involved in research in this area. (Coppieters & Alshami, 2007; Coppieters & Butler D, 2007). We are delighted to hear that Michel Coppieters at the University of Queensland has gained an Australian NHMRC research grant to research CTS, allowing three PhD students to begin research in areas such as syndrome deconstruction and better assessment and conservative therapies.

All research directions suggest that expectations for outcome of conservative treatment should lift.

Carpal Tunnel Trivia

  • Carpal tunnel syndrome only became recognized as a common syndrome in the 1950’s
  • There is a prevalence of around 50 cases per 1000 people in the US with CTS
  • CTS is relatively unknown in the developing world
  • Pirates don’t get CTS
  • There are reports in the literature of CTS following insect and snake bites

Got chronic CTS? Try Recognise™ Online
The graded motor imagery programme including Recognise may well be appropriate for treatment of some chronic carpal tunnel syndrome, especially those involving brain changes.

Posters
I see red! I see red! I see red! If you’re not already familiar with the Explain Pain Poster set, they are for people in the recovery journey in a pain peer group setting or a place like the waiting room of your clinic. They are designed to empower patients with more knowledge to make informed choices about their recovery path. The posters even made it to a scene in ‘Cold Case’ last year.

The four titles are: Take Control, Pacing Activity, Thought Viruses, The Road to Recovery. 4 poster set, A2 size (40 x 60cm) 2 colour, matte print, laminated. Check them on the web first.

References from CTS Notes above
Coppieters, M. W., & Alshami, A. M. (2007). Longitudinal excursion and strain of the median nerve during novel nerve gliding exercises for carpal tunnel synrome. J. Orthop Res, 25, 972-980.

Coppieters, M. W., & Butler D, S. (2007). Do “sliders” slide and “tensioners” tension? An analysis of neuyrodynamic techniques and considerations regarding their applications. Manual Therapy, Epub ahead of print.

Druschky, K., Kaltenhauser, M., Hummel, C., & al., E. (2000). Alternation of the somatosensory cortical map in peripheral mononeuropathy due to carpal tunnel syndrome. Neuroreport, 11, 3925-3930.

Napadow, V. (2006). Somatosensory cortical plasticity in carpal tunnel syndrome. Neuroimage, 31, 520-530.

Thacker, M. A., Clark, A. K., Marchand, F., & McMahon, S. B. (2007). Pathophysiology of peripheral neuropathic pain: Immune cells and molecules. Anesth Analg, 105, 838-847.

Watkins, L. R., Milligan, E. D., & Maier, S. F. (2003). Immune and glial involvement in physiological and pathological exaggerated pain states. In J. O. Dostrovsky, D. B. Carr & M. Kolzenburg (Eds.), Progress in pain research and management (Vol. 24, pp. 369-386). Seattle: IASP Press.

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