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Carpal
Tunnel Syndrome / Shoulder, Arm, Hand
The double crush syndrome is a compression neuropathy
of two areas, one usually distant from the other. A
growing number of researchers have suggested a correlation
between some peripheral neuropathies, of which carpal
tunnel syndrome is one and cervical nerve root compression
another. The nerve is “crushed” or irritated
in the spine, “priming” more distal areas
of the nerve for dysfunction when that part is stressed
(second “crush”).
Comparative efficacy of conservative
medical and chiropractic treatments for carpal
tunnel syndrome: a randomized clinical trial.
Davis PT, Hulbert JR, Kassak KM, et al.
Journal of Manipulative and Physiological Therapeutics,
June 1998, vol.21/no.5, pp317-26. This study showed that
chiropractic was as effective as medical treatment in reducing
symptoms of CTS. Chiropractic care included spinal adjustments,
ultrasound over the carpal tunnel, and the use of nighttime
wrist supports. Carpal tunnel syndrome (CTS) can affect
just about everyone, but particularly people involved in
occupations requiring repetitive use of the hands and wrists
(i.e., office and skilled labor jobs). Medical doctors
commonly prescribe anti-inflammatory drugs, which prove
ineffective in some patients and cause adverse side effects
in others, for patients diagnosed with carpal tunnel syndrome.
Clinical commentary: pathogenesis of
cumulative trauma disorders. Mackinnon
S. Journal of Hand Surgery, Sept. 1994,
873-883. Dr. Susan MacKinnon professor of surgery
at Washington University School of Medicine
in St. Louis in a study of 64 patients with
repetitive stress disorders of whom 34 had wrist
surgery it was discovered that wrist pain or
discomfort was not the only symptom the patients
complained of. Most patients had multiple problems,
especially muscle imbalance. The high failure
rate of surgery has caused her to rethink the
cause of CTS: “Unnatural postures for
extended periods creating pressure on the nerves
in the neck, leading to neurological and other
symptoms...even when extremity surgery improves
the peripheral symptoms such as numbness in
the hands, other associated problems like neck
stiffness and shoulder pain persist,” her
article states.
Research finds surface EMG useful in
treatment of CTS. Prosanti MP. Advances
For Physical Therapists, July 6, 1992.
From the article: “The notion that
muscles of the neck could be involved in problems within
the arm and wrist has been a subject of discussion for
several years.”
A treatment for carpal tunnel syndrome:
evaluation of objective and subjective measures. Bonebrake
AR, Fernandez JE, Marley RJ et al. JMPT Vol.13
No.9 Nov/Dec 1990. Thirty eight CTS sufferers
underwent spinal manipulation and extremity
adjusting. In addition, soft tissue manipulation,
dietary modifications or supplements and daily
exercises were prescribed. Post treatment results
showed improvement in all strength and range
of motion measures. A significant reduction
of nearly 15% in pain and distress ratings were
documented.
Resolution of a double-crush syndrome.
Flatt DW. Journal of Manipulative and Physiological
Therapeutics, July/August 1994; 17(6):
395-397. A 63-year-old man suffered from a 36-month
history of right anterior leg numbness and recurrent
lower back pain. Complete resolution of right
anterior leg numbness followed
chiropractic treatment. Although not a carpal tunnel problem the double crush
phenomenon, in this case involving the leg, and its resolution under chiropractic
care is of interest.
The double crush in nerve entrapment
syndromes. Upton, ARM, McComas AJ. Lancet 2:329,
1973. 67% to 75% of patients studied who had
carpal tunnel syndrome or ulnar neuropathy also
had spine nerve root irritation.
Impaired axoplasmic transport and the
double crush syndrome: food for chiropractic
thought. Czaplak S, Clinical Chiropractic/Jan.
1993 p.8-9. “Chiropractic has an extensive
anecdotal history of patients being relieved
of classic carpal
tunnel symptoms with spinal adjustments and/or cervical tractioning only.”
Carpal tunnel syndrome as an expression
of muscular dysfunction in the neck.
Skubick DL, Clasby R, Donaldson CCS et al. J
Occup Rehabil 3:31-44, 1993. Carpal tunnel
syndrome can occur from increased forearm flexor
activity caused by muscle
dysfunction in the neck. Study of 18 patients.
Comparison of physiotherapy, manipulation,
and corticosteroid injection for treating shoulder
complaints in general practice: randomized,
single blind study. Sobel JS, Winters
JC, Groenier K, Arendzen JH, Meyboom de Jong
B. British Medical Journal 1997; 314:1320-5.
198 patients with shoulder complaints were divided
into two diagnostic groups: 58 in a
shoulder girdle group and 114 into a synovial group. Patients in the shoulder
girdle group were randomized to manipulation or physiotherapy and patients
in the synovial group were randomized to corticosteroid injection, manipulation
or physiotherapy. In the shoulder girdle group, the duration of complaints
was significantly shorter after manipulation compared to physiotherapy. The
number of patients reporting treatment failure was less with manipulation.
In the synovial group duration of complaints was shortest after corticosteroid
injection compared with manipulation and physiotherapy. (Note: either G.P.s
or physiotherapists performed the manipulations).
Physical examination of the cervical spine and
shoulder girdle in patients with shoulder complaints. Sobel
JS, Winters JC, Groenier K, Arendzen JH, Meyboom de Jong
B. JMPT 1997; 20:257-62.
From the abstract: In the population of
patients without shoulder complaints the mobility in the
cervical and upper thoracic spine was found to decrease
with aging…functional disorders in the cervical spine,
the higher thoracic spine and the adjoining ribs are not
extrinsic causes of shoulder complaints, but an integral
part of the intrinsic causes of shoulder complaints.
Double crush syndrome: what is the evidence? Swenson
RS. J Neuromusculoskeletal System,
Spring 1993; 1(1): 23-29. The hypothesis that
a nerve injury close to the spine may weaken
the nerves further away is discussed. The author
concludes that more data is needed.
Surgery of the peripheral nerve.
MacKinnon SE, Dellon AL. Thieme Medical
Publishers. New York, 1988. Nerve compression
near the spine is found in people with carpal
tunnel syndrome.
The neurone and its response to peripheral
nerve compression. Dahlin LB, Lundborg
G. J Hand Surg (Br Vol, 1990) 15B:
5-10.
Double crush syndrome: cervical radiculopathy
and carpal tunnel syndrome. Osterman
AL, Pfeffer G, Chu J, et al. Presented at the
41st annual American Society for Surgery of
the Hand, New Orleans, LA 1986. Describes in
detail the double crush syndrome.
The double lesion neuropathy: an experimental
study and clinical cases. Nemoto et
al Abstract 123, Second Int’l
Congress. Boston, MA Oct. 1983. Shows that nerve
compression such as in the neck will block the
distribution of necessary cellular material
to the distal nerve axon such as in the wrist,
making it more susceptible to
injury.
The relationship of the double crush
syndrome (an analysis of 1,000 cases of carpal
tunnel syndrome). Hurst LC, Weissberg
D, Carroll RE. J Hand Surg 10B: 202,
1985. A significant correlation was found between
bilateral carpal tunnel syndrome and radiologically
diagnosed cervical arthritis.
Double crush syndrome: a chiropractic/surgical
approach to treatment. Cramer SR, Cramer
LM Dig of Chiropractic Economics Mar/April,
1991.
From the abstract: Seventy five patients
had dual treatment of chiropractic and hand surgery/rehabilitation, “concluding
that these two...treatments are complementary and can be
effective in improving the lives and prognoses of patients....”
Carpal tunnel syndrome: a case report.
Ferezy, JS, Norlin, WT. Chiropractic Technique,
Jan/Feb 1989 P.19-22. Electromyelography demonstrated
objective improvement in this case of CTS following
chiropractic care.
Spinal Manipulation, 5th
edition by Bourdillon JE, Day EA, Bookhout MR:
Oxford, England, Butterworth-Heinemann Ltd,
1992:
“Faulty innervation caused by spinal joint lesions is one of the main factors
in the production of carpal tunnel syndrome. p. 207
Carpal tunnel syndrome in 100 patients:
sensitivity, specificity of multi-neurophysiological
procedures and estimation of axonal loss of
motor, sensory and sympathetic
median nerve fibers. Kuntzer T. Journal of the Neurological Sciences,
1994 Dec 20,127(2): 221-9.
[Diagnostic tests in carpal tunnel syndrome] Megele
R. Nervenarzt, 1991 Jun, 62(6): 354-9. Language:
German.
Double crush syndrome: chiropractic
care of an entrapment neuropathy. Mariano
KA; McDougle MA; Tanksley GW. Journal of
Manipulative and Physiological Therapeutics,
1991 May, 14(4): 262-5.
Thoracic outlet syndrome: diagnosis
and conservative management. Liebenson,
CS JMPT Vol. 11 No. 6, Dec 1988.
Thoracic outlet syndrome is caused by compression or irritation of the nerves
as they exit the neck toward the upper extremity. Often it is the compression
or irritation of the brachial plexus, not from compression of the subclavian
artery. In this discussion, the author notes some researchers who believe that
the sacroiliac plays a
large role in the etiology of this condition. Others feel an abnormal thoracic
curve is thecause.
The role of thoracic outlet syndrome
in the double crush syndrome. Narakas
AO.. Annales de Chirurgie de la Main et du Membre
Superieur, 1990, 9(5): 331-40.
The numb arm and hand. Bracker
MD, Ralph LP American Family Physician 51(1):
103-116, 1995. Medical article that discusses
thoracic outlet syndrome.
Abstract:
Trauma and compression along the course of the median, ulnar or radial nerve
from the brachial plexus to the fingers may cause pain, weakness, numbness
or tingling the upper extremity. Diabetes, smoking, alcohol consumption, rheumatoid
arthritis and hypothyroidism are risk factors for nerve entrapment although
these disorders typically produce bilateral symptoms.
Treating Shoulder Dysfunction and “Frozen
Shoulders”. Ferguson LW. Chiropractic
Technique, 1995; 7:73-81.
Author’s Abstract: This article
presents three case histories to illustrate the treatment
of “frozen shoulder” and related shoulder dysfunction
as a combined disorder involving jointdysfunction and myofascial
pain syndrome. The author reviews the literature and questions
the traditional treatment approaches, which focus on treating
inflammation and breaking adhesions. The concept of adhesive
capsulitis as the only cause of “frozen shoulder” is
challenged. The author proposes an alternative treatment protocol that addresses
specific patterns of joint dysfunction and myofascial disorder. Comment: Dr.
Ferguson utilized spinal adjustments and shoulder adjustments.
References from Koren Publications’ brochure:
Help for Carpal Tunnel Sufferers
Nonsurgical relief for carpal tunnel sufferers. Let’s
Live, August 1993.
Pfeffer, G.B. & Gelberman, R.H.
The carpal tunnel syndrome. In N.M. Hadler (Ed.), Clinical
concepts inregional musculoskeletal illness.
Orlando, FL: Grune & Stratton, Inc., 1987,
pp. 201-215.
Brody, J.E. Epidemic
at the computer: Hand and arm injuries. New
York Times, March 3, 1992, pp. C1;C10.
Rietz, K.A. & Onne, L. Analysis of sixty-five operated cases of carpal
tunnel syndrome. Acta Chir Scand,
1967, 133, pp. 443-447.
Mendelsohn, R. Treating carpal tunnel syndrome. The People’s Doctor,
8 (9), p.7.
Fisher, H. Prevention Magazine.
Ferezy, J. & Norlin, W. Carpal tunnel syndrome: A case report. Chiropractic
Technique, Jan/Feb 1989, pp. 19-22.
Upton, A.R.M. & McComas, A.J. The double crush in nerve entrapment syndromes. Lancet, 1973,
2, p. 329.
Nemoto, K. et al. The double lesion neuropathy: An experimental study and clinical
cases. Abstract 123, Second Int’l. Congress. Boston, MA, Oct.
1983.
Hurst, L.C., Weissburg, D. & Carroll, R.E. The relationship of the double
crush syndrome (an analysis of 1,000
cases of carpal tunnel syndrome). J Hand Surg, 1985, 10B, p. 202.
Czaplak, S. Impaired axoplasmic transport and the double crush syndrome: Food
for chiropractic thought.
Clinical Chiropractic, Jan. 1993, pp. 8-9.
Bonebrake, A.R. et al. A treatment for carpal tunnel syndrome: Evaluation of
objective and subjective measures.
JMPT,1990, 13, pp. 507-520.
Stoddard, A. Manual of osteopathic practice (2nd ed.). Melbourne,
Australia: Hutchinson & Co., 1983, p. 228.
Bourdillon, J.F. Spinal manipulation (3rd ed.). New York: Appleton-Century-Crofts,
1984, pp.207; 210-211; 219-224.
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