Wrist Pain Treatment Solution-Carpal Tunnel Syndrome

M BRACE RCA™

Technical Paper

A Revolution in Carpal Tunnel Syndrome Treatment

Mark A. Davini, DC, DABCN & Inventor of the M BRACE RCA™

Carpal Tunnel Syndrome (CTS) has become the #1 industrial problem in the United States. Current rationale for the mechanism and etiology of CTS do not fully explain the epidemic we are now faced with and needs to be further examined. Traditional approaches to bracing for CTS fail to incorporate evolving concepts of soft tissue rehabilitation and thereby limit results. The M BRACE Radi-ul Carpression Angle™ offers an alternative support for the treatment and prevention of CTS.

CTS Defined

Carpal Tunnel Syndrome (CTS) is defined as an entrapment or compression of the median nerve as it passes through the anatomical structures that form the carpal tunnel of the wrist. (4)

Societal Implications

The CTS incident rate in the general population is greater than 1.5%. Frequency of reported cases in high risk circumstances are in excess of 25%. Prevalent in the high tech and manufacturing industries, certain occupations such as computer operators, meat packers and manual handlers top the list of occurrences. A single case of CTS may range from $3,500 to $50,000 after factoring the direct costs of treatment and lost wages, in addition to the indirect costs of lost production, retraining and personnel replacement. (1)

Symptomatology

In true cases of CTS, patients characteristically present with numbness, and frequently pain, along the median nerve distribution distal to the carpal tunnel that worsens at night. Less commonly, the symptoms may refer to the elbow and to the shoulder/neck region. Lack of coordination from associated muscle weakness, and in time muscle atrophy, may also manifest. (4,5,8,16)

Causation

Causes of CTS may be any activity or condition resulting in a mechanical alteration of the carpal tunnel that interferes with the soft tissue structures within most notably the median nerve. (14) These changes in orientation of the carpal tunnel may be caused by repetitive activities of the wrists and arms, direct trauma or fluid imbalance from hormonal/metabolic conditions such as pregnancy, hypothyroidism and diabetes. (11)

Differential Diagnosis

Diagnosis of CTS is often rendered in error. (10) The physician must differentially consider cervical root syndromes, shoulder/hand disorders, peripheral nerve compression syndromes proximal to the carpal tunnel, thoracic outlet syndromes, brachial plexus disorders and myofascial syndromes. (8) Pain location may strongly suggest peripheral nerve entrapment as opposed to nerve root or scleratogenous referral patterns. (7,8,13) This area frequently presents the most confusion.

Clinical Considerations

Examination of the patient for CTS should involve general and specific histories to include onset, duration, location and time references to the numbness and/or pain. Sensory loss is the first area of involvement, particularly light touch. A full sensory evaluation for pain, light/deep touch, two-point discrimination and joint position sense should be performed, with emphasis on the median nerve distribution. Deep tendon reflexes for the upper extremity are often normal. Motor examination of the muscles supplied by the median nerve distal to the carpal tunnel are also of important diagnostic value. (7) Notably, the abductor pollicis brevis and flexor pollicis brevis will show weakness and eventually atrophy. The opponens muscle although less reliable, can offer corroborating value, as there is commonly collateral innervation from the deep ulna nerve. (3,13) Orthopedic testing should include tethering test, Tinel's tap, Phalen's maneuvers and Ellis Functional Test, (19) however the reliability of any one of these tests does not exceed 40%. (7) Electrodiagnostic studies may lend the final bit of information needed to determine the true presence of CTS. This may prove invaluable in ascertaining variations in median nerve anatomy. (11)

Functional Model

Etiology of CTS as a repetitive action cumulative trauma may best be explained as factors of fatigue, as well as resultant structural and histological alterations.

The carpal tunnel is a conduit for the median nerve and nine tendons that pass from the forearm to the hand. The strength and stability of that passageway is maintained almost exclusively by ligamentous integrity, as there are no muscles at the wrist. Thus, the stability of the carpal tunnel is at risk. The traverse ligaments offer little support to the carpal tunnel and some even believe it to be a vestigial structure. (19) Repetitive use of the wrist during the course of the day naturally promotes laxity of the supportive ligaments. Lacking the compensating muscles to stabilize, the vulnerable carpal tunnel configuration will be altered. The proper juxtaposition of the radius and ulna is contingent upon a stable interosseous ligament and, more importantly, a structurally sound articular capsule. (3) The latter commonly displays significant damage and deterioration on MRI studies of confirmed CTS cases. The ensuing functional disrelationship results in a structural alteration that is best described as a decrease or flattening of the normally deep "U" shape of the carpal tunnel.

Anatomically, the carpal bones are wider at the posterior surface than the anterior, with the exception of the lunate bone. (3) This wedging orientation forms the arch shape of the carpal tunnel, held in place by the ligaments pulling in opposite directions. The lunate bone functions as the structural "linch-pin" much the same way as a Roman arch is stable against gravity. Ligamentous tension is the greatest on the palm side maintaining a vector force opposed to the structural shape of the carpal bones. Directional pull of the ligaments connecting the radius and ulna to the carpal bones are of major concern. The radiolunate and the ulnolunate ligaments form a three-point attachment with the radius and ulna as the base and the lunate bone forming the peak of the triangle. The carpal tunnel is formed from a combination of the shapes of the wider posterior surfaces of the carpal bones and ligamentous tension.

Providing that ligamentous integrity is maintained, the configuration of the deep "U" shape of the carpal tunnel is sustained. Mechanical deformation of the carpal tunnel occurs initially from fatigue of the intercarpal, interosseous and articular capsule ligaments. This allows the radius and ulna to separate, spreading the base of the triangular orientation formed by the radiolunate and ulnolunate ligaments. Separations of the radius and ulna from the midline will result in a migration of the lunate bone to the volar surface, protruding into the carpal tunnel itself and diminishing the available space within.

This distortion of the carpal tunnel, when present over an extended period of time, will cause compression, irritation and inflammation of the soft tissue structures within, especially the median nerve. The subsequent symptoms of CTS directly relate to the use of the wrist after the presence of this functional disrelationship, and the mechanical, chemical and metabolic aberrations described.

Treatment

Medical treatment of CTS traditionally begins with a trial of NSAIDS, commonly accompanied with an immobilization splint. This splint might be advised throughout the day or at night only. Upon this initial treatment protocol failing, a more aggressive approach might be taken. Physical therapy modalities in conjunction with flexibility exercises might then be used. More extreme forms of treatment include steroid injections and surgery to release the transverse ligaments, however the complications and instabilities that may result should place these treatments as a last resort. (10,14) Common alternative approaches to traditional treatments might include chiropractic, acupuncture, nutritional counseling, homeopathy and ergonomic recommendations. (9,17,19)

If a patient's condition is allowed to progress to the state of diseased tissue, conservative care may now be futile. (2,12,18) Effective results would best be obtained if the situations that created the condition are identified and corrected, and as always, swift diagnosis and treatment would be essential.

Bracing

When inflammation is severe, immobilization may have limited short term benefit. However, maintaining lack of motion is counterproductive. Current management of soft tissue injuries advocates the rapid initiation of passive movement to prevent the development of adhesions and ultimately permanent scar formation.

Proper splinting of the wrist for CTS should incorporate state of the art concepts of tissue rehabilitation.

Elastic wrist straps should also be used rarely. These compress the radius and ulna together, limiting proper translation upon flexion and extension, and expand the anterior to posterior dimension of the wrist by increasing intratunnel pressure. (15) The median nerve is thereby further compressed. Additionally, the vector forces of the elastic band are 360 degrees, directly pressuring the already protruding open anterior portion, worsening the symptoms the longer it is used. Finally, elastic bands place an unnatural pressure on the articular capsule surfaces. This extra pressure accelerates the degeneration process as a result of the piezo-electric effects on bones and joints.

M BRACE RCA Radi-ul Carpression Angle™

Characteristics of the M BRACE Radi-ul Carpression Angle (RCA)™ differ from the aforementioned treatment and braces in many beneficial ways. The M BRACE RCA's patented design restricts the lateral migration of the radius and ulna caused by repetitive use of the wrist, and acts as an artificial check ligament. The M BRACE RCA™ consequently supports the ligamentous structure that maintains the normally deep "U" shape of the carpal tunnel, thereby preventing compression of the median nerve. Furthermore, the M BRACE RCA™ does not encroach on the anterior portion of the wrist, and by allowing expansion and retraction without interference, the resultant irritation within the carpal tunnel is effectively limited. Finally, the M BRACE RCA™ allows for full flexibility of the wrist, promoting rehabilitation of the soft tissue structures within from passive use.

Conclusion

In review of the braces currently available, the M BRACE RCA™ is the only product that satisfies the requirements of a truly effective support for CTS. It is not only inexpensive but also comfortable for the end user in that complete mobility is sustained during use. The foregoing depiction not only suggests that the M BRACE RCA™ is the best therapeutic solution available, but that it is simultaneously a viable preventative. The M BRACE RCA™ is truly a revolution in the prevention and treatment of CTS.

References

1. Armstrong T: "An Ergonomics Guide to Carpal Tunnel Syndrome", Ergonomics Guides, 1983.

2. Banta C: "A Prospective, Nonrandomized Study of Iontophoresis, Wrist Splinting, and Anti-inflammatory Medication in the Treatment of Early-Mild Carpal Tunnel Syndrome', Journal of Orthopedic Medicine, vol. 36, #2, 1994, 166-168.

3. Calliet R: Hand Pain and Impairment, 3rd ea., 1982, 1-16.

4. Calliet R: Neck and Arm Pain, 2nd ea., 1964, 154-157.

5. Chusid J: Correlative Neuroanatomy & Functional Neurology, 17th ea., 1967, 124-125.

6. Diamond M: "Carpal Tunnel Syndrome: A Review" Chiropractic Sports Medicine, vol. 3, #2, 1989.

7. Hoppenfeld S: Orthopedic Neurology, 1977, 28-36.

8. Hoppenfeld S: Physical Examination of the Spine and Extremities, 1976, 81-84.

9. Karpen M: "Treating Carpal Tunnel Syndrome" Alternative & Complimentary Therapies, September/October, 1995.

10. Kemp Miller B: "Carpal Tunnel Syndrome: A Frequently Misdiagnosed Common Hand Problem" Nurse Practitioner, vol. 18, #12, 1993, 52-56.

11. Kimura J: Electrodiagnosis in Disease of Nerve and Muscles, 2nd ea., 1985, 14-15.501-503.

12. Kruger V, Kraft G, Deitz J, Ameis A, Polissar L: "Carpal Tunnel Syndrome: Objective Measures and Splint Use" Archives of Physical Medicine and Rehabilitation, vol. 72, 1991, 517-520.

13. Patten J: Neurological Differential Diagnosis, 6th ea., 1987, 94-205

14. Pecina M, Krmpotic-Nemanic J, Markiewitz A: Tunnel Syndromes, 1991, 55-67.

15. Rempel D, Manojlovic R, Levinsohn D, Bloom T, Gordon L: "The Effect of Wearing a Flexible Wrist Splint on Carpal Tunnel Pressure During Repetitive Hand Activity" The Journal of Hand Surgery, vol. 19A, #1, 1994, 106-110.

16. Seidal H, Ball J, Dains L, Benedict G: Mosby's Guide to Physical Examination, 1991, 612.

17. Venditti P: "Carpal Tunnel Syndrome: T'ne New Industrial Epidemic", DC Tracts, vol. 2, #2, 1990.

18. Weiss A, Sachar K, Gendreau M: "Conservative Management of Carpal Tunnel Syndrome: A Reexamination of Steroid Injection and Splinting",The Journal of Hand Surgery, vol. 19A, #3, 1994,410-415

19. Wunderlich R: The Natural Treatment of Carpal Tunnel Syndrome, 1993.


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