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Post-Polio Health (ISSN 1066-5331)

Vol. 7, No. 2, Spring 1991

Read selected articles from this issue ...

A Look at Carpal Tunnel Syndrome
Charlotte Gollobin, MS, LN

A Ten Year Experience
Stanley K. Yarnell, MD, Saint Mary's Hospital Post-Polio Clinic, San Francisco, CA


A Look at Carpal Tunnel Syndrome

Charlotte Gollobin, MS, LN

The approach to carpal tunnel syndrome varies, so we have studied some of the recent medical literature to determine standard as well as newer treatment. Alone and in combination, the recommendations include wrist splints, anti-inflammatory drugs, rest, diuretics, local steroid injection, surgery and vitamins B6 and B2.

In August 1989, the Washington Post carried an article on carpal tunnel syndrome reporting the possible cause to be repetition and stressful motions of the hand and wrist. It quoted results of a California study which suggested the number of people suffering from this disorder may be far higher than recognized; that health professionals may not be trained to detect it which compounds the problem according to the Centers for Disease Control.

Thirty-three patients with long-term histories of poliomyelitis and diagnoses of CTS were surveyed in another study (2). There was no significant resolution of symptoms in the patients who had surgery or were currently using wrist supports compared to patients without such treatment. In ten patients who used a single cane or ten who use crutches, there was a direct correlation between the hand holding the cane or crutch and the hand in which CTS developed. It was concluded that the chronic use of cane and crutch predisposes these patients to development of CTS and caution was suggested when considering wrist surgery.

According to the most recent issue of Harrison's Principles of Internal Medicine, the indispensable reference for medical students and many practicing physicians, carpal tunnel syndrome is defined as "an entrapment neuropathy of the median nerve at the wrist producing parasthesias* and weakness of the hands. The syndrome is caused by pressure on the median nerve where it passes in company with the flexor tendons of the fingers through the tunnel formed by carpal bones and the transverse carpal ligament."

*Abnormal tactile sensation, often described as creeping, burning, tingling or numbness.

This compression can be produced by any process that encroaches on the carpal tunnel. Premenstrual swelling or retention of fluid in pregnancy (3,4) may cause the same symptoms. Often, people engaged in activities which require repeated wrist motion may experience these symptoms. (CTS is reported to be an occupational disability of sign language interpreting associated with repetitive wrist movements and pinching [ 5].) Other cause of bilateral (in both wrists) CTS may be rheumatoid arthritis, diabetes mellitus, hypothyroidism and pregnancy. Sometimes unilateral (one wrist only) CTS may be due to some trauma, physical activity involving one wrist, gout or calcium deposition disease.

Symptoms may be described as numbness on the palmar surface of the thumb, index and middle fingers. Numbness or burning or tingling of the whole hand has been reported as well. This may be intermittent at first, becoming chronic with time (6). Pain may be experienced in the forearm as well as the shoulders and neck region, while the muscles of the fleshy part of the hand below the thumb can develop weakness or degeneration. Pain or tingling of the fingers often occurs at night.

The pain is often described as aching or burning and is aggravated by use of the hand. Motor involvement occurs late in the course of carpal tunnel syndrome. Initially, it may be manifested by stiffness or clumsiness in the hand. Later, general weakness occurs, causing difficulty with pinch and grasp. But, complete paralysis is rare, even in advance cases.

The accepted treatment of patients with only sensory symptoms and minor nerve conduction abnormalities consist of wrist splint to be worn mainly at night, anti-inflammatory drugs, and local injection with steroids. If symptoms persist or motor abnormalities are present, surgical decompression of the carpal tunnel is indicated. However, there are non-operative treatments which decrease the volume of the contents within the carpal tunnel by decreasing edema (accumulation of fluid) or inflammation. To help, diuretics are sometimes used.

Physicians can perform many simple tests to determine the extent of CTS, such as median nerve percussion, wrist flexion, and tourniquet tests. More sensitive tests include vibration and pressure threshold measurements with electrophysiologic testing.

Recently, 12 patients with CTS were studied (7). Estimates of vitamin B6 status by enzyme assays were made. Although no patients were found to have outright B6 deficiency, they nonetheless treated all with 150 mg of B6 daily for three months. The vitamin B6-dependent enzyme measured increased significantly in all patients. Six patients showed clinical and electrophysiological improvement and in these six, the target enzyme increased more than in the other six. The conclusion was reached that vitamin B6 supplementation can be recommended as adjuvant treatment in those undergoing surgery.

Another article (8) notes conservative therapy as first-line treatment unless the condition is severely advanced or immediate resolution of symptoms of CTS is essential. It recommends use of wrist splints, steroid injection, nonsteroidal anti-inflammatory drugs and vitamin B6 followed by reexamination in three weeks or earlier, if symptoms progress. For persistent or acute symptoms, surgical treatment may be necessary.

Yet another study (9) measuring B6 levels in patients concluded that vitamin B6 deficiency may accompany carpal tunnel syndrome.

Two recent articles (10, 11) further discuss the use of vitamin B6 in treatment of CTS. Drs. Karl Folkers and John Ellis and others have been publishing on this subject for many years. These reports described experiments conducted which identified cases of CTS treated with vitamin B6. Assays of the specific activity of a vitamin B6 enzyme determined the status of the patient as well as the efficacy of treatment. Three of the patients developed CTS during pregnancy while others were recommended for the study prior to surgery.

Of the 22 cases treated, 17 patients had bilateral and five had unilateral CTS. All were treated with vitamin B6 in amounts of 50-200 mg daily for minimum of 12 weeks. All hands were relieved of pain, tingling and numbness of median nerve distribution except one, for a rate much higher than that usually achieved by surgery alone. (Several medical books list CTS as the most common compression disease of the peripheral nervous system in the upper extremity of the body and note that from a few percent to as high as 20% fail to respond to surgery.)

Riboflavin (vitamin B2) is required for the first step in the activation of vitamin B6. When vitamin B2 was given together with B6 (11), treatment was more effective. Ellis and Folkers conclude that carpal tunnel syndrome is the clinical result of deficiencies of both vitamins B6 and B2.

With several options available, those with CTS now can choose from variety of treatments. If you wish to increase your B2 and B6 intakes, learning to eat foods which contain these vitamins may be beneficial.

Foods high in vitamins B2 and B6 are listed below:

Vitamin B2
Vitamin B6
Whole grains Whole grains
Legumes Legumes
Egg yolks Meats
Nuts Green leafy vegetables

Avoid excess fluid retention by keeping salt intake down and potassium intake up. Foods high in potassium include whole grains, legumes, lean meats, vegetables and dried fruits.

Please note: Whole grains (such as cereals, whole grain breads, rice, brown rice, barley, bulgur) and legumes (such as beans, peas, lentils) will give you all three of these nutrients.

REFERENCES:

1. Werner, R.; Waring, W.; Davidoff, G. Risk factors for median mononeuropathy of the wrist in post poliomyelitis patients. Arch Phys Med Rehabil 1989 Jun; 70(6); 464-7.

2. Waring, W.P.; Werner, R.A. Clinical management of carpal tunnel syndrome in patients with long-term sequelae of poliomyelitis. J Hand Surg [Am] 1989 Sep; 14(5); 865-9.

3. Nygaard, I.E.; Saltzman, C.L.; Whitehouse, M.B.; Harkin, F.M. Hand problems in pregnancy. Am Fam Phys 1989 Jan; 39(6); 123-6.

4. Wand, J.S. Carpal tunnel syndrome in pregnancy and lactation. J Hand Surg [Br] 1990 Feb; 15(1); 93-5.

5. Stedt, J.D. Carpal tunnel syndrome; the risk to educational interpreters. Am Ann Deaf 1989 Jul; 134(3); 223-6.

6. Pfeffer, G.B.; Gelberman, R.H. The carpal tunnel syndrome. Clinical Concepts in Regional Musculoskeletal Illness. Grune & Stratton, Inc., 1987.

7. Guzman, F.T., Gonzalez-Buitrago, J.M.; deArriba, F.; Mateo, F., et al. Carpal tunnel syndrome and vitamin B6. Klin Wochenschr 1989 Jan 4; 67(1); 38-41.

8. Greenspan, J. Carpal tunnel syndrome. A common but treatable cause of wrist pain. Postgrad Med 1988 Nov 15; 84(7); 34-9, 43.

9. Fuhr, J.E.; Farrow, A.; Nelson, H.S., Jr. Vitamin B6 levels in patients with carpal tunnel syndrome. Arch Surg 1989 Nov; 124(11); 1329-30.

10. Ellis, J.M.; Folkers, K. Clinical aspects of treatments of carpal tunnel syndrome with vitamin B6. Ann NY Acad Sci 1990; 585; 302-20.

11. Folkers, K.; Ellis, J. Successful therapy with vitamin B6 and vitamin B2 of the carpal tunnel syndrome and need for determination of the RDAs for vitamins B6 and B2 for disease states. Ann NY Acad Sci 1990; 585; 295-301.

RESOURCES:

American Carpal Tunnel Syndrome Association, P.O. Box 6730, Saginaw, MI 48608 USA.

Charlotte Gollobin, M.S., Nutrition Consultant, Lower Level, 11510 Old Georgetown Road, Rockville, MD 20852 USA (301/365-1622). Charlotte is the immediate past president of the American Nutritionists Association.

Dr. Siegel comments ...

Carpal tunnel syndrome (CTS) is indeed a common condition, as noted in this excellent review. In addition to repetitive motion stress, CTS may be caused by alcoholism or gout, various endocrine abnormalities, including diabetes and hypothroidism, tumors, hemophilia, any number of drugs, including Vincristine, Isoniazid, oral contraceptives and heavy metals, vascular disease, diffuse inflammatory diseases, and a variety of other diseases of unknown etiology. A common condition to be ruled out in diagnosing CTS is radiculitis secondary to cervical spine osteoarthritis. Not infrequently, pressure on the peripheral nerves in the neck, shoulder, or arm can mimic CTS. In addition to the tests listed, thermography is an excellent tool for diagnosing CTS.

Concerning therapy, first-line treatment should be to change or modify those repetitive motions which put the wrist at risk for CTS. As suggested, conservative therapy should be given every chance before turning to surgery. The use of vitamins B2 and B6 as adjunctive treatment is intriguing and may indeed prove of value.

Comments by Irwin M. Siegel, MD, 4640 Marine Dr., Chicago, IL 60640 USA).

 

Repetitive Motion Disorders Lead Increase in Job Illnesses

The Labor Department said that 32,000 more cases of repetitive motion disorders were reported in 1989 than in 1988, making it the leading cause of increases in job-related illnesses. Such illnesses result from repeating the same motions with arms and hands throughout the day, as frequently occurs on assembly lines and at computer terminals.

Repetitive motion disorders, such as carpal tunnel syndrome, rose from 115,000 in 1988 to 147,000.

Source: OT Week, Dec 13, 1990.

 

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