Behind Carpal Tunnel Sydrome: Do Nerves Actually Move?













As you sit at your computer working or surfing the Internet, you may be aware of your hands, arms, or neck, painful, or feeling numb or pins and needles. Most people, who work on computers, are aware of the increasing prevalence of a group of maladies known as "repetitive strain injuries". These include carpal tunnel syndrome, lateral epicondylitis, and tendinitis to name a few. The hallmark of these conditions are the symptoms mentioned above, as they progress and the nerve is more involved weakness may develop. The tricky part about these problems is that their symptoms can be similar to other problems such as nerve root irritation (a "pinched nerve") in the neck, a nerve entrapment problem which can occur at many points along the course of the nerve. Just to confuse the picture more, it is not unusual to find "double crush"(1) syndromes, where the nerve may be irritated peripherally, e.g. at the carpal tunnel and in the neck.

There are many ways to approach treatment of these problems. I tell my patients that if they go to ten different practitioners about a problem, that they are going to get ten different opinions about what is going on and ten different recommendations on the best way to treat the problem. It is not necessarily that one approach is right and that the others are wrong, but that there are many aspects to approach problems from. Each individual must find the approach that feels best to them.

One way that I have found to be effective to help people manage these problems is to consider the movement dynamics of the nerve. Movement of the nervous system seems to be a neglected component of these problems. Indeed, some might question whether nerves move at all. Since we are wonderful pieces of mobile architecture, I dismiss it as common sense that nerves move. Normal movement of the nervous system as well as the joints, muscles and connective tissues is important to maintaining the health of our neuromusculoskeletal system. In 1979, an Australian Physical Therapist, Robert Elvey(2) was working with patients with shoulder and arm pain that was not behaving or responding like many of the problems that are usually considered. His frustration led him to return to the anatomy lab and work on cadavers to analyze the movement of the nerves from the neck to the arms. He found lack of normal longitudinal and side to side movement of nerves to be the missing piece to many of these problems. He coined the term Upper Limb Tension Test for the series of maneuvers that evaluated the movement of the nerves, especially the nerve involved in carpal tunnel syndrome (median nerve).

His work was expanded on by another Aussie Physiotherapist named David Butler(3) who devised further tests to examine the other major nerves of the arm. The research on this clinical approach is continued by Physical Therapists both in Australia and in the U.S..This concept of movement of the nervous system is not new. Research that forms the basis for this work started as early as the fifties. Alf Brieg(4), a Swedish physician published a book in 1978 on Adverse Mechanical Tension in the Central Nervous System. There was also a study done in 1976 where a needle was inserted in the median nerve in the lower arm. The arm was moved into different positions to measure the longitudinal sliding of the nerve.(5) You wouldn't catch me volunteering to be a subject for that one!

One of the primary culprits for causing interference with the movement of the nervous system seems to be inflammation and the ensuing fibrotic changes around and within the nerve involved. Repetitive movements causes irritation and inflammation and swelling of the tissues surrounding the nerve and if it advances the inflammation can get into the nerve sheath. The after math of this inflammatory reaction is the formation of fibrotic tissue (similar to scar tissue but different) which essentially gums up the movement works. This process can be progressive with subsequent bouts of pain and tissue damage or irritation, inflammation and fibrotic changes. Often the fibrotic changes and lack of normal movement in and around the nerve seem to perpetuate the problem.

Where is this all leading and how does is relate to those in Cyberspace? It is important to remember that a little prevention and maintenance exercise can go a long way to keeping repetitive strain injuries from becoming a big problem. Most people are aware of the benefits of stretching. Just as hamstring stretching not only stretches the muscles but also moves the sciatic nerve. Stretching of the arms in a certain ways can help to maintain the muscle length and normal mobility of the nerves.

A Simple Stretch for Your Arms and Hands

Here is an exercise to try next time your arms or hands start to ache or get mildly tingly:

(This advice and exercise description is not intended to substitute for proper attention to a problem. If you have severe pain, numbness, tingling or weakness you should get proper help. Trying these exercises could be counterproductive and irritating with severe symptoms.)

Stand and place the palm of your hand against the wall with the fingers facing the ceiling, or for a stronger mobilization, with the fingers facing backwards.

Step away from the wall so that your shoulders are perpendicular to the wall and your elbow is extended fully or to a comfortable amount. You should feel some pulling in your upper or lower arm. If you do not feel pulling in this position, you can turn your body and/or head away from your arm. to get a stronger movement.

Once you feel a pull but no pain, hold the position for 15- 20 seconds. Relax and feel how your arm moves in ways you may never have thought of. You can repeat this a few times on each arm.

*** If you feel any tingling/pins and needles in the arm during this maneuver, put your arm down right away and this should stop in a few seconds. You should not be stretching so hard that you produce pain or tingling. Remember, my motto is "Motion is the Lotion" not "No pain, no gain".

This exercise primarily moves the Median nerve involved in carpal tunnel syndrome. I have found it to be helpful to people even after a surgery to keep the tissues moving. There has usually been significant inflammation involving the nerve by the time someone gets to surgery.

Tips For Working on the Computer

In addition to this particular exercise, remember all the good things that you have heard and read about preventing problems due to extended use of the computer:

  • Take frequent "pause beaks" to change position and activity
  • Stretch your neck, upper back and shoulders periodically. For example, pay attention to a starting position of elongating the back of the neck, tucking the chin and glide the ears back over the shoulder, now you can turn your head to each side and hold for 5-15 seconds. Also from this position you can bend your neck to the side bringing your ear to your shoulder, hold and then add bending forward, hold 5-15 seconds.
  • It is important have a good ergonomic set up of your computer station. More on that later.

Good luck, remember to listen to your body!


Written by Krista J. Clark, PT


References:

  1. Upon A and McComas A: The double crush in nerve entrapment syndrome. The Lancet 2:359- 362, 1973
  2. Elvey RL: The investigation of arm pain. Grieve ed, Modern Manual Therapy of the Vertebral Column, Churchill Livingstone, Edinburgh 1986
  3. Butler D: Adverse mechanical tension in the nervous system: A model for assessment and treatment. Aust J Physio 35(4): 227-238 1989
  4. Brieg A: Adverse Mechanical Tension in the Central Nervous System. Almquist & Wiskell, Stockholm,1978
  5. McLellan DL and Swash M. Longitudinal sliding of the median nerve during movements of the upper limb. J of Neurology, Neurosurgery and Psychiatry 39: 566-570. 1976


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