Debatable Therapies

(Chapter 14, excerpted from the book, "(Amazon) It's Not Carpal Tunnel Syndrome: RSI Theory & Therapy for Computer Professionals")

Before diving into our treatment recommendations, let’s discuss some of the most popular therapies you’ll encounter, and see how they stack up against our explanation for RSI.

Wrist Braces and Other Crutches

Physicians will routinely prescribe wrist braces for RSI sufferers who first complain of symptoms anywhere near the wrist. This is common, first because it’s easy and conservative. Second, the publicity—can we call it notoriety?—given to carpal tunnel syndrome convinces many practitioners that the problem is in the wrist. We believe that the prevalence of failed carpal tunnel surgery attests to the fact that the wrist is the result, not the cause.

     
    "He prescribed a wrist brace and said to make a follow-up appointment in six weeks. When I went back, he prescribed a wrist brace on the other hand. He prescribed Relafen, an anti-inflammatory, and said to make a follow-up appointment in six more weeks&ldots; if I was still in pain, he would order an EMG test. The Relafen did not help."

    -- Patient A.

Wrist braces are a type of crutch, an assist for a limb or joint that is believed to be in need of help. Doctors prescribe wrist braces in the belief that bending the wrist is the cause of all the problems, thinking that ulnar deviation is causing most of the aggravation in the carpal tunnel. Another line of reasoning is that if you have symptoms at night, it’s hoped that the brace will prevent the wrist from bending too much while you sleep.

On the first count, bending the wrist outward while typing, the concern is certainly valid&ldots; but the remedy is shortsighted. Instead we believe that you must train yourself to work as much as possible in the preferred neutral position. We’ll get into more of that later. The second concern, that bending the wrist at night might be a serious component of the problem, is probably a distraction. If you’ve got all the signs of computer-related RSI, long-term nighttime solutions will most likely be derived from daytime corrections. However, there’s little or no cost or risk to using the wrist brace at night, so we don’t flatly object to this practice. But we do have a concern: if you match up strongly against our predisposing factors, and using a wrist brace at night removes your symptoms, you may be convinced you have solved your problem. If in fact, you have solved your problem, good for you. We’re delighted one more person has defeated RSI. But if you’ve simply placated a symptom, you’ve missed valuable time that could have been spent addressing the underlying causes. For some patients, this lost time is vital.

The more important problem with prescribing wrist braces for use at work is that it will contribute to the conditions that have caused (!) your problems, namely loss of muscle strength and stamina.

Surgery

Options for carpal tunnel surgery are broadening rapidly, but the typical surgery consists of cutting the ligament that constrains the tunnel. You may ask, "How can we simply cut the ligament&ldots; don’t we need it? Won’t the wrist come apart?" No, surgeons would have you believe that we don’t really need the ligament because we don’t walk on our wrists like our four-footed friends&ldots; so we can get by with less support at the wrist. Others are of a different opinion, citing instances where the carpal bones drift out of position and the hand actually becomes deformed.

We are not going to throw statistics at you, trying to convince you that carpal tunnel surgery has a good or poor record. Statistics like this have always been manipulated to the liking of the presenter. We’ll trust that your presence here is sufficient testimony that you have some doubts about the surgery. Here’s one experience that we believe is all too common:

 

     
    "The doctor said my only option was surgery. I went to another hand doctor to get a second opinion. She said that I could try six months of therapy, which could not be guaranteed to help, or surgery. She said that in three months I would be good as new. Normal recovery from carpal tunnel release surgery is six weeks. I would need two separate operations, one for each hand. I opted for the surgery because I did not want to be out of commission for six more months.

    "I had one surgery in December and the next surgery in February. The numbness and tingling went away immediately after surgery. I went to rehabilitation and therapy for each hand. I was taught nerve glides and various stretches. I did certain strengthening exercises with putty and weights. I was massaged, but only at the wrist and hands, especially the scars on my palms. Eventually, they started me typing at therapy. My hands started going numb again within a week of typing. I still had the neck and shoulder pain that I just thought of as normal at this point. My hands would go numb whenever I lifted my arms up to my shoulders."

    -- Patient A.

This is the patient that was subsequently diagnosed by Suparna with thoracic outlet syndrome. After a few months of non-invasive therapy, she is now back at work&ldots; not 100% symptom free, but very close, and getting closer every day.

Surgeons probably can suggest an operation for every part of the anatomy that might be subject to symptoms. The problem, however, is that in the case of computer-related RSI, the surgery usually treats the symptoms, not the source. They can operate on your wrists if that’s where the pain is, or maybe a particular nerve if it’s being aggravated at a spot, but with RSI, the pain is often "referred," meaning that the nerve is sending a misleading message to the brain. For instance, if the nerve that controls the fingers is pinched at a point in the chest, it might cause the nerve to send a signal to the brain resembling pain in the fingers. Or the blood supply within the nerve itself might be constricted by the pinch point, causing erroneous sensation further along on the nerve.

When do we think surgery might be justified for nerve problems? When the nerve is so frayed or pinched that the only way it has a chance to heal is to physically alter the structural circumstances that are aggravating it. Some surgeries do this by moving the nerve&ldots; some by moving or reducing the surrounding tissues. How do you know if you've crossed this line and it’s the right thing to do? The answer has two parts:

References

"Repetitive Motion Injuries"
Philip E. Higgs, M.D. and Susan E. Mackinnon, M.D.
Washington University School of Medicine
http://biomedical.annualreviews.org
(Only the abstract is now available for free)
This article from two surgeons makes a strong case for non-surgical strategies.

Palliatives and Pain Killers

We’re in favor of anything like aspirin that can reduce your pain. But if it’s used interminably as a substitute for eliminating the causes of trauma, it doesn’t take sophisticated medical knowledge to predict that debilitation will follow somewhere down the road, while you’re preoccupied with suppressing the pain.

Doctors frequently prescribe anti-inflammatory drugs call NSAIDs (non-steroidal anti-inflammatories) to combat initial RSI symptoms, particularly wrist symptoms. NSAIDs will cause extreme irritation to your stomach, especially if it’s not made crystal clear to you that you must consume considerable quantities of food and fluid along with them. But even if they directly combat the muscle inflammation that is causing your symptoms, this still does not address the source of the abuse that is causing the inflammation. An RSI sufferer’s muscles are inflamed because of a habit of activity that will very likely continue even while taking the medicine. The drugs don’t stand a chance, and neither do you. The only good bet is that your stomach, which was initially healthy, will also start to hurt.

When might drugs be a viable option? When you clearly have a short-term situation&ldots; when your work or life circumstances are different than usual and you don’t match up well against our predisposing factors.

Vitamins

Vitamin B6 is reported to have healing powers for nerve problems, but there is hardly unanimous proof of its value. There’s no substantive body of research compelling enough for us to recommend that you resort to B6 megadoses. Moreover, there are substantial, though controversial reports suggesting that large doses are risky. When we weigh these two factors against the larger logic of how we believe chronic, computer-related RSI is caused, vitamin therapy is not likely to be a solution, and we have little basis for recommending it.

     
    "I tried Vitamin B6, beta carotene, Proanthenols, and chondroitin sulfate/glucosamine sulfate. Beta carotene and Proanthenols (a proprietary name for one brand made from grape and peanut bark extracts) are anti-oxidants, purported to have generalized healing powers because they kill off dangerous free radical molecules. CS/GS is supposed to help joint health, and is suggested for arthritis sufferers.

    "None had a noticeable effect for me."

    -- Patient E.

Are vitamins worth trying, considering how easy they are? That’s up to you. If your doctor says that large doses of certain supplements won’t hurt you, only you can decide.

Cortisone Shots and Iontopheresis

Cortisone is used to treat RSI by injecting it directly into muscles to reduce spasms. Iontopheresis uses electrical signals to infuse the medicine into your tissues without the need for an injection. The medicine can be cortisone with or without Lidocaine, a local anesthetic. Iontopheresis can also be used with other chemicals in localized areas to relieve pain, inflammation, or muscle spasm. Its effects are specific to that area and temporary, but useful until the causes of the damage are controlled.

While there are patients who experience improvement with these techniques, and cortisone is occasionally used in conjunction with the course of therapy that we recommend, it is nonetheless a symptomatic measure. Consider these techniques with the guidance of medical professionals, but use the information we provide to determine if you are unwisely expecting it to be a "quick fix" to a problem that was years in the making.