Yoga and Carpal Tunnel Syndrome - Khoury College



Yoga and Carpal Tunnel Syndrome

Research paper by Ruth Lieberherr

(Final Version April 2004)

I. Theory and Analysis: What is Carpal Tunnel Syndrome?

a. Introduction

In recent years "Repetitive Strain or Stress Injuries" (RSI) or "Cumulative Trauma Disorders" (CTD) have increased dramatically, and one of the most frequently reported is Carpal Tunnel Syndrome (CTS) - according to "NIOSH Facts", a report of the Center of Disease Control (1).

b. Anatomy

The carpal tunnel is named after eight bones in the wrist, called carpals. They form a tunnel like structure, covered on the palm side by the transverse carpal ligament. (Ligaments connect the bones together.) Passing through this tunnel are the nine flexor tendons, connecting the fingers to the muscles in the forearm, and the median nerve. The median nerve gives sensation to the thumb, also the thenar muscle at the base of the thumb, the forefinger, the middle finger and half of the ring finger, but NOT to the little finger.

Each tendon has been compared in size to a "thick piece of linguine" (2) or almost as wide as a pencil (3), the median nerve in size to a pencil (2, 3). When you look at your wrist, you realize that there is no extra space!

A slippery lining called tendosynovium or tendon sheath, which helps them slide through this narrow tunnel, covers the tendons.

c. What Causes Carpal Tunnel Syndrome?

"Any condition that makes the area inside the carpal tunnel smaller or increases the size of tissue within the tunnel can lead to symptoms of CTS." (4)

The following conditions or illnesses can affect the carpal tunnel, the tendons and nerve inside:

- Bone fractures

- Arthritis

- Diabetes

- Thyroid disease

- Pregnancy (increased fluid retention can cause swelling in the wrist)

- Menopause (same as above)

- Smoking

- Obesity

- Caffeine consumption

External, mechanical conditions that can affect the carpal tunnel, tendons and nerve within:

- Force

- Body posture

- Wrist alignment

- Repetitive motion

- Temperature

- Vibration (e.g. a power tool)

It is generally agreed, that repetition of the same movement for many hours can cause the tendosynovium to swell and thus press on the median nerve. Repeated pressure on the median nerve can lead to "numbness, tingling, pain, and discomfort" (5), the symptoms of Carpal Tunnel Syndrome.

Some publications are skeptical and one government publication questions this assumption completely:

"Most likely the disorder is due to a congenital predisposition - the carpal tunnel is simply smaller in some people than in others." (6) The same publication notes that women are three times as likely to get CTS as men, probably again because their carpal tunnels are smaller.

It may be that a combination of causes over a period of time is necessary to induce Carpal Tunnel Syndrome. It is also evident, that any repetitive motion aggravates the symptoms, if they are already present.

What all studies agree on is that the symptoms should not be ignored. If the inflammation and the outer (bad) conditions persist, the injury becomes chronic. It can lead to scarring of the nerve tissue. The injury then needs less irritation or trauma to be aggravated and finally it could lead to permanent nerve damage and atrophy of the affected muscles.

c. Symptoms and Tests for CTS

Symptoms for CTS are:

- Numbness and/or tingling in the fingers of either hand (mostly thumb, forefinger and ring finger, NOT in little finger, see anatomy). In general it first affects the hand the patient predominantly uses, i.e. the right hand for right handed people.

At the beginning the numbness/tingling especially happens when the patient wakes up in the morning, as movement during the day relieves the swelling from excess fluid caused by the inflammation, while the pressure on the nerve builds up during the night. Bending the wrist while sleeping may also increase pressure on the median nerve. (7)

More symptoms of CTS:

- Clumsiness or weakness in the fingers

- Pain from the wrist that can either shoot up into the arm or down into the hand

- Pain or discomfort radiating or shooting up to the neck or down into the hand

- Burning in hands and fingers

- Insensitivity to cold or heat

- With progression of the condition, numbness and/or sudden pain can waken the patient from deep sleep. (8)

Other disorders could cause similar symptoms. Therefore it is important to be precise with a description of the symptoms and the affected areas (e.g. one important telltale is that the little finger is NOT affected by the numbness and/or tingling).

Doctors can test for CTS with the Tinel, the Phalen test or with electradiagnostic tests.

"In the Tinel test, the doctor taps on or presses on the median nerve in the patient's wrist. The test is positive when tingling in the fingers or a resultant shock-like sensation occurs. The Phalen, or wrist-flexion, test involves having the patient hold his or her forearms upright by pointing the fingers down and pressing the backs of the hands together. The presence of carpal tunnel syndrome is suggested if one or more symptoms, such as tingling or increasing numbness, is felt in the fingers within 1 minute." (9)

"(...) electrical studies of the nerves in the wrist may be requested by your doctor (...) including the nerve conduction velocity (NCV) test. This test measures how fast nerve impulses move through the nerve." (10)

d. Who Is Affected By CTS?

CTS affects a very wide range of people, from accountants, assembly line workers to artists, butchers, musicians, gardeners, programmers, knitters, writers and golfers ...The eclectic list goes on. (11)

As noted earlier, women are three times more likely than men to be affected by CTS. Adults, especially people over 50, are affected by CTS.

Several articles ventured a psychological interpretation and postulated that a certain personality type is more prone to CTS, namely people who tend to be more driven and more of a perfectionist. In her Yoga Journal Nov. 2002 article, Carol Krucoff quotes Gail Dubinsky, a yoga instructor and M.D., as saying that RSI seldom happens to "slacker” individuals. "Much more often than not, affected people have an excessive work ethic and push themselves to complete tasks or perform in the workplace. (...) There is commonly a profound lack of body awareness or a suppressing of any awareness that does arise, so they can perform in a way a 'good employee' should." (12)

II. Preventions and Cures for CTS

a. Prevention

The general agreement is that it is best to prevent CTS!

One way of prevention was to study the work place and implement changes there. One approach was to redesign tools to allow a more natural hand position or modifying layouts of workstations.

"Still other approaches include altering the existing method for performing the job task, providing more frequent rest breaks, and rotating workers across jobs."(13)

Obviously, the latter is much harder to accomplish.

b. Traditional Treatments of CTS

Anti-inflammatory drugs as Advil, ibuprofen, as well as hand splinting (wrist braces) are used. Of course if a patient goes back to the same habits and work conditions, the symptoms might just reoccur. Some doctors use physical and occupational therapists to evaluate the patient's work environment, his/her body posture and wrist alignment.

If the symptoms are more severe, oral steroid intake or cortisone injections into the wrist might be the next step. After that different kinds of surgery are used. In essence all involve one or more cuts through the palm and cutting the transverse carpal ligament. The ends are left and eventually scar tissue will connect them again, thus widening the carpal tunnel and giving the tendons and median nerve more room.

Recovery from the surgery takes between four and six weeks. The operation has a high success rate. Full recovery sometimes needs physical or occupational therapy (e.g. squeezing and manipulating a small rubber ball). Full recovery depends also on the severity of the nerve damage or whether some muscles have atrophied, like the thenar muscle at the base of the thumb. (14) (The thenar muscle lets us touch the thumb pad to the fingertips. This is called opposition.)

c. Alternative Paths of Healing

In some articles it was mentioned that patients seemed to have benefited from acupuncture and chiropractic treatment. Yet currently there are no scientific studies, which prove the effectiveness of these treatments.

However it is widely acknowledged, that yoga is an effective alternative treatment. This is mainly so because of just ONE scientific study! It was led by Marian Garfinkel and reported in the Journal of the American Medical Association on November 11, 1998. (15) (The study was quoted in most new publications I found.)

d. Yoga and CTS

Marian Garfinkel led a study on the effect of yoga on CTS and published the results in the Journal of the American Medical Association in 1998. (15)

The study tested 42 individuals with CTS over a period of 8 weeks. The subjects assigned to the yoga group practiced "11 yoga postures designed for strengthening, stretching and balancing each joint in the upper body along with relaxation twice weekly (...) Patients in the control group were offered wrist splints to supplement their current treatment." (16) The yoga group showed significant improvement in grip strength and Phalen sign.

III. Practical Part

a. Common Sense Prevention and Remedies

Even without introducing yoga, it is generally agreed to use common sense procedures to reduce the risks of CTS by

- Adjusting physical work conditions.

- Taking regular breaks from repetitive movements. (Get up and move around every half hour. Maybe set a timer to remind yourself.)

- Doing stretching and muscle relaxing exercises.

- Working with a physical or occupational therapist on healthy body alignment and wrist position, if problems occur.

Especially the middle two points, taking breaks and doing stretching/relaxation exercises, are hard for the driven, perfectionist personality type, described earlier. For him/her yoga might help to find a quieter, peaceful mindset, besides the benefits of the yoga stretches. Gail Dubinsky expresses this in her article in Yoga International, Dec/Jan 2002:

" We need to practice the yama of ahimsa (non-harming) toward ourselves. We need to nurture ourselves, set limits on work, and cultivate self-love as well as respect and compassion for our limitations." (17)

b. Simple Exercises to Be Done At the Desk

There are many suggestions for short exercise programs that include specific stretches and relaxations. The following description I found least technical and therefore easiest to remember and include with one's own favorite stretch(es):

" - Take short breaks.

- Stand up. Move the hips and legs around and stretch them.

- Exercise your fingers by closing and opening your fists.

- Move your shoulders; interlace your fingers and press, squeeze and release.

- Stretch your arms outwards, rotate them; right arm moves counterclockwise, left moves clockwise; pull them back behind you.

- Include some neck exercises too: side to side, back to front.

- Let your torso move upward and stretch backwards while supporting your lumbar with your hands.

- Take deep yoga breaths." (18)

Also include twists and side stretching.

c. The Eleven Yoga Postures used in the JAMA Study Led by Marian Garfinkel (Penn Study)

In his review of the Penn study, Chuck Chandler describes the yoga postures in the following way:

"1. Staff pose - Sit on a chair, trunk upright, press hands into chair, press shoulder blades into back, move shoulders back and down.

2. Prayer position - Press palms and fingers together, stretch and bend fingers.

3. Arms overhead - Keep arms straight overhead with shoulders down.

4. Arms overhead with fingers interlocked - Same as No.3, turn palms upward.

5. Chair twist - Sit sideways in chair with right side against back of chair, twist to the right using hands for additional support. Repeat on other side.

6. Mountain - Stand straight, facing forward, with inner ankles touching. Balance weight evenly on inner and outer edges of both feet, heels and soles. Lift kneecaps into joints. Raise upper chest and collarbones.

7. Ninety-degree forward bend to wall - Stand with feet about hip-width apart, raise arms over head, bend at hips, bringing hands to rest on wall.

8. Arms overhead with hands in prayer position - Stand in mountain position, raise arms to "T" position, turn palms up, then rotate arms in small circles, first forward, then back. Lift arms straight overhead, join hands in prayer position, stretch up and look up at hands.

9. Dog pose with chair - Stand with feet hip-width apart, facing the seat of a chair. Bend, placing palms on seat, shoulder-width apart. Straighten arms and lift waist, hips and knees a few inches above the chair. Turn arms out and curve trunk back between them. Bring coccyx, sacrum, and lumbar spine forward, keeping buttocks tight. Stretch front of body from the pubis. Raise sternum and ribs. Hold shoulders back. Press shoulder blades and dorsal spine in.

10. Hands in prayer position behind back - Stand in mountain position, bring palms together behind back, fingers pointing down. Turn fingers up and raise as high as possible between the shoulder blades." (19)

11. Relaxation (Savasana) (In original Penn study, not in Chandler's list.)

Each of the poses should be held for a minimum of 30 seconds, of course much longer for savasana, at least for 5-10 minutes. (20)

Chuck Chandler also quotes Atul K. Singhal, MD, and a co-author of the Penn study. Singhal notes that “one of the major advantages of yoga is that it is pretty much self-sustaining after you get started" and that 5-10 lessons "should be more than adequate to teach you the right stuff" to overcome CTS (21). He also warns: “It is absolutely of critical importance to go to someone capable of teaching yoga the right way(...)

It could be harmful if not done the right way." (22)

Carol Krucoff writes about yoga and carpal tunnel syndrome in an article published in Yoga Journal, November 2002 (22), and later modified in Third Age - Health Newsletter (23). In the latter she describes the following sequence of chair-based yoga exercises, designed by Marian Garfinkel (based on her 1998 Penn study). The series should take less than 10 minutes.

"1. Dandasana (staff pose in chair)

2. Namaste (hands in prayer position)

3. Urdhva Hastasana (arms extended overhead)

4.Utthita Hasta Padasana (arms only)

[She describes this as raising arms to shoulder level, palms facing down, while sitting upright in a chair (staff pose in chair).]

5. Bharadvajasana (chair twists)

6. Urdhva Mukha Svanasana (modified upward facing dog pose)

7. Adho Mukha Svanasana (modified downward facing dog pose)

8. Savasana in chair (modified relaxation pose)"

d. My Experience with Yoga Poses to Relieve Symptoms of CTS

1. Ardha Salabhasana - Half locust with palms facing floor, little fingers touching

Although this pose was originally very uncomfortable, I eventually began to really like it. The relief, after the pose, of bringing the hands out from under my body and circling the wrists brought a lot of blood and a feeling of rejuvenation to my wrists.

2. Interlacing the fingers, while extending the forefingers and pressing the palms together strongly in various asanas (e.g. Tadasana urdhva hastasana - mountain pose with arms overhead, Ardha kati chakrasana - overhead and side stretch, Virabhadrasana I - Warrior I).

This has helped to strengthen my fingers and hands and stretched out my wrists.

3. Lying on back, with a twist of the legs to one side (e.g. right side) - bring arms overhead and grasp the right hand from the back with the left hand and stretch the right wrist to the left (palms facing up). Then repeat, with switching legs and the hand stretch to the other side.

This is a gentle stretch to the wrist that feels good. It is nice to combine it with a twist to the spine.

III. Carpal Tunnel Syndrome - My Personal Account

Informing myself about the anatomy, symptoms and even more anecdotal accounts about CTS personality types, has proved to be very helpful for me.

I had several helpful and healing insights about myself:

1. I take the health of my family very seriously and act promptly, if anybody has an ailment. If I, however, unconsciously suspect, that a physical symptom I have, could be a token of a serious condition, I try to ignore it. My unconscious assumption is, if I don't acknowledge it, it does not exist. (I have gone through a similar process concerning a cyst about ten years ago.)

2. I realized (again), that I am a perfectionist and rather compromise my comfort or health in accomplishing a goal, than compromising the results of my efforts.

My personal background concerning CTS:

For about a year I have been waking up in the morning to find that my thumb, forefinger and to a lesser degree my middle finger were completely numb. That was quite scary, but I massaged my fingers, did not tell anybody and made plausible excuses to myself. E.g. I had been working a lot on oil pastel paintings and had rubbed the pigment into the paper with my fingers. I told myself that I just squashed the nerve endings in my fingers a little bit and that this was nothing to be concerned about.

On the other hand, I knew quite well that my father had a very traumatic experience with CTS. He ignored the symptoms for so long that he finally had both hands operated on within days from each other, as the doctors found that the median nerve in his hand had almost atrophied. My father was between 78 and 80 years old at the time, and still working. The operation had a huge impact on his life, as it rendered him almost helpless for several months.

After my research confirmed to me that I probably had symptoms of CTS, I took action:

1. I acknowledged that the symptoms I have might be the symptoms of CTS.

2. I started to be aware of and to change my work habits:

- Taking care of my body alignment when I do something.

- Adjusting the position of my wrist.

- Taking breaks from repetitive movements.

- Forcing myself to pause and stretch.

All of this is not easy and I am constantly struggling with it.

3. At night I try to change my sleeping position - not to sleep with my hands under my head, with the wrists curling in. (I think of buying a wrist brace to wear at night and sometimes during the day.)

4. I want to incorporate yoga poses for CTS at last twice a week into my schedule (a slow start so far).

5. At my next acupuncture treatment, I will tell my acupuncturist about my symptoms.

6. I also considered getting CTS tests done at my doctor's office. (Ironically, I had my yearly check-up about two weeks ago and did not think of mentioning my symptoms!)

For right now, I want to see how I can improve the health of my wrists by changing my work habits, bringing awareness to body and wrist, incorporating acupuncture and doing yoga poses for CTS. Since Carpal Tunnel Syndrome may be caused by a combination of causes, I decided to use a multipronged approach to curing myself as well:

- Changing work space

- Changing work patterns

- Body alignment

- Wrist alignment

- Yoga

- Acupuncture

- Wrist brace

Updates:

February 23, 2004

I told my acupuncturist about my symptoms of CTS. She responded

very positively. In her seven years working as an acupuncturist, all her patients with CTS improved after acupuncture treatment. She also said that her colleagues feel similarly that CTS can be treated very successfully with acupuncture. What is necessary to convince the medical establishment is to do an at least single blind research study with a control group! My acupuncturist was very responsive to the idea.

Acupuncture works to remove blockages in the flow of energy along the meridians in the body. CTS is caused by a swelling or inflammation, i.e. a blockage in the carpal tunnel. Even western medicine tries to remove this blockage. It makes sense that acupuncture would work well with CTS. My acupuncturist pointed out to me that denying my problem is a blockage, too. Sometimes even acknowledging a problem opens the flow of energy.

April 19, 2004

Doing the research and writing this paper on CTS helped me become aware of my own problem with CTS and showed me ways to work with it. It helped me to see my own habits and shortcomings again and to address them.

My hand has improved dramatically. I rarely wake up in the morning with any numbness in my fingers. I usually don’t have any symptoms (like tingling or pain) in my hand or wrist during the day. My hand and fingers feel as good as new.

It also was helpful to start working with a person who suffers more severely from CTS. I hope the yoga exercises helped her. They reminded me to continue with yoga for CTS, to integrate breaks as well as body and wrist alignments into my work routines and above all to keep listening more to my body.

Thank you, Debbie!

Notes

1. NIOSH, p. 1

2. Fried, p. 5

3. Eaton, p. 1

4. Patient, p. 2

5. Fried, p. 6

6. NINDS, p. 3-4

7. Fried, p. 6; also NINDS, p. 3; Eaton, p. 2

8. NIOSH, p.1-2; NINDS, p. 3

9. NINDS, p. 4

10. Patient, p. 5

11. Chapelle CT, p. 2-3

12. Krucoff YJ, p. 105-6

13. NIOSH, p. 3; also Patient, p. 5

14. NIOSH, p. 2; also Patient, p. 5-6

15. Garfinkel

16. Chapelle CTSstudy, p. 2

17. Dubinsky, p. 91

18. Ranjanasyoga, p. 2-3

19. Chandler, p. 2-3

20. Chapelle YfCTS, p. 1-3

21. Chandler, p. 2

22. Chandler, p. 3

23. Krucoff YJ, p. 101 ff.

24. Krucoff TAHN, p. 2-3

Bibliography

Scientific study about yoga and carpal tunnel syndrome, quoted by many of the publications:

Garfinkel, Marian S., A. Singhal, W. Katz, et al., “Yoga-based intervention for Carpal Tunnel Syndrome: A randomized trial”, The Journal of the American Medical Association, November 11, 1998 (Garfinkel)

Fried, Scott M., Dr., The Carpal Tunnel Helpbook, Self-Healing Alternatives for Carpal Tunnel Syndrome and Other Repetitive Strain Injuries (Fried)

Articles, pamphlets :

(All web information printed February 2004)

“Alternative Medicine: Yoga and Carpal Tunnel Syndrome”

076alt_med/2.html

“Carpal Tunnel Syndrome – 10 Great At-Your-Desk-Exercises”, exercise.php

Chandler, Chuck, “Is Yoga a Remedy for Carpal Tunnel Syndrome?”, Health South Information Center, yogaCTS.html

(Chandler)

Chapelle, Rich,”Carpel [sic!] Tunnel Syndrome and Yoga: What is Repetitive Strain Injury (RSI) of the Hand?”, yoga/CTS-RSI.htm

(Chapelle CTS-RSI)

Chapelle, Rich, “Carpal Tunnel Syndrome and Yoga”, yoga/carpaltunnel.htm (Chapelle CT)

Chapelle, Rich, “Carpel [sic!] Tunnel Syndrome and Yoga: The University of Pennsylvania School of Medicine Study”, yoga/CTSstudy.htm (Chapelle CTSstudy)

Chapelle, Rich, “Carpel [sic!] Tunnel Syndrome and Yoga: How can Yoga Help Reduce the Symptoms of CTS?”, yogaforCTS.htm (Chapelle YfCTS) (Description of 11 poses from Garfinkel study)

Dubinsky, Gail, M.D., “too much for too long – healing repetitive strain injury”, Yoga International, December/January 2002, p. 90-97 (Dubinsky)

Eaton, Charles, M.D., “Carpal Tunnel Syndrome”, Hand World patient information brochure, hw/hw006.htm? (Eaton)

Krucoff, Carol, “Occupational Hazard” (with Asanas by Marian S. Garfinkel, Ed.D.), Yoga Journal, November 2002, p. 101-107 f. (Krucoff YJ)

Krucoff, Carol, “Exercises to Help with Carpal Tunnel Syndrome”, Third Age Health Newsletter, 2002, news/archive/ALT02030915-01.html?std (Krucoff TAHN)

Layton, Stephanie, “Carpal Tunnel Relief”, Yoga Journal, March/April 1999

Lee, Cyndi, “Yoga Poses at a Desk”, practice/714.cfm

Medical Multimedia Group, Missoula, MT 59802, “A Patient’s Guide to Carpal Tunnel Syndrome”, eorhopodV2/index.php/fuseaction/topics.detail/ID/b0dc8c853 (Patient)

Miller, Elise Browning; Blackman, Carol, “Six Stretches to Do at Your Desk”, Yoga Journal, March/April 1999

National Institute of Neurological Disorders and Stroke (NINDS), “Carpal Tunnel Syndrome Fact Sheet”, Reviewed November 1, 2002, accessible.ninds../health_and_medical/pubs/carpal-tunnel.htm (NINDS)

NIOSH Facts, “Carpal Tunnel Syndrome”, June 1997, updated August 12,1997, Document # 705001, niosh/ctsfs.html (NIOSH)

(NIOSH= The National Institute for Occupational Safety and Health, part of CDC= Center for Disease Control and Prevention)

Pirisi, Angela, “Carpal Tunnel Cure – Take a yoga break from your computer to prevent wrist injury”, Yoga Journal, July/August 2000

“Preventing Carpal Tunnel Syndrome”, Linda J. Johnson, OTR, consultant, et. al., Krames Communications

Ranjanasyoga, “Surgery, Scar Tissue, Whiplash & Carpal Tunnel, article_s.htm (Ranjanasyoga)

Serber, Ellen, “RSI exercises, Preventing and healing* Carpal Tunnel Syndrome & Repetitive Stress Injuries”, yoga/rsi.html

“The Yoga Prescription: Carpal Tunnel Syndrome”, print/view/1,1560,AR_1,00.html

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