Carpal tunnel syndrome (CTS) is not difficult to confirm by electrodiagnosis (EDx), but the challenge lies in whether to grade the severity and the method for doing so. The arguments about grading are discussed, with an emphasis in favor, using a method that relies on the EDx data, but qualifies that it is the median neuropathy being graded and not the syndrome of CTS. Although use of latencies can be arbitrary and misleading, it is possible to apply other criteria, such as low amplitudes or conduction block and denervation, to develop a grading scale that could be applied widely. Several previously published grading schemes are reviewed, and a new method is described that combines the prior ranking criteria into 3 basic categories. Application of a grading system identifies the degree of nerve injury and thus allows the referring physician to utilize optimally the EDx report to manage the patient.
Carpal tunnel syndrome was studied by use of supplemental palpatory diagnosis in 20 abnormal wrists. Restriction in motion at the carpal tunnel was quantified with a rating system. All wrists with carpal tunnel syndrome revealed at least moderate restriction to motion, as compared with only mild or no restriction in 20 wrists in normal, symptom-free subjects. Several participants (16 abnormal wrists) underwent osteopathic manipulative treatment, including a new "opponens roll" maneuver, and self-stretching, or a similar treatment accomplished by use of a self-treatment appliance. In those treated, palpatory restriction decreased into the normal range, often before symptoms decreased. Improvement in nerve conduction studies usually followed within 1 to 3 months. Palpatory diagnosis is a useful adjunctive method of assessing patient status in carpal tunnel syndrome and helpful in prognosticating outcome. The modified manipulative technique described for the treatment of mild to moderate carpal tunnel syndrome may be effective in more severe cases.
Four patients with carpal tunnel syndrome, unresponsive to routine conservative care, underwent treatment with myofascial release manipulation and selfstretching. Magnetic resonance imaging analysis of the cross-sectional area of the carpal tunnel and electrodiagnosis were performed before and after treatment. The patients improved clinically. The nerve conduction studies showed concomitant reduction in distal latencies or increase in motor response amplitudes. Magnetic resonance imaging demonstrated that the anteroposterior and transverse dimensions of the carpal canal significantly increased after treatment. This study demonstrates that the carpal canal is a distensible structure with the potential to yield to a relatively simple, aggressive, nonsurgical treatment for carpal tunnel syndrome.
Current treatment for carpal tunnel syndrome may be ineffective or associated with complications or recurrence. In the case reported here, a myofascial release by the physician combined with the patient's self-stretch reduced pain and numbness and improved electromyographic results. The manipulative approach releases the transverse carpal ligament,and "opens"or dilates the canal. The patient stretches the wrist, digits, and thumb, including myofascial components. An aggressive, conservative approach lessens the need for surgery in mild to moderate cases. Studies with magnetic resonance imaging may be helpful to document canal size before and after treatment.
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