VOL 47: MARCH • MARS 2001❖Canadian Family Physician•Le Médecin de famille canadien 547
CME
arpal tunnel syndrome (CTS) is a common, painful disorder that occurs predominantly in adults 40 to 60 years old. It is five times more likely to occur in women than in men but is extremely rare in children. Traditional treatment includes splinting, nonsteroidal anti-inflammator y drugs (NSAIDs), vitamin B6, steroids, physiotherapy, restricting hand activity, and changing occupations.
Steroid injection into the carpal tunnel provides effective short-term relief 80% of the time.1Surgery is recommended in 40% of cases. Postsurgical recovery from conventional techniques is slow; light work can resume at 4 to 8 weeks and heavy gripping or repeti- tive work at 3 months.
Endoscopic techniques have reduced functional recover y times but are not always available.
Complications arise in 10% of carpal tunnel surgery cases, including failure to relieve symptoms or symp- tom recurrence.
This case report documents use of acupuncture in a patient who wanted to avoid surgery. Using soft-tis- sue ultrasound to diagnose and follow the effects of acupuncture treatment is highlighted.
Case report
A 36-year-old woman was referred to one of the authors (R.B.) for acupuncture treatment for CTS. The author had incorporated acupuncture into his practice, and over the past several years had developed a referral practice in Prince Rupert, BC, using needle acupuncture for vari- ous musculoskeletal complaints. This patient had been
complaining of numbness and pain in her right hand and wrist for 9 months. The left hand was asymptomatic. Her only prior treatment was a custom-made wrist splint worn at bedtime. It was only somewhat helpful.
The patient had been diagnosed with Crohn’s dis- ease 13 years earlier, but it required no treatment. A physical examination showed severe CTS evidenced by true wasting of the right thenar muscle as well as the first and second dorsal interossei muscles together with weakness of the opponens pollicis.2 Tinel and Phalen’s signs were positive on the right. Results of an arterial blood pressure cuff occlusion test were posi- tive with reproduction of symptoms in less than 60 sec- onds. The patient had a normal body mass index of 25.
Laboratory investigations included normal fasting blood sugar, glycosylated hemoglobin (HbA1c), and thyroid-stimulating hormone. The nearest facility for nerve conduction studies was 2 hours away in Terrace, BC, and it was not standard practice to refer patients for this test unless they were being considered for surger y, which this patient was tr ying to avoid.
Diagnosis was thus based on clinical history and find- ings together with soft-tissue ultrasound findings.
Soft-tissue sonograms of both carpal tunnels were conducted before treatment and after symptoms dis- appeared. The median nerve in normal wrists has a standard size and appearance, flattening ratios, and limits to palmar displacement. At least one of the fol- lowing is considered diagnostic of CTS on ultrasound examination: diffuse or localized swelling of the medi- an nerve at the entrance and in the proximal part of the tunnel, flattening of the median nerve in the distal part of the tunnel, and increased bowing of the flexor retinaculum. Initial examination showed both median ner ves to be flattened with an anterior-posterior diameter of 2 mm; the right was hypoechoic in rela- tion to the left. Mean cross-sectional area of the right median ner ve was 5 mm2 and of the left median ner ve 9 mm2. Acupuncture treatments were per- formed weekly for 5 weeks.
During the treatment period, the patient decided on her own to stop wearing her night splint, and in 5 weeks without any other treatment she was symptom free. Results of a follow-up ultrasound evaluation showed that both nerves had symmetric echogenicity, Dr Banner is a family physician currently in his final year
of anesthesia residency at the University of Saskatchewan in Saskatoon. He is a Certificant of the Medical
Acupuncture Course for Physicians from the Universities of Saskatchewan and Alberta and is recognized by the College of Physicians and Surgeons of Saskatchewan as having spe- cial training in acupuncture. Dr “Mac” Hudson is Head of the Department of Medical Imaging at Mills Memorial Hospital in Terrace, BC.
This article has been peer reviewed.
Cet article a fait l’objet d’une évaluation externe.
Can Fam Physician2001;47:547-549.
C
Case report: Acupuncture for carpal tunnel syndrome
Ultrasound assessment of adjunct therapy
Robert Banner, MD, CCFP Emanuel William Hudson, MD, FRCPC, DABR
CME
Acupuncture for carpal tunnel syndrome
548 Canadian Family Physician•Le Médecin de famille canadien❖VOL 47: MARCH • MARS 2001
with a normal anterior-posterior diameter (1.4 mm) and mean cross-sectional area (3 mm2).
Discussion
Electromyography (EMG) is considered the criterion standard for diagnosing CTS. Practices located in remote areas often do not have access to EMG; ultra- sound evaluation is generally more accessible. For patients who present for surgery with an EMG diagno- sis of CTS, ultrasound and magnetic resonance imag- ing are equally reliable and valid for demonstrating anatomical abnormalities consistent with symptoms.3-5 In 1997, a National Institutes of Health Consensus Conference was held to answer a predefined set of questions concerning acupuncture. A 12-member panel reviewed the literature (as described below);
heard presentations from 25 experts from various fields; and, in an open forum of 1200 people, devel- oped conclusions and recommendations based on the weight of evidence provided. They concluded that acupuncture might be effective as an adjunct therapy, as an acceptable alternative, or as part of a compre- hensive treatment program for CTS.6
To facilitate deliberations of the consensus devel- opment panel, the National Librar y of Medicine (NLM) conducted an extensive review of the litera- ture from January 1970 through September 1997. All NLM databases were searched electronically and NLM journals searched manually for articles with rel- evant clinical data on acupuncture. The bibliography also incorporated much of the Medical Acupuncture Research Foundation’s bibliography disseminated by the American Academy of Medical Acupuncture.
Only two of 2302 citations in the primary biblio- graphic source for this conference dealt with acupuncture and CTS. One abstract of a prospective observational study reported successful use of a galli- um arsenide laser along five points of the distal medi- an ner ve.7 Unfor tunately, no publication could be found in follow up to the abstract.
In this abstract, symptom relief with normaliza- tion of latencies occurred in nine of 11 patients who had clinical and EMG evidence of CTS. In the only other reference, Chen8retrospectively reviewed use of acupuncture in 36 patients with EMG-diagnosed CTS. Using either manual or electrical stimulation with acupuncture needles at pericardial 6 and 7, gave 24 patients complete relief of symptoms. They con- tinued to report being symptom free for 2.5 to 8.5 years. Subsequent searches of EMBASE, MANTIS, and MEDLINE after 1997 did not find any new rele- vant articles.
The response of this patient to acupuncture is typi- cal of that seen by medical practitioners who use acupuncture as an adjunct treatment for CTS.
Acupuncture is relatively innocuous and generally well tolerated. The points chosen for this patient are com- mon in treatment of ner ve entrapment syndromes.
Pericardial 6 and kidney 3 and 5 were chosen for their regenerative effect on nervous tissue.
Gallbladder 34 was chosen for its effect on mus- cle and tendon. Small intestine 6 is a general regen- erative point, and spleen 6 and 9 were used to reduce edema. Although the conventional theory of endogenous endorphin release might explain its analgesic effect, it is inadequate to explain anatomic resolution of CTS. The challenge in studying acupuncture is to integrate the theory of traditional Chinese medicine with its concepts of yin-yang, energy flows, and “qi” or “chi” with the conventional biophysical model.
Conclusion
Using ultrasound to show evidence of anatomic change from successful acupuncture treatment for CTS (with symptom resolution) has not been reported previously. A randomized controlled clini- cal trial to confirm this finding is currently under way; completion is anticipated in June 2001. If results seen in this case repor t are reproducible, future research should be directed toward investi- gating the biochemical mechanism of action of acupuncture in CTS.
Editor’s key points
•Acupuncture treatment for carpal tunnel syndrome (CTS) has shown some promise as an adjunct therapy.
• This case demonstrates subjective and objective ultra- sound evidence of improvement after acupuncture.
• High-resolution ultrasound might be useful for diag- nosing CTS when electromyography is unavailable.
Points de repère du rédacteur
• Le traitement à l’acupuncture pour le syndrome du canal carpien (SCC) s’est révélé assez prometteur à titre de thérapie auxiliaire.
• Ce cas fait valoir des preuves échographiques sub- jectives et objectives d’amélioration à la suite de l’acupuncture.
• L’échographie à haute résolution pourrait être utile dans le diagnostic du SCC lorsque l’électromyogra- phie n’est pas disponible.
Acknowledgment
We appreciate the efforts of Dr R. Yip in review- ing this manuscript. Dr Yip is Head of the Department of Anaesthesia at the University of Saskatchewan in Saskatoon.
Competing interests None declared
Correspondence to: Dr Robert Banner, Department of Anaesthesia, Royal University Hospital, 103 Hospital Dr, Saskatoon, SK S7N 0W8
References
1. Seror P. Nerve conduction studies after treatment for carpal tunnel syndrome. J Hand Surg [Br] 1992;17(6):641-5.
2. Mathon G. Carpal tunnel syndrome: how do I diagnose and treat? Can J CME 1996;8(5):27–32,37-40.
3. Wind FJ, Habes DJ. MSE carpal tunnel area as a risk factor for carpal tunnel syndrome. Muscle Nerve 1990;13:254–8.
4. Klein LJ, Trachtenberg AI, compilers. Acupuncture [web- page]. Bethesda, Md: National Library of Medicine; 1997 Oct (Current bibliographies in medicine; no. 97-6).
Available from: http://www.nlm.gov/pubs/resources.html.
Accessed 1998 Nov 18.
5. Buckberger W, Judmaier W, Birbamer G, Lener M, Schmidauer C. Carpal tunnel syndrome: diagnosis with high–resolution sonography. AJR Am J Roentgenol 1992;159(4):793-8.
6. Acupuncture. NIH Consens Statement 1997;15(5):1-34.
7. Weintraub M. Laser photoablation and neurolysis in carpal tunnel syndrome: a novel, non-surgical approach—prelimi- nary data. Neurology 1996;46(Suppl 2):A282.
8. Chen G. The effect of acupuncture treatment on carpal tun- nel syndrome. Am J Acupunct 1990;18(1):5-9.
...
VOL 47: MARCH • MARS 2001❖Canadian Family Physician•Le Médecin de famille canadien 549
CME
