May 11 2007

Chiropractic Nonsense and Carpal Tunnel Syndrome

Mainstream medicine and so-called complementary and alternative medicine (CAM) exist in two different intellectual worlds. While mainstream medicine is conscientiously scientific, open minded, transparent, and fair, CAM (by its own machinations) ranges from anti-scientific to pseudoscientific, closed-minded, and decidedly unfair. CAM proponents often accuse mainstream doctors and scientists of treating them poorly and being biased against them, when the reality is that science, by its very methodology, is a meritocracy. Further, if anything CAM has been given a free-ride because of a well-meaning but completely inappropriate “political correctness” within academia that treats CAM far more gently and uncritically than mainstream medical practices and claims.

Ironically, while crying about being treated unfairly (by which they mean not being allowed to make outrageous claims and perform unethical and absurd treatments without any criticism or being held to the slightest scientific standard), many CAM proponents engage freely in what can only be called a “bashing” of scientific or mainstream medicine. Such bashing is rife with distortions, half-truths, self-serving propaganda, and outright lies.

(Standard disclaimer – Of course I am not saying that ALL CAM proponents do this. CAM is a big tent with a wide variety of practices, philosophies, and even degrees of integrity. But it is all “alternative” for a reason – it cannot meet the standard of scientific medicine, so it exists in this alternate universe deliberately crafted from intellectual, academic, and legal constructs that allow for a double standard – one in which essentially anything goes.)

I recently received the following letter detailing one example of mainstream medicine bashing:

Greetings SGU Folks,

First off, thanks for the most entertaining and informative podcast going. I found your March 28 interview with David Seaman very interesting, and when the company I work for offered a wellness seminar led by a local chiropractor, I signed up. It turns out the chiropractor who led the one-hour class is a straight chiropractor, and his presentation was all unsubstantiated claims, Western medicine bashing, and just plain nuttiness.

Amid all the regular silly woo, he made a claim that I have never heard before. While he was explaining that trigger points can cure carpal tunnel syndrome, the chiropractor claimed that the man who developed carpal tunnel release surgery ended up committing suicide because the surgery is such a horrible failure. Never mind the facts that a) carpal tunnel release surgery is at least 90% effective; b) it is irrelevant whether its creator committed suicide; and c) any decent scientist would realize that horrible failure just means there is more work to do. Forget about all of those obvious problems; I would like to know if there is even one tiny ghost of truth to anything this chiropractor said. Did the creator of CTR surgery take his (or her) own life? I have not been able to find even the name of the surgery’s developer. Any help you can offer is much appreciated.

I plan to complain to the committee that hired this man for the wellness seminar, as I heard this afternoon that he will be presenting an entire series over the coming months.

Keep fighting the good fight,

James Wilson

First let me deal with the factual claims here – that the surgical treatment for carpal tunnel syndrome (CTS), called carpal tunnel release (CTR), is a “horrible failure;” and that the developer of CTR committed suicide out of shame. I will start with some background information on CTS.

Carpal Tunnel Syndrome

CTS, first described by Sir James Paget in 1863, is the most common type of nerve injury. It results from compression of the median nerve (the nerve that supplies some of the muscles of the hand and also sensation to the palmar side of the thumb, first two fingers, and half of the fourth finger) in the carpal tunnel. The carpal tunnel is an enclosed ring formed by the transverse carpal ligament. This ring acts as a gateway from the forearm to the hand, through which pass not only the median nerve but also many of the tendons that connect the forearm muscle to the fingers they flex.

The primary anatomical “design flaw” of the carpal tunnel is that it is completely enclosed and not very flexible. So if there is any swelling of the tissue within the carpal tunnel it cannot expand to accommodate the swelling and the result is an increase in pressure inside the ligament. This pressure compresses the median nerve, damaging it. Swelling, in turn, can be caused by trauma, repeated use, direct external compression, flexing the wrist, inflammation, edema (water retention in the tissues), and even rarely tumors or masses.

Treatment of CTS

Treatment for CTS is divided into two categories, surgery and conservative (everything other than surgery). Conservative management is almost always tried first and/or in combination with surgery. It consists of removing or avoiding the trauma that is causing the increased pressure in the carpal tunnel, wearing a wrist brace to protect the wrist and avoid hyperflexion, taking anti-inflammatories to treat inflammation (this can either be aspirin-like medications or steroids, which can either be oral or injected), and treating edema if necessary. There is some evidence that vitamin B6 may help nerve recovery, but by itself does not address the nerve compression. Also there are a number of symptomatic treatments for the pain, but again these are not curative as they do not address the underlying mechanism of nerve injury.

Conservative treatment usually helps to some degree (largely dependent upon compliance), but is often not sufficient for long-term control of CTS. When conservative management fails, or is not sufficient, there are a variety of surgical options.

The first surgical procedure developed was carpal tunnel release (CTR), now called open CTR, which consists of cutting the transverse carpal ligament, thereby opening up the carpal tunnel and releasing the pressure. This procedure was developed in 1933 for traumatic CTS by Dr. Learmonth, and in 1946 for spontaneous CTS by Drs. Cannon and Love. It was the standard of surgical care, without rival, for over 40 years.

In 1988 the first alternative to open CTR was developed by Dr. Michael G. Brown, who developed the process of endoscopic CTR. This procedure involves a smaller incision in the skin than open CTR and uses small cameras to visualize the transverse carpal ligament to make the proper transection.

These two options, open vs endoscopic CTR, remain the only procedures for CTS. There are some newer technologies, for example using a less invasive Knife Light cutting tool, that are promising yet incremental technological advances but are still somewhat new and experimental. But the basic concept of cutting the ligament to relieve the pressure is still the gold standard.

Does CTR Work?

CTR not only works it is one of the most successful surgical procedures ever developed. Recent studies and reviews show that both open and endoscopic CTR are 98-100% successful in significantly improving symptoms of CTS, with an 84% overall satisfaction rate. Long term success is also impressive, more than 80%, and largely depends upon subsequent compliance with post-surgical conservative management. The complication rate of CTR is also very low; a recent review involving thousands of procedures showed that it was 0.49% for open and 0.19% for endoscopic CTR.

In short – carpal tunnel release surgery is the poster-child for a nearly perfect surgical procedure. The underlying pathophysiology is well known, the theoretical basis for the surgery is rock solid and fairly straightforward, the success rate is extremely high and the complication rate is extremely low. It just doesn’t get better than this.

Does Trigger Point Treatment Work for CTS?

This is much more complex to assess. I could not find any prospective peer-reviewed trials (which doesn’t mean they don’t exist, it’s possible a more exhaustive search would have yielded results, but the fact that a search on “carpal tunnel syndrome” and “trigger point” in yielded zero results indicates there probably isn’t much peer-reviewed research in this area). But there are many articles on the web, and I can also speak from my knowledge of other various modalities used to treat CTS.

First, it is important to realize that physical activity is not a good treatment for CTS. So massage, exercise, physical therapy, etc. do not generally work. This makes sense because CTS is caused by tissue swelling or inflammation, and this, if anything, is exacerbated by any kind of manipulation or activity. Nerves themselves like to be left alone – there is no physical manipulation that helps them.

However, there are two situations where there is at least a plausible mechanism for an effect. The first is when there is a more proximal nerve compression – in the neck or shoulder, that is caused or exacerbated by muscle spasm or hypertrophy. This situation is not CTS, but rather a compression of the nerve farther up that can mimic some of the symptoms of CTS. So this really would not be a treatment for CTS, but for another syndrome that can be mistaken for CTS. As an aside, as a neuromuscular expert I can say that a good clinician should not confuse these syndromes, and if there is clinical overlap then a nerve conduction study should be able to sort out the proper diagnosis.

There is also a possible scenario whereby compression of the brachial vein in the shoulder, part of what is called thoracic outlet syndrome, can lead to edema in the arm and secondary CTS. Treating the thoracic outlet syndrome with physical therapy may therefore relieve the CTS. But this is a special situation, and very uncommon compared to other causes of CTS.

The bottom line is that for garden-variety CTS trigger point treatments such as massage, manipulation, or physical therapy, is not a plausible treatment and lacks evidence of efficacy.

Did the Developers of CTR Commit Suicide from Shame?

No. Sir James Learmonth died in 1967 at the age of 73. I could not find documentation of the cause of his death (if anyone can, please send me a reference), but it seems unlikely that this successful and respected surgeon would have committed suicide because of the “failure” of a procedure he developed 34 years earlier – a procedure that was and continues to be in widespread use. Dr. Browne is alive and well, still practicing medicine, peforming and teaching endoscopic CTR.

Bashing the Mainstream

Attacking and undermining your critics is an effective debating and propaganda tactic, and CAM proponents have used it quite successfully. They have demonized the pharmaceutical industry and fomented a mistrust of establishment medicine. To here them tell it, physicians (or “allopaths”) treat symptoms not causes, only know drugs and surgery, know nothing of nutrition (they would even have you believe that “they” developed the science of nutrition and that nutrition is “alternative”), hide proven cures, and care only for profits. Now of course (another disclaimer) I am not taking the position that medicine is beyond criticism or that there are no quacks or con-artists in the ranks of scientific medicine. There are. But CAM proponents have created a caricature of what is typical in mainstream medicine and know little of the actual practice of scientific medicine.

The statement reported by James Wilson in the letter above is not unusual. I admit I could not find a source to validate that any chiropractor is actually making such a claim – and if anyone has a reference please pass it along. But it is a similar type of claim to many I have directly read or heard. James himself already pointed out the fallacies in the claim – it is a non-sequitur and also a false premise.

Here is a typical chiropractic advertisement regarding CTS:

Why have Surgery when you don’t have to?

Taking medication to cover up the pain is short term solution at best because it does not fix the problem. Don’t become one of the 400,000 such operations performed nationwide each year. Please, believe me when I say, surgery should only be considered as a last resort if all else fails.

Use chiropractic as your first line of defense in overcoming Carpal Tunnel Syndrome,
Our Chiropractic treatment for Carpal Tunnel Syndrome provides a fast, highly effective and affordable solution to relieve hand/wrist pain and numbness. The focus is to treat the cause of these conditions and prevent their return.

These types of statements are representative – you can find them on any of hundreds of chiropractic website. The claims are typical – for example, doctors only cover up the pain with drugs and do not fix the problem. Given what I described above as the standard treatment for CTS, this can clearly be seen as a false premise.

They then exhort their potential patients to not have surgery, at least not before trying chiropractic first. This is followed by an unsubstantiated claim for the efficacy of chiropractic, and the false claim that chiropractic care addresses the underlying cause of CTS. The reality is, mainstream doctors use conservative management first, using modalities that are theoretically sound and proven effective. When this is not enough they consider a proven safe and effect simple surgical procedure. Meanwhile, surgeons are constantly trying to improve the technology of the surgery as well as develop better techniques for predicting who should have it.

Basically, some in the (admittedly highly heterogeneous) chiropractic profession lie about the evidence and make unsubstantiated claims against their competitors. The result is a sales pitch that would make a used car salesman blush. All of this makes me cringe when I hear a CAM proponent accuse scientific physicians of being deceptive.

Imagine how the chiropractic profession would respond if the AMA used their own tactics against them. (Well we don’t have to imagine – they sued the AMA in the 80’s for restraint of trade. They won, but only a narrow judgment saying that the AMA specifically cannot tell its members not to refer to chiropractors. The judgment said nothing about criticizing chiropractic, or the legitimacy of chiropractic as a profession.)

The double standard lives on.

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