Carpal Tunnel

For all of the benefits computers bring to the modern recording studio, wrist health isn't one of them. The repetitive motion typically required to operate music software using a mouse and keyboard — paired with often less-than-ergonomic workstations — makes engineers and producers prone to developing carpal tunnel syndrome (CTS). The resulting numbness and pain in the forearm and wrist can take a serious toll on productivity and health. But even if you're experiencing CTS now, it doesn't mean you're stuck with it forever. The sooner this common malady is diagnosed, the better the odds of successful treatment — and the greater the chances that you'll be able to keep doing the work you love, without pain. If you're free of CTS now, following a few simple guidelines can help stave it off down the road.

The Culprits

Carpal tunnel syndrome is a chronic irritation of the median nerve, one of the three major nerves to the hand. The median nerve extends down through the arm and passes through a narrow wrist space known as the carpal tunnel. It supplies nerves to the hand, thumb and fingers (except the pinkie). Swelling of the walls of this tunnel (the wrist bones and the transverse ligament) or its contents (the median nerve and nine tendons) can compress the median nerve, resulting in numbness, tingling and pain in the hand, especially in the thumb and long fingers. Over time, the hand can become weak or clumsy. Chronic misuse and overuse of the arms through repetitive motion and poor ergonomics (marathon studio sessions come to mind) are common causes of CTS. Underlying conditions — obesity, hypothyroidism, diabetes, arthritis, pregnancy and trauma — are other contributors.

Figure 1. Anatomical Picture of the carpal tunnel in the wrist and hand

Where It Hurts

As with all syndromes, there isn't one test that can determine if someone has carpal tunnel syndrome. A diagnosis is based on a constellation of patient complaints, physical findings and tests.

A doctor will usually examine the patient and look for evidence of complaints — decreases in sensation in the fingers, muscle mass or strength. He or she will also

attempt to provoke the carpal tunnel by positioning the wrist in ways that tend to exacerbate the carpal tunnel if the syndrome is present.

"Typically, if there's a question of diagnosis or if the non-operative approach isn't working, the patient would want a referral for a hand surgeon," advises Dr. Robert M. Orfaly, MDCM, FRCS, Assistant Professor in the Department of Orthopaedics and Rehabilitation at Oregon Health Sciences University. To confirm the diagnosis, a non-invasive nerve conduction study is commonly used, especially if surgery is being considered. Sometimes doctors also use an electromyogram (EMG), which involves placing fine needles (similar to acupuncture needles) into the muscle mass at the base of the thumb to look for changes in the muscle.

Numbness and weakness in parts of the arm and hand are sometimes caused by nerve compression in another part of the body and often lead to a misdiagnosis of CTS. These include compression of the nerves as they come out of the spine in the neck (a pinched nerve, for example), compression as the nerves run through the brachial plexus (a nerve bundle) area of the shoulder and compression in the pronator teres muscle near the elbow.

Tendonitis is sometimes mistaken for carpal tunnel syn- drome, too, and if CTS-like symptoms appear after a traumatic injury, a Colle's fracture of the wrist could be to blame.

A good doctor should be able to single out the true root of the problem (the place of compression). A trusted naturopathic (N.D.) or conventional (M.D.) primary care physician is a good starting point. Once the root of the problem is clear, a naturopathic physician will commonly prescribe a customized combination of therapies to provide relief. If natural, non-invasive approaches aren't effective, a referral for cortisone injections or surgery is next.

Help Yourself

Some cases of carpal tunnel syndrome may require surgery for significant improvement, but simple, non- invasive strategies are effective for many sufferers and worth a try before going under the knife.

Ergonomics

Whether or not ergonomic workspaces truly prevent carpal tunnel syndrome remains controversial, so focus on these simple ergonomic tips (courtesy of the OHSU hand therapy department) instead of complex furniture and other equipment.

1. Maintain a neutral position of the wrists and take breaks during repetitive activity. If you're going to be typing for four hours, take a ten-minute break every 45 minutes or an hour (switch tasks during that time), then come back.

2. Position your chair at a height that enables your elbows to be close your sides, with your forearms horizontal, rather than typing on a laptop at a table with your wrists flexed. This can relieve tendonitis and muscle fatigue, too.

3. Stretch your hands and wrists before a session at the keyboard. Treat it like any other workout, warming up slowly and stretching for a few minutes.

4. Try to use both sides of your body (alternate right and left hand on a mouse or track ball, for example) to eliminate muscle strain on one muscle group.

5. Use a track ball instead of a mouse.

6. Use a firm, smooth, gel support under your palm while typing and using the mouse/track ball to reduce muscle fatigue at your elbow.

Exercises

Tendon gliding is one exercise that can help reduce symptoms of CTS. Gliding helps "flush" out fluid within the carpal tunnel.

Tendon gliding how-to:

1. Start with straight fingers.

2. Then make a hook fist, holding the large knuckles straight and bending the middle and end joints.

3. Make a straight fist, bending the big knuckle and middle joint into your palm and trying to touch your wrist. (Keep the end joints straight.)

4. Make a full fist, bending all joints into the palm of your hand.

5. Return to straight fingers and repeat. Do five sets of each "glide", five times a day.

Yoga

You don't have to roll out the yoga mat or sport workout wear to benefit from this pose. Reverse Prayer Pose brings relief by putting the body in a position that's the opposite of being hunched forward over a computer or console. In addition to stretching the wrists, it stretches the entire arms (including the shoulders and elbows) — even the ribcage and back, if it's done properly: standing tall with chest opening forward and shoulders back.

Reverse Prayer Pose how-to:

1) Stand in Tadasana, or Mountain Pose: stance is tall with feet parallel and hips-width apart, arms by your side and looking straight ahead.

2) Place your palms together behind your back with the fingers pointing towards the floor. (This may be enough of a stretch for some people. If so, open up the chest by rolling the shoulders down and back. Hold and breathe. Hold for as long as it's comfortable — at least for several deep breaths and up to several minutes.)

3) If possible, keep the palms together and turn your fingertips inward and up towards the ceiling. It may help to bend at the knees and lean slightly forward in order to get the fingers pointing straight up. Stand tall again, roll the shoulders back and open the chest. Hold and breathe. (Once again, hold for as long as it's comfortable.)

4) Repeat several times throughout the day.

Cock-Up Splint

Funny name, but it's no joke. Splinting the wrist with this inexpensive support aid can help align the forearm into a position of ease and alleviate pressure on the median nerve. People tend to hold their wrists in a flexed position during sleep, curling them into a ball, so splints or braces can prevent this when worn at night. Splints can be bought over-the-counter at most drugstores.

Hydrotherapy

Ice packs can provide relief for acute flare-ups of CTS, but alternating hot and cold packs or water baths are more effective for long-term alleviation or prevention. The following technique also increases circulation to help speed up healing. For best results, repeat several times a day, or at least daily.

Hot/cold hydrotherapy how-to:

1) Submerge the affected wrist and hand in tolerably hot water (ideally between 104-112 degrees Fahrenheit, 40 to 44.4 degrees Celsius) for three minutes.

2) Remove and immediately submerge the affected area in cold water for 30 to 60 seconds.

3) Repeat Step 1 and 2 twice more for a total of three hot/cold cycles, always beginning with heat and ending with cold.

Natural Supplements/Remedies

Generally speaking, anti-inflammatory substances and supplements that support nerve and muscle health — digestive enzymes, essential fatty acids, vitamin B6 and magnesium — may help alleviate symptoms of CTS. It's best to consult a naturopathic physician to determine the best regimen for you, though many of these products are available over the counter. In the realm of topical natural products, Traumeel Cream aids in minimizing trauma, swelling and pain in the muscles and nerves.

Acupuncture and Massage

Acupuncture is a well-studied and well-known therapy for pain relief. It improves CTS in some cases by removing blockages in the carpal tunnel area, increasing mobility and strength while alleviating pain. Massage therapy works by relaxing muscles, improving joint mobility and enhancing circulation, thereby potentially clearing away carpal tunnel blockages.

When All Else Fails: Surgery

If the approaches above don't help, surgery is likely in your future. Some surgeons feel that cortisone injections are useful in treating CTS. However, research suggests that they only work reliably for mild cases, according to Dr. Orfaly, and the majority of symptoms return within a year. Carpal tunnel surgery is a commonly performed procedure, and is usually covered by medical insurance. It results in significant improvement in 90 to 95 percent of cases, with the best results among those who have had CTS for less than two years.

The carpal tunnel has bone on three sides and a ligament over the top, with several tendons and the nerve passing through the tunnel. During surgery, the ligament is divided so the arch opens up and has more room. Dr. Orfaly performs it with a scope, and there is an open technique as well. The scope version involves a quarter-inch incision in the wrist, followed by the ligament division, then three or four stitches and covering in a soft dressing. Recovery time is typically about two weeks for someone who works at a computer — sometimes longer for those who do a lot of repetitive gripping (operating tools in the palm, for example). Whatever the downtime, odds are that when you heal and return to the studio, you'll be able to focus on the music, not the misery. r

Tips from the Studio

"After wearing out the mousing muscles and the trackball rotator cuff miasma, I use a Wacom tablet with a stylus. This is a big improvement. I also do Pilates, Rolfing, Acutonics and yoga, which all help cope with the repeat injuries and traveling 'weak spots.'" -Steve Fisk

"Learn hotkeys! Almost every program I know has extensive hotkeys, which I find greatly reduces 'mouse wrist'. In some applications the hotkeys are assignable, and I assign the most used functions to keys that are ergonomically easiest to hit." -Scott Hampton

"Crazy as it sounds, this thing is magic — the Kensington TurboBall. Clunky? Yup. Gums up pretty fast? Yeah. Breaks often? Sure. Ugly? Ugly as hell. But hours of editing with no wrist pain... pricele$$$$$$$." -F. Reid Shippen

"One thing that might be useful is the 'praying man' stretch: putting the palms together in front of the body and then gently lowering them." -Mark Rubel

"I keep a thin piece of foam left over from an Auralex MoPAD set under my track ball to support my wrist. I also use a Digidesign Command 8 control surface. That setup, along with a common sense approach to sitting (good office chair with lumbar support), keeps carpal tunnel [syndrome] from developing." -Matt Boudreau

"My solution involves sharing any epic amount of editing with my assistant, or [with] the producer. We are all on the same page as to the way we like to do things and can trade off with each other every hour or so to ease wrist and arm aches." -Matthew Cullen

"I use a trackball, a Turbo Mouse from Kensington. I find this has saved my life as far as editing and mousing goes. I also recommend yoga for stretching out muscles and increasing flexibility."

- David Cuetter

Resources: Carpal tunnel syndrome fact sheet and organizations: www. ninds. nih. gov/disorders/carpal_tunnel/carpal_tunnel. htm

American Society for Surgery of the Hand: ASSH. org Find a naturopathic physician in your area: www. naturopathic. org

Disclaimer: The information in this article is based on the personal and professional experiences and research of the authors. It is not intended as a substitute for consulting with a health-care provider for diagnosis and treatment.

Thanks to Dr. Orfaly and all of the contributors who wrote in with their tips.

Dr. Sarah Murphy is a licensed naturopathic doctor, massage therapist, and yoga teacher with a Masters degree in acupuncture and Chinese herbs. She enjoys working with patients in her private practice in Los Angeles, CA. Dr. Murphy is also dedicated to her mobile health care practice that caters to musicians and music industry professionals on the road and at home. drmurphy@themusiciansphysician. com

Liz Brown is a health and travel writer based in Portland, Oregon. She holds a B. S. in Nutrition, has co-authored two health books and is a contributing editor for Spa magazine. Her previous Tape Op articles have covered treating tinnitus and combating fatigue (the latter with co-author Sarah Murphy, N. D.). Also a singer/songwriter, Brown is a featured performer on the Papillon EP Patterns on Your Fingertips.

Illustrations by Garr Ugalde