Casebook: how to improve CTS treatment outcomes
When I have a patient with carpal tunnel syndrome (CTS) diagnosis, I typically see an improvement in symptoms in just a few acupuncture treatments. Strangely enough, I found that only a few studies report acupuncture treatment of CTS success rates to be greater than the effectiveness of placebo. Naturally, I was curious which points the researchers were using.
As I had suspected, the list was obvious: P 7 da ling, P 4 xi men, P 6 nei guan, P 8 lao gong, HT 2 qing ling, HT 7 shen men, HT 8 shao fu, LU 9 tai yuan, and LI 11 qu chi. These points are widely recommended by various authors of books on acupuncture.
Some studies approached the treatment of CTS classically – from the perspective of zang fu as well as the five elements differential diagnoses – but here too the success rate was often statistically insignificant.
Now while it was important to conduct all those studies and collect their outcomes – after all the success rate may have been higher – there is one component that is difficult to include in research design. Palpation.
Palpation may make the difference between success and failure of the treatment. In fact, as the following examples illustrate, palpation can provide acupuncturists with additional useful information that they can immediately apply to their treatment – perhaps more so than any other diagnostic method.
The medical doctor
A 54-year old female patient with intermittent numbness in the right hand and index finger for eight months was diagnosed with CTS by her family physician. Before trying acupuncture, she had been treated by a physical therapist 12 times. The symptoms had become rarer and less intense for two weeks, but then they returned.
The patient – a medical doctor – mentioned that she had lately been writing her notes at work more than usually, thus revealing the possible cause of her condition.
Surprisingly, palpation of the right wrist revealed no abnormalities, and the patient reported no pain or discomfort. At the same time, the Phalen test was positive – the patient, however, reported that the pain intensity was about three out of possible ten. The median nerve compression test caused discomfort, rather than pain.
Palpation of the right forearm revealed only one abnormality: muscle tightness in the LI 10 shou san li area. A large light-pressure pinch of the area, though, revealed more information.
The muscle underneath the point LI 10 – most likely extensor carpi radialis – was enlarged. Also, when the same light pressure was applied at a different angle with a smaller pinch, the patient reported experiencing sharp pain at the site, which also radiated to her hand and the index finger.
Careful palpation of the area demonstrated that four points adjacent to LI 10 were exceptionally painful – disproportionally so to the light pressure applied – coinciding with the greater tightness and enlargement compared with the surrounding tissues.
The four acupuncture treatments that followed resolved completely the symptoms that were erroneously diagnosed as CTS. I used 25 x 0.16 mm needles and inserted them in the tight areas that reproduced the patient’s symptoms, only one of which touched LI 10 – the rest may be classified as local ashi points.
The computer programmer
In another typical example, a 49-year-old male patient was referred for acupuncture by his family physician for treatment of his CTS of his right hand. He reported that his hand and forearm often hurt him at rest and night-time – more so after a long day at work. He also often felt a tingling sensation in the palm of his right hand. The patient was a computer programmer.
Surprisingly, careful palpation of the patient’s right wrist and palm revealed no abnormalities and no pain or discomfort. However, moving palpation proximally to the wrist revealed a whole area of tissues on the side of the flexor muscles that appeared noticeably tighter than the surrounding tissues.
The pinch-like palpation provided considerably more detail: the tight area consisted of transverse narrow compression lines, which felt like dense scarring crossing the forearm between radius and ulna – most likely caused by the forearm being pressed against a table’s edge for long periods of time.
Acupuncture and tui na relieved the symptoms of this condition in six treatments. The 25 x 0.16 mm needles were inserted in the tight points where the patient reported experiencing pain or discomfort during light pressure. The needles were left in for 15 minutes, with additional needle stimulation every five minutes.
I then massaged the compression lines with my fingertips to break the tissue adhesions. This part of the treatment caused the patient considerably more pain than the needle insertion, as with other patients, and the sessions were scheduled first three and then two days apart – to allow time for the forearm to heal.
The medical biller
The third typical example of a patient with CTS symptoms was a 55-year-old female who reported feeling weakness in her hands and fingers for the last four months – more so on the right side. Her doctor diagnosed CTS and first prescribed a course of physical therapy before referring her for acupuncture.
While the woman felt better for a day or two after the physical therapy sessions, her symptoms then returned. The woman worked as a medical biller and spent much of her working day at the computer.
The Phalen test was positive, but the patient reported that the pain intensity was about two out of a possible ten and numbness about four out of ten. Visual examination of the patient’s wrist revealed no abnormalities. Palpation, however, revealed tissue adhesions between the ulna and radius, with a larger, thicker, and denser area of adhesion in her right forearm.
From conversations with the patient, the probable cause of the symptoms was the way she slept: she reported regularly placing her forearm under her head when she slept on her side, preferring to sleep on her right side more than on the left. Since the patient did not wish to change her sleeping habit, the treatment took 17 sessions, but the outcome was successful.
Treatment involved insertion of 25 x 0.16 mm needles around the edges of the areas of tissue adhesions – followed by tui na of the same areas. Even light pressure on the areas with the adhesions immediately reproduced and worsened the patient’s symptoms – particularly numbness in the hands and fingers – which decreased in intensity when the pressure was released.
After each treatment, the reproduction of the patient’s symptoms had decreased. In the last three sessions, the areas of adhesions were barely noticeable during palpation.
Developing your palpation techniques
Many reports describe CTS as a commonly misdiagnosed disorder. These reports, however, have very little practical value to a clinical acupuncture practitioner.
According to my experience over more than two decades in practice, if you do your own diagnostic work – rather than relying on medical reports, conclusions, recommendations, and diagnoses – you can greatly improve the clinical outcome of your acupuncture treatment for symptoms associated with CTS. And the type of palpation you use can play a decisive role in whether or not treatment will be a success.
While research studies recommend well-known, intuitive palpation techniques, the focus of palpation is primarily on the correct positioning of the arm – so the practitioner can have better access to specific anatomical structures. But the western medical approach does little to help acupuncture practitioners identify active points.
However, the use of light-pressure pinches when examining the anatomical structures of the hand, wrist, and forearm can provide crucial information regarding the exact point locations – including their depth and angle. (Shudo Denmei briefly describes this method on page eight of his book Finding Effective Acupuncture Points.)
The goal is to identify the points that conflate the tightness felt under your own fingertips with your patient’s reporting that their symptoms are being reproduced or made worse by the disproportionally light pressure.
Informal experiments conducted with other acupuncturists during continuing education courses have demonstrated to me that practitioners can learn this somewhat unusual palpation style faster when they begin their explorations on themselves. More specifically, once you establish which sensations under your fingertips correspond to which sensations in your arms and hands, you create references in your memory.
Practitioners need to be able to distinguish between muscle tightness, calcifications, scar tissues, and normal anatomical structures. Importantly, while some tight knots that can be felt with the fingertips translate into the symptoms of numbness or pain in the hand and fingers, others do not.
The intricacies of sensations under the fingertips are too subtle and too vast to describe. But learning this type of palpation on yourself can greatly speed up the learning process, turning seemingly subjective findings into a versatile and reliable clinical tool.
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Many medical scientists compare trigger point palpation to identifying trigger points. In my experience, however, not every hyperirritable painful spot will reproduce the symptoms that the patient wants addressed. Moreover, as muscle fibres become hyperirritable, they can become too painful for a direct needle insertion, even more so when they entrap a local nerve branch. When that happens, inserting needles at the edge of the tightness causes less discomfort and can be even more effective.
Self-inspection reveals what sensations various points may cause in our patients, while at the same time we become aware what each point feels like under our own fingertips. I also recommend that practitioners insert needles in or near the points they find to be abnormal on themselves and keep track of their findings in a journal.
Lastly, while this method can complicate research study design a lot, fine-tuning acupuncture treatment for each individual patient in this way can significantly improve clinical outcomes in the treatment of CTS.
Vladislav Korostyshevskiy graduated from the New York campus of the Pacific College of Oriental Medicine and has his own acupuncture practice in Brooklyn, New York. Articles by him have appeared in many academic and professional publications, and he regularly teaches NCCAOM-approved continuing education courses, mostly online. His books Secret Techniques for Controlling Sadness, Anger, Fear, Anxiety, and Other Emotions and Acupuncture for Knee Pain: Possible Improvements of Clinical Outcomes are sold all over the world.
