Recently I have had four patients come in with wrist pain, two of which were possibly the beginnings of carpal tunnel syndrome, and they all have been responded well within 1-2 shock wave therapy sessions (EPAT), using a combination of both focused and radial devices which I use in the office (Storz Medical, Focused and Radial Devices ). The usual treatment course for musculoskeletal problems is 3-5 weekly treatments.
Shock waves are sound waves created by a mechanical pellet moving up and down via compressed air in a tube (radial or pressure wave device) or by an electromagnetic coil (focused device). The radial device’s maximum strength is delivered at the surface of the skin where the tip hits and spreads the energy in a radial fashion with minimal depth while the focused device’s maximum strength is a focal point below the skin surface which can go to several centimeters. Using a combination of both allows for more versatility in problems treated, though the radial device (“Lil Jack Hammer” from the way it sounds) has been used by itself successfully in most musculoskeletal conditions.
These two devices are “low intensity” shock wave devices (compared to high intensity shock waves used in the disintegration of kidney stones called lithotripsy for almost 40 years) that create a biological response from the body that releases healing factors that 1) build new blood vessels (neovascularization or angiogenesis) 2) increase nitric oxide, thereby improving blood flow 3) build new tissue (stimulates stem cells) 4) break down fibrous tissue 5) reduces inflammation and 6) reduces pain by both an immediate numbing action in some cases and more rapid healing do to all the above. ( see Handout: Benefits & Function of Shock Wave Therapy).
In the cases mentioned the wrist pain was due to inflammation from generalized arthritis; a prior trauma to the wrist (fall); and an over-use issue caused by riding a motorcycle and holding the throttle for long periods of time and typing on a keyboard. The cases that might have been the beginnings of Carpal Tunnel Syndrome presented with numbness, tingling and some pain in the palm from overuse and/or the ergonomics of using a keyboard and holding the throttle for long periods of time. These both responded very positively to the first treatment with SWT. As mentioned 3-5 weekly treatments is the common course of therapy with each treatment building upon the last treatment. The key to getting well faster is what you do to help your body heal along with shock wave or EPAT treatments (discussed below).
What is Carpal Tunnel Syndrome and It’s Causes?
Diagnosis & Treatment
Carpal tunnel syndrome is caused by pressure on the median nerve which comes down the middle of your forearm and through the middle of the wrist. The carpal tunnel is a narrow passageway surrounded by bones and ligaments on the palm side of your hand. When the median nerve is compressed, the symptoms include numbness, tingling and weakness in the hand and/or arm.
Ergonomic adjustments help some patients at their work stations while splinting, stretching and exercises are sometimes recommended. Anti-inflammatory medications can be used for the short-term but you should avoid long-term use if possible because these medications may increase gut permeability and eventually at fuel to-the-fire” by increasing molecules to pass through the gut wall in a larger state and cause of the inflammation. Nutrients such as vitamin C and vitamin B6 may be of value. But whatever you do you the goal is to reduce the swelling within the forearm around the wrist and palm (wrist joint) especially. Surgery is a last resort but done fairly frequently by cutting the ligament that crosses the wrist (to view scroll down to Surgery - Illustration) to reduce the pressure on the median nerve and thereby improve feeling and function.
So if there is a way to avoid surgery that would be a good thing. Extracoporeal shock wave therapy or what we call EPAT for short (can be radial shock wave therapy (rSWT) or focused shock wave therapy (fSWT) is a great tool along with diet, exercise/physical therapy, adjusting your environment, a few supplements and hopefully minimal medication. The great thing about EPAT therapy it is actually healing and correcting the problem, not just the symptoms.
Extracorporeal shock wave therapy (see videos and references below) is non-invasive and relatively pain-free (there is some very tolerable discomfort) that works rather quickly to stimulate the body to heal itself (See explanations on handout) .
Shock Wave Therapy Video Demonstrations
Carpal Tunnel (3:37 min)
Carpal Tunnel & Tennis Elbow (3:43 min)
Why Focused Shock Wave Therapy ( 1:54 min)
Radial Vs Focus Shockwave - What is the Difference? (8:42 min)
Wrist Pain Primary Causes
Arthritis (joint inflammation)
Diet Inflammation - processed foods, high in meats (poultry, pork, etc.), eggs and dairy, processed fats, processed oil and sugar-rich fiber-less, grain products, alcohol and caffeine products (needs to be checked)
Gut Microflora Imbalance - not enough fiber, too much sugar, high fat, medications i.e. acid blockers, antacids - increases intestinal permeability and subsequent inflammation; antibiotics can be problems
Over-Use - especially keyboard work
Tendinitis - from overuse or injury
Trauma - injury or overuse
Approaches to Wrist Pain and Carpal Tunnel Syndrome
Diet - Anti-Inflammatory Diet - 1) Eat of BED Diet Food List - page 2 of handout and/or 2) Water fast 4-7 days and/or 3) Fasting Mimicking Diet (can get Prolon 5 day program online or at our office at discount) and/or 4) Eat only for 7 days whole fruits and non-starchy vegetables (avoid night shade family - See BED Food List - page 2) - steamed, water stir- fried, roasted, baked, raw and/or grilled (no oil frying) 5) Inflamx (anti-inflammatory pea and rice protein meal replacement) 2 scoops 2-4 times per day mixed with water initially for 4-7 days (available from our office). If you can do it solely for 4-7 days add non-starchy vegetables and whole fruit plus the Inflamx.
Exercise - structured physical therapy with a professional or general common sense stretching, weight lifting, circuit training and doing your normal physical activities. Obviously don’t do an exercise that aggravates your wrist. Work up to and around the pain.
Wrist Stretches - Aikido (videos demonstrations 1. 2. 3. ) - For a decade or so I took Aikido a Japanese martial art that does a lot of wrist locks so we had to do 4-5 wrist stretches and exercises before each training session. I always thought these would be great stretches for office workers or those who have to do repetitive hand work that might make their wrists susceptible to repetitive movement injury. You do a minute or so with each wrist exercise and in five minutes you loosen up your wrists increasing blood flow, strength and flexibility. GENTLE when you start! Always go up to pain and around it, but don’t push through the pain! Especially at the beginning. Maybe after a week or two when you get a feel for the exercises and your progress. You could cause more pain if you do these valuable exercises too vigorously to an injured or inflamed wrist.
Supplements
Algal Oil (omega-3 fatty acids from algae) 2-4/d
Curcumin/Turmeric (MERIVA is a good trademarked and tested product) 500-2000 mg/d
Magnesium chelate 200-500 mg/d
Vitamin B6 (in a B complex of 50-100 mg/d)
Vitamin C - 1000--4000 mg/d
Vitamin D - 2000-5000 IU/d
Other products that can be used include Glucosamine and/or chondtroitn sulfate, haluronic acid, collagen, Wobenzyme
What Makes My Approach Different for Pain?
Emphasizing a whole food, anti-inflamamtory, low allergy, mostly plant-based diet; looking at gut health to reduce inflammation (food intolerance, fiber for the microbiome, medication reduction, pathogens in gut); reducing environmental toxins in some cases; improving blood flow to the whole body by reducing or reversing heart and vascular disease; and normalizing blood sugar and insulin resistance which reduces inflammation, improves nerve health and blood flow; and an emphasis on self-help exercises PLUS Shock Wave Therapy (EPAT) mentioned above.
WHAT NEXT?…
Change your diet. Get some exercise. Stretch and strengthen the body part. Take a few nutrients and consider shock wave therapy (EPAT).
CALL ME OR MAKE AN APPOINTMENT!
1) If you think shock wave therapy may be for you with regards to your joints or any musculoskeletal pain problem (See list of treatable problems ) make an hour appointment for the first appointment so I can take a history, do an exam and then we’ll do the first treatment that meeting. Then treatment sessions after that are 30 minutes or less per body part ($150). Two-three body parts 45-60 minutes ($270).
2) Call Kirk Hamilton PAC at Health Associates Medical Group for a quick discussion between 8-9 a.m. in the morning. If unavailable leave your name and number and I will call you back for a short discussion of your problem.
3) Call for appointment 916-489-4400.
Have a grateful and healthful day!
Kirk Hamilton PA-C
NOTE: Three of the studies below show that shock wave therapy is sometimes a better long-term treatment for carpal tunnel syndrome than steroid injections.
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Research on Carpal Tunnel Syndrome and Shock Wave Therapy
Extracorporeal shock wave therapy as a conservative treatment option for carpal tunnel syndrome: A double-blind, prospective, randomized, placebo-controlled study. Turk J Phys Med Rehabil. 2020 Nov 9;66(4):388-397. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7756840/ CONCLUSION: rESWT was applied with 1,000 shots, 0.05 mJ/mm2 intensity of energy at a frequency of 5 Hz weekly for 3 weeks. Pain and functionality significantly improved with ESWT. ESWT is a valuable and reliable treatment modality for mild-to-moderate CTS.
A randomized controlled trial: comparing extracorporeal shock wave therapy versus local corticosteroid injection for the treatment of carpal tunnel syndrome. Int Orthop. 2020 Jan;44(1):141-146. CONCLUSION: ESWT is a useful noninvasive short-term treatment for mild to moderate carpal tunnel syndrome and elicits a better recovery than local cortisone injections.
Effect of extracorporeal shockwave therapy on carpal tunnel syndrome: A systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore). 2019 Aug;98(33):e16870. CONCLUSION: ESWT can improve symptoms, functional outcomes, and electrophysiologic parameters in patients with CTS.
Comparison of single-dose radial extracorporeal shock wave and local corticosteroid injection for treatment of carpal tunnel syndrome including mid-term efficacy: a prospective randomized controlled trial. BMC Musculoskelet Disord. 2018 Jan 25;19(1):32. CONCLUSION: The rESWT group received shockwaves of continuous frequency and intensity (4 Bar, 15 Hz frequency, 5000 shocks, BTL-6000 SWT, radial shockwave mode). The duration of treatment was 3–7 min. A cold pack was applied for 15 min after rESWT. 1 ml. of triamcinolone (acetonide) 10 mg mixed with 1 ml of 1% lidocaine in a 3 ml disposable syringe was given with a 25 gauge needle applied 1 cm proximal to the wrist flexion crease between the palmaris longus and flexor carpi radialis tendons. The angle of the needle was about 45 degrees distally and was advanced 1 cm, where it penetrated the flexor retinaculum. Single-dose rESWT, showed significant improvement with clinical symptoms and functional recovery compared to LCsI from weeks 12 to week 24. The single rESWT provided greater symptom severity reduction and functional improvement compared to LCsI during weeks 12 and 24. Our single-dose rESWT protocol had a higher dose intensity than that study (3–7 min 4 Bar, frequency: 15 Hz, number of shocks: 5000 shocks VS 4 Bar, frequency: 5 Hz, number of shocks: 2000 shocks). This rESWT protocol provided a long-lasting effect, up to 24 weeks, without multiple-session attempts. Single-dose rESWT provides longer-lasting benefits than LCsI in the treatment of mild to moderate CTS.
The dose-dependent efficiency of radial shock wave therapy for patients with carpal tunnel syndrome: a prospective, randomized, single-blind, placebo-controlled trial. Sci Rep. 2016 Dec 2;6:38344. CONCLUSION: Compared to the control group, the three-session rESWT group demonstrated significant reductions in symptoms and the effect was much longer lasting in patients with moderate CTS than mild CTS. rESWT is a valuable strategy for treating CTS and multiple-session rESWT has a clinically cumulative effect.
Effect of radial shock wave therapy for carpal tunnel syndrome: A prospective randomized, double-blind, placebo-controlled trial. J Orthop Res. 2016 Jun;34(6):977-84. CONCLUSION: rESWT is a safe and effective method for relieving pain and disability in patients with CTS. rESWT was administered with 2,000 shots, at a pressure of four Bar, and a frequency of 5 Hz in 3 weekly session.
The effectiveness of extracorporeal shock wave therapy vs. local steroid injection for management of carpal tunnel syndrome: a randomized controlled trial. Am J Phys Med Rehabil. 2013 Apr;92(4):327-34. CONCLUSION: ESWT is as useful as cortisone injections for relieving symptoms of carpal tunnel syndrome and is noninvasive.