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Letters to the Editor  |   June 2012
Osteopathic Manipulative Medicine for Carpal Tunnel Syndrome
Author Affiliations
  • Benjamin M. Sucher, DO
    EMG Labs of Arizona Arthritis and Rheumatology Associates, Paradise Valley, Arizona
    Medical Director
Article Information
Neuromusculoskeletal Disorders
Letters to the Editor   |   June 2012
Osteopathic Manipulative Medicine for Carpal Tunnel Syndrome
The Journal of the American Osteopathic Association, June 2012, Vol. 112, 383-384. doi:10.7556/jaoa.2012.112.6.383
The Journal of the American Osteopathic Association, June 2012, Vol. 112, 383-384. doi:10.7556/jaoa.2012.112.6.383
To the Editor: 
I read the article by Gilbert Siu and colleagues1 in the March issue with great interest, and I was delighted to see that the authors presented such a comprehensive review of the approaches of osteopathic manipulative medicine (OMM) to carpal tunnel syndrome (CTS). I commend them for this work, including the wonderful photographs used to demonstrate the various palpatory and manipulative techniques. However, I have a few comments and corrections regarding their interpretations or descriptions of my previous work and of diagnostic ultrasonography (US). 
My recent studies2,3 of CTS have led to a broader understanding of the causes of this condition, which include thenar muscle hypertrophy and protrusion into the carpal tunnel during hand activity, leading to median nerve compression between the flexor tendons dorsally and the muscle mass ventrally. Siu et al1 present an oversimplified view of the carpal tunnel in Figure 2 on page 128 of their article, with the median nerve appearing to float in an open space. This representation does not allow the reader to appreciate how closely the flexor tendons approximate the median nerve. Likewise, it does not allow the reader to visualize how the transverse carpal ligament (TCL) contacts and impresses upon the median nerve as the thenar muscle mass (attached to the TCL) contracts and squeezes downward, sandwiching the nerve between tendon and muscle. 
Interestingly, osteopathic manipulative treatment (OMT) techniques can decompress the median nerve—not simply by elongating the TCL, but also by elongating the thenar muscles, thereby eliminating mounding and intrusion of muscle upon nerve. In addition, the flexor tendons are stretched by OMT techniques, so they are not as thick and tight against the nerve. As a result, when median nerve adhesions are released, the nerve has more mobility, allowing it to slide out of harm's way as the muscle and tendon begin to impinge it.2,3 
I have no way of confirming which component is more clinically significant—the alleviation of pressure by TCL elongation, the release of median nerve adhesions, or the effects on the thenar muscles and flexor tendons. Nevertheless, all of these factors appear contributory and are impacted positively with OMM. 
Palpatory assessment of restriction about the carpal tunnel is discussed on page 130 by Siu et al1: “First, the carpal tunnel contents should be examined using modified range-of-motion procedures reported by Sucher.” In the cited article4 as well as in another article,3 I may have implied that the actual contents of the carpal tunnel could be examined by these maneuvers, but my primary intention was to note the use of the maneuvers for assessing the status of restricted motion about the exterior of the carpal tunnel—specifically the TCL and its various muscle attachments. In addition, my own clinical observations demonstrated that palpatory predictability of CTS could be achieved to a high degree of sensitivity (92%) and reasonable specificity (75%), as reported in a published series of 60 cases.5 I have found even greater sensitivity (95%) in an unpublished series of 100 cases. 
I also want to correct the authors regarding their comments about the use of diagnostic US for CTS, which they discuss on pages 129 and 130.1 Neuromuscular US, a subset of musculoskeletal ultrasonography, can be used to demonstrate lumbrical or sublimis muscle intrusion into the carpal tunnel during finger flexion and extension.6 Patients can observe this effect in real-time as the physician obtains the neuromuscular US images. This visual information is helpful in advising patients to modify hand activity that is creating median nerve compression. In fact, using neuromuscular US as a teaching tool for patients with CTS has become a vital component of case management, further improving outcomes in these patients. The “higher cost” mentioned by the authors1 does not apply to neuromuscular US—at least not relative to the cost of electrodiagnosis or the cost according to the added value toward more effective management. 
Finally, in the authors' discussion of the Opponens roll maneuver on page 134,1 they omitted an essential aspect of this technique—that it not only stretches the TCL but simultaneously elevates the TCL off the median nerve.4 Because of this elevation of the TCL, the Opponens roll maneuver is safer than other manipulative techniques to use in more advanced cases of CTS (ie, it is less likely to irritate or further injure the median nerve). The photograph shown in the article as Figure 10B illustrates the Opponens roll maneuver accurately, but the text states, “The physician gradually pulls the patient's thenar area laterally while simultaneously moving the thumb into extension to create traction.”1 This description fails to add the final essential element involving rotating the thumb laterally (the maneuver that lifts the TCL up and off the nerve). 
The article by Dr Siu and his coauthors1 is a good review of the literature, albeit not quite complete. New technological advances, such as neuromuscular US, are helping us to better understand the pathophysiologic mechanisms involved in CTS. In future studies, researchers should consider investigating neuromuscular US–guided use of OMT in patients with CTS, which may provide even more insight into effective management of this highly prevalent disorder. 
References
Siu G, Jaffe JD, Rafique M, Weinik MM. Osteopathic manipulative medicine for carpal tunnel syndrome [review]. J Am Osteopath Assoc. 2012;112 (3):127-139. http://www.jaoa.org/content/112/3/127.full. Accessed April 14, 2012.
Sucher BM. Carpal tunnel syndrome: ultrasonographic imaging and pathologic mechanisms of median nerve compression. J Am Osteopath Assoc. 2009;109(12):641-647. [PubMed]
Sucher BM. Ultrasound imaging of the carpal tunnel during median nerve compression. Curr Rev Musculoskelet Med. 2009;2(3):134-146. [CrossRef] [PubMed]
Sucher BM. Palpatory diagnosis and manipulative management of carpal tunnel syndrome [review]. J Am Osteopath Assoc. 1994;94(8):647-663. [PubMed]
Sucher BM, Glassman JH. Upper extremity syndromes. In: Kraft GH, Stanton DF, Mein EA. Manual Medicine: Physical Medicine and Rehabilitation Clinics of North America. Philadelphia, PA: WB Saunders; 1996:787-810.
Walker FO, Cartwright MS. Neuromuscular Ultrasound. Philadelphia, PA: Saunders; 2011:72-90,187.