Carpel Tunnel Syndrome

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Abstract

 

Carpel tunnels syndrome is the entrapment median nerve and the most common peripheral neuropathy condition in the world[1]. This article discusses carpel tunnel syndrome from a western medicine perspective, the channel sinews, muscles on the channel pathways. Including a six treatment case study using Japanese acupuncture, moxibustion and tui na. The style of Japanese acupuncture is Iyashi no Michi, following the principles of the Shang Han Lun, taoist practice and needling principles of the Ling Shu. To simplify understanding of the treatment, the main focus is just on the treatment of carpel tunnels, needling and moxibustion techniques.

 

Western Medicine

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Signs and Symptoms

• Numbness

• Tingling

• Nocturnal parasthesia (numbness of the hand at the night)

• Pins and needles

 

The median nerve originates from the brachial plexus at the anterior shoulder, to the axilla and passes through the elbow crease and inferior to the pronator teres. Following the path down to the central and anterior aspect of the forearm to the wrist underneath the flexor retinaculum of the wrist. Then to the plantar hand branching to the muscles of the thenar muscles, first, second and third fingers. The nerve roots at C5 to T1. The carpel tunnel is located on the palmar aspect of the wrist and the transverse carpal ligament. The carpel tunnel is formed from the tubercle of the scaphoid and trapezium bones. Medially it is pisiform and hamate bones. The carpel tunnel protects the medial nerve and tendons when flexing the fingers by holding the flexor tendons close to the carpel bones.[2] Compression on the has several common areas that must be explored to determine where acupuncture should be applied. This ranges from the origin of the median nerve at C5 to T1, the supraclavicular fossa at the plexus of nerves or inferior to the clavicle where the nerve branches divide. Assessments must be made to determine what channel sinews are stagnated and the cause of stagnation.

 

Chinese Medicine

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Differential diagnosis must be considered. These are some potential patterns. The case study highlights, cold bi stagnating blood, cold bi generating heat and hot bi.

 

Differential Diagnosis

 

• Blood deficiency leading to blood stagnation

• Cold Bi stagnating blood

• Cold Bi generating heat Hot Bi

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The Channel Sinews

 

The channels sinew pathways, consists of fascia, muscles and their tendon attachments to bones and joints. By addressing the location or origin of the pain, restriction of movement, the nature of the pain, the cause and what makes it feel better or worse a diagnosis is possible. For this case study it is important to state that Japanese acupuncture was applied throughout and any Japanese terminology will be written to brackets to help the reader follow the series of treatments. The pericardium channel sinew is the most common of the channels to be affected with carpel tunnels. However, this case study describes the complexities of the channel sinews of the arm that might need to be addressed. The patient had a variety of issues with the wrist and dealing with each aspect was like peeling away layers to reveal the carpel tunnels.

 

Japanese Needling TechniquesIyashi no Michi needling techniques require the patient to experience hibiki, a needling sensation that is like an echo of the qi, similar to deqi but subtle with quality. Once the sensation is felt by the patient then the needle is removed. Nekko Jutsu (warming the muscle layers) Nekko jutsu gently softens tight muscles by gathering warmth in the muscle layers and indicated for chronic pain due to cold stagnation. This technique can also be applied to areas of the abdomen to treat diarrhoea, urinary issues. By holding the needle in place with your oshide (non needling hand) and by moving or twisting the needle to create a “heat action” under the needle [3]. It is important to understand the quality of the muscle. Whether it is hard, tight, ropey or cold. All indications that nekko jutsu will soften the muscle. Clients report of feeling a sensation of warmth at the needle site and the sensation can flow up or down the channel. By palpating the site after needling, the muscle should be smooth, softer and less tender for patient.

 

Haya Toge jo ba No xie ho (quick insertion and slow extraction). This technique removes evil heat that is lodged inside the body for various conditions for example bronchitis, gastritis or heat in the muscles or joints. By collecting the internal heat at the tip of the needle and slowly pulling the heat out as the needle is withdrawn from the body and not closing the point to allow the heat to drain out. “The fast then slow method to empty [drain], this is the doctrine of fast insertion and slow withdrawal” Ling Shu Chapter 3.

 

Chinetsukyu hard moxa conesA hard cone is referring to the density, when lit will generate a hotter cone. “Large fire scatters qi” Su Wen Chapter 5. Making it highly affective for scattering cold, by disersing cold stagnation or blood stagnation. Size of the little finger nail, density is tight to make it hot, burn to 90%, the cone take off when it is too hot or maximum of 90%.

 

Case Study

 

First treatment 18th March 2025

 

Male, 87, a retired engineer who likes gardening, mowing and watering his tomatoes (water sometimes pours on to his wrist). He has a good spirit and constitution.Wrist pain on both sides alternate between sharp and a dull ache. The left side for one year and started getting severe four to five months ago. The right side started one month before the first treatment. It was swollen but there are no longer signs of swelling.The right wrist pain when sharp is 10/10 (10 being highest level of pain) and when a dull ache 4/10. On the day of the treatment left side 5/10 and right 8-9/10. The pain is better for heat, especially deep heat initially but is no longer helping. The pain is sometimes worse in the morning. The right hand cannot fully close into a fist and is painful when lifting a jar or mug with his right hand and pain sometimes radiates up the arm. He experiences a sharp pain or burning sensation when laterally rotating (to open a bottle), flexion or radial adduction the wrist. The wrist on the yin side from LU9 (taiyuan) to HT7 (shenmen) and LU7 (lieque) to HT5 (tongli) including the pericardium channel were darker in colour and the median antebrachial vein close to PC6 (neiguan) was dark in colour.

 

Medication co-codamol 2-3 times a day. Stool are usually normal but due to co-codamol he is constipated. Urination 4-6 times a day although is taking tamsulosin due to urination urgency the started 3 years ago. Energy is overall good. Cold feet.

 

Pulse - fast. Cun positions both tight big mid-deep level. Right - guan tight and middle level. Right chi wiry and deep. Left - guan weak and middle level. Left chi weak to faint and deep

 

Tongue - Red body, swollen, crack at the tip and thin white coating either side of the centre from lower to middle jiao.

 

Diagnosis

 

• Cold bi (kan doku) causing qi and blood stagnation in PC, LI and SJ channel sinew of left wrist.

• Cold bi (kan doku) causing qi and blood stagnation in HT, SJ, PC and LI channel sinew in the right wrist and qi and blood stagnation of LI channel extends into the first, second, third and fourth fingers.

 

Treatment Principle

 

• Scatter cold and move qi and blood stagnation in the PC, LI and SJ channel sinew in the left wrist.

• Scatter cold and move qi and blood stagnation in the PC, LI and SJ channel sinew in the right and first, second, third and fourth fingers.

 

Treatment with Iyashi no Michi (Japanese acupuncture and moxibustion) and tui naAshi on tender areas where the skin is visibly a dark red apply nekko jutsu (warming technique) LU7, LU9, PC6, PC7, HT5, HT7 both sides. Ashi applying nekko jutsu (warming technique) on the tight ropey muscle fibres of the flexor carpi radialis, palmaris longus and pronator quadratus on the pericardium channel sinew both sides. Ashi SJ5-6, LI10 both sides. Ashi at the proximal end of extensor digitorum on the san jiao channel sinew both sides. Right side only - hard chinetsukyu cone x2 applied to interphalangueal joints of 1st, 2nd, 3rd and 4th fingers, followed by gentle yao and ba shen fa of the wrist

 

Second treatment 25th March 2025

 

The right wrist feels better, can feel a burning sensation around PC8 area, the grip has improved. The right hand pain level 2/10 after the last treatment. Today 4/10The left wrist 2/10 after the last treatment. Today 7/10.Assessments shows the wrists is visibly less dark of both arms. When palpating the interphalangeal joints of the right hand tenderness is on the first and third fingers.

 

Diagnosis

 

• Cold bi (kan doku) in the PC, LI and SJ channel sinews of left wrist.

• Cold bi (kan doku) in HT, SJ, PC and LI channel right wrists with stagnation of LI and PC channel sinews extends into the finger.

 

Treatment Principles

 

• Scatter cold and move qi and blood stagnation in the PC, LI and SJ channel sinew in the left wrist.

• Scatter cold and move qi and blood stagnation in the PC, LI and SJ channel sinew in the right and first and third fingers.

 

Treatment with Iyashi no Michi (Japanese acupuncture and moxibustion) and tui na

 

Right side - nekko jutsu (warming technique) ashi LU6 on brachioradialis, ashi distal PC3 on pronator teres, ashi medial PC6.Right side - Haya Toge jo ba No xie ho (quick insertion and slow extraction, to pull heat in the channel) PC6, PC7. Chinestuskyu hard moxa cones x2 on interphalangeal joints of first and third fingers of the right hand followed yao fa and ba shen fa of both wrists.

 

Third treatment 1st April

 

The grip has improved and movement in the fingers with a pain level of 3/10 when lifting heavy objects. The patient reports of it feeling hot between PC7 and PC8 on the right side. The left side is 6/10 with a gentle ache in san jiao channel when clenching a fist. A visible dark blood vessel at PC6 and palpably hard.

 

Diagnosis

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• Cold bi (kan doku) causing qi and blood stagnation in the PC channel of the right wrist.

• Qi and blood stagnation in the SJ, LI channel of the left wrist.

 

Treatment Principles

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• Scatter cold and move qi and blood stagnation in the PC of the right wrist

• Move qi and blood in the LI and SJ channel sinews of left wrist.

 

Treatment with Iyashi no Michi (Japanese acupuncture and moxibustion)

 

Right side - nekko jutsu (warming technique) ashi LU6 on brachioradialis, ashi distal PC3 on pronator teres. PC6 chinetsukyu hard moxa cones x4, ashi proximal PC7 chinestusku hard moxa cones x2, nekko jutsu warming technique PC7.

 

Left side - nekko jutsu (warming technique) ashi LI10, LI4, ashi level with LI10 on san jiao channel, ashi SJ7, SJ4, ashi in the interspace between first and second metatarsal level with SJ4

 

Fourth treatment 8th April

 

Hands are much better. The right side, the patient reports of a burning sensation with no specific movement creating that sensation with a discomfort level of 2/10. Pain on the left side 4/10

 

Diagnosis

 

• Cold bi generating heat in PC and LU channel sinews on both sides.

 

Treatment Principles

 

• Scatter cold and move qi and blood stagnation in the PC and LU channel sinews both sides.

 

Treatment with Iyashi no Michi (Japanese acupuncture and moxibustion) and tui na

 

Right side - ashi LU6 chinetsukyu hard moxa cones x4 and an rou fa. Nekko jutsu ashi proximal to elbow crease between HT and PC channel followed chinetsukyu x2 hard cones and an rou fa. nekko jutsu ashi between HT7 and PC6. Chinetsukyu x2 hard cones PC6. Nekko jutsu SJ6

Left side - Nekko jutsu ashi LU6, ashi distal elbow crease between HT and PC channel, ashi PC5, SJ5Fifth treatment 16th AprilRight side, burning sensation into palm 2/10. Left side, aching when opening bottles 4/10.

 

Gripping ok on both hands. When palpating the arms, the areas of stagnation have reduced to a small area and just the pericardium channel sinew on the right and the san jiao channel on the left.

 

Diagnosis

 

• Cold bi generating heat PC channel of right hand.

• Cold bi in SJ channel of left hand.

 

Treatment Principles

 

• Scatter cold and move qi and blood stagnation in PC channel sinew of right hand.

• Scatter cold and move qi and blood stagnation in SJ channel sinews of left hand.

 

Treatment with Iyashi no Michi (Japanese acupuncture and moxibustion)

 

Right side - nekko jutsu PC6, PC7 (followed by chinetsukyu x2 hard cones), ashi SJ5-SJ6, SJ4 dispersive gentle lift and thrust (jakutaku jutsu). Yao fa and ba shen fa of wrist.

 

Left side - nekko jutsu SJ5, ashi SJ6-SJ7Sixth treatment 30th AprilThe patient reported wrists and hands “pretty good, able to do anything and not much to complain about!” No burning sensation, able to open bottles using the right hand. The left hand “not feeling so good” on around PC6, SJ5 and SJ6 area, tender on the first metacarpal, pain on the left side 1/10.

 

The carpel tunnel syndrome was completely resolved after this treatment.

 

Diagnosis

 

• Qi stagnation in LI channel of the right hand and cold bi in SJ channel of left the right arm.

 

Treatment Principles

 

• Move qi stagnation in LI channel of right hand

• Scatter cold in SJ channel in left and right arm

 

Treatment with Iyashi no Michi (Japanese acupuncture and moxibustion)

 

Right side - ashi LI10-11 dispersive gentle lift and thrust (jakutaku jutsu)Left side - nekko jutsu ashi linggu, SJ5, SJ6, SJ7, 2 ashi proximal forearm on extensor digitorum

 

Conclusion

 

Although the patient is elderly and carpel tunnel syndrome was chronic, the constitutional strength helped with the clinical outcome. A key factor is observing the whole arm, the quality of the muscle structure and the colour at the wrists and blood vessels was important in my diagnosis as cold stagnation. Cold, with long term stagnation generates heat. “The illness qi is victorious when the yang meets the yin creating hot bi.” Su Wen Chapter 43. It is important to address the root, if the branch the main focus of the treatment then issue will return. Sometimes the sensation of heat can give a false impression and by simply clearing heat from the channel in some cases increase the symptoms. The technique Haya Toge jo ba No xie ho (quick insertion and slow extraction) for clearing heat out of the muscle was ineffective proving that the heat generated by long term cold stagnation. By addressing the tightness in the muscles that insert into the hand and wrist putting constraint onto the carpel tunnel will prevent carpel tunnel syndrome returning in the future.

 

References

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1. Osiak et al. Carpel tunnel syndrome: state-of-the-art review. Via Medica. Vol.81, No. 4 pp 851-862

2. Legge, D. Close To The Bone. Sydney College Press. 2nd Ed. pp 204

3. Oura, J. Sugiyama Shindenryu Clinical Instruction. pp.69