October 1992

Research finds surface EMG useful in treatment of Carpal Tunnel Syndrome

by Michelle P. Prosanti

A clinical psychologist and a neurologist have developed an unusual approach to the treatment of carpal tunnel syndrome that involves neuromuscular re‑education using surface electromyography.

The EMG biofeedback is not applied to the arms and wrists but to the sternocleidomastoids, the large, thick muscles that pass obliquely across each side of the neck and contribute to arm movement.

These neck muscles, the two health professionals contend, are intricately involved in the progression of carpal tunnel syndrome. When the muscles are treated using their EMG protocol, there is evidence of electrophysiologic changes.

This new approach to carpal tunnel syndrome, actually has fairly well‑established roots. The notion that muscles of the neck could be involved in problems within the arm and wrist has been a subject of discussion for several years.

Some neurologists have wondered about a possible connection through something called a "double crush lesion," explained Daniel Skubick, M.C., a neurologist practicing in suburban Philadelphia. Such a lesion involves an injury inside the carpal tunnel as well as at a more proximal site, probably at the nerve root or the brachial plexus.

Neither the precise location of this proximal injury nor the exact relationship between the two sites has ever been defined. But Dr. Skubick and Stuart Donaldson, Ph.D., a psychologist practicing in Canada, believe they have made great strides in this process. The two have identified a connection between the sternocleidomastoids and inflammation of the tendons inside the carpal tunnel, and through their treatment protocol have rid more than 50 people of carpal tunnel syndrome.

To understand the evolution of this treatment, it is necessary to take a look at the approaches each man has used in his practice and how the two converged.

Dr. Donaldson, who is in private practice in Calgary, Alberta, has specialized in chronic pain issues for a decade. His treatment philosophy has been dominated by classic trigger point theory and extensive side‑to‑side comparisons of muscle activity, particularly in the low back.

This approach, which relies on surface EMG testings and neuromuscular re‑education, was the subject of Dr. Donaldson's doctoral work and a presentation he made at the international conference where he first met Dr. Skubick.

The Pennsylvania neurologist, whose practice includes numerous patients with carpal tunnel syndrome, believed there could be a trigger point scenario involved in the debilitating disorder and became interested in the psychologist's methods. He eventually asked Dr. Donaldson to work on developing a treatment protocol for carpal tunnel syndrome.

Dr. Donaldson launched this effort about two years ago by performing electrophysiologic assessments of muscle activity in individuals diagnosed with carpal tunnel syndrome. He initially believed that the scalene muscles were the site of significant involvement and focused his testing efforts there. But the objective assessment of electrical activity shed little light on the subject.

"In the assessment procedure, we have the patient perform the movement that is primary for the muscle we are testing," Dr. Donaldson explained. "In the scalenes, deep breathing is natural. But the bilateral readings there produced very little feedback."

With that theory apparently discredited, the psychologist moved to the flexorextensor bundles, the muscles responsible for movement in the forearm and hand. To his surprise, activity in the flexorextensor muscles increased significantly when the subject with carpal tunnel syndrome moved her head and neck -- a clear indication that the neck muscles (later proven to be the sternocleidomastoids) were actively involved in carpal tunnel syndrome.

In repeated assessments of other individuals with a diagnosis of carpal tunnel syndrome, the same patterns were documented. In these assessments, electrical activity was first measured while the arms were at rest and the head stationary; it was measured again while the subject performed a sustained contraction of the head. In this latter scenario there was an immediate electrical response in the arms.

Based on these findings, Drs. Donaldson and Skubick developed a new approach to treating carpal tunnel syndrome that focuses on returning the neck muscles to normal symmetry through neuromuscular re‑education. This method, executed through surface EMG biofeedback using a Physiotech 4000 machine that analyzes data on site, is based on principles of single‑motor unit training, Dr. Donaldson explained. The treatment focuses on decreasing electrical activity where it is high or excessive and maintaining constant reading where it is low.

By returning the sternocleidomastoid muscles to symmetry, an equilibrium is achieved and electrical activity is normalized, Dr. Donaldson said. In the majority of patients treated with this method thus far, the painful symptoms of carpal tunnel syndrome subside and nerve conduction studies return to normal within three to five sessions. "Electrophysiologically, the patient is back to normal," Skubick said. "The inflammation disappears."

After symptoms are reduced, patients participate in an educational program that provides information about muscle symmetry and posture. At this time, work station design and/or other applicable contributory factors are addressed.

While the patient successes that Drs. Donaldson and Skubick have experienced as a result of this approach are numerous, a few key issues remain to be resolved, both acknowledged. One of these is an identification of the precise role that the sternocleidomastoids play in the development of carpal tunnel syndrome. While both professionals agree with the conventional definition -- that the disorder occurs as a result of median nerve entrapment -- each offers a different theory as to how the sternocleidomastoids influence this entrapment.

(Reprinted, with permission, from ADVANCE FOR PHYSICAL THERAPISTS, July 6, 1992. Part 2 continues in November.)

Using your hands -- and heart -- to heal your patients by Thomas Lipsitz, Ph.D.

Chiropractors use their hands and their hearts to help heal their patients. Giving in this way creates a closeness and an atmosphere of healthy change rarely experienced by most helping professionals.

It has been proven that, beyond the physical interventions, "Tender Loving Care (TLC)" is almost as important to promoting wellness as anything else. The bulk of the current research in psychimmunology continues to show strong positive correlations between mental state and physical illness.

This mind/body connection is evidenced in medicine in the placebo effect. Many medical doctors freely acknowledge that as many as 80% of their patients present with psychosomatic problems. They routinely prescribe placebos with incredible results. The number of physical diseases which have an emotional component are numerous, including asthma, ulcers, migraine headaches, etc.

The contemporary disorder, Chronic Fatigue Syndrome has recently been scrutinized through research. It was found that at least one‑third of the people diagnosed with CFS may be misdiagnosed and had more symptoms of clinical depression and other emotional disorders.

Are we getting worse?

Our society seems to be becoming more ill each day despite billions of dollars spent on health care and supposedly the best doctors in the world. Why is this? I believe we need to examine some of the aberrant trends present in our society, patterns that appear to be worsening, not improving. It seems more evident each day that the stresses of living in our contemporary society are having an increasingly powerful effect on our health.

One disturbing characteristic of our daily life which is taking its toll both physically and emotionally is the aggressive nature of our society. The violence we are exposed to in the media, on our streets and in our sports has created a climate that sanctions verbal and physical aggression as commonplace and accepted ways of relating. We have become so desensitized to violence that we see stabbings, shootings and fighting and we are not even surprised anymore.

However, we seem to internalize our fears and live in a world of semi‑paranoia. To validate this claim, just jog down your street past a small child. Watch her freeze when you pass, fearing you may harm her in some way. Go into a toy store "supermarkets" and see the aisles and aisles of toy weapons which bear witness to the type of training our children are receiving about violence.

What happened this past summer in Los Angeles is the first "volcanic" eruption of the boiling lava of hostility and frustration which is building in all of our large urban cities.

What can you do?

I began this article talking about how a single helping professional can, through touching and "TLC" connect with another human being in a healing, caring way. This is one way we can begin to stem this tide towards sickness in our society. I wrote my doctoral dissertation on the subject of assertiveness and how using this cognitive/behavioral technique can improve relationships.

However, my study was somewhat different than what is usually researched in this area. I examined the aspect of assertiveness which involves the verbal expression of tenderness. I found that when one member of a relationship verbalizes honest feelings of warmth and empathy, the other person will reciprocate and the relationship as a whole becomes enhanced.

I found that, regardless of the gender of the trainer or the subject, training people in this skill was easy to accomplish and significantly effective, at least in the short‑run. My findings were certainly not surprising. What is surprising is the lack of emphasis in our land on communicating positive regard for each other. How often do you see someone giving positive feedback?

Consequently, in addition to the individual healer contributing we need to flood the media with kindness and tenderness for our fellow human beings.

As a group, healing professionals need to stand together as advocates and positive role models to denounce violence and aggression as major contributors to the sickness in our country and the world at large. We need to extend our tenderness to the animal and plant world. The psychology of healing might extend to discouraging the supplementary of millions of dollars for fattening up and then butchering animals for food. We need to unite to address the disappearing rain forests and ozone layer.

When we begin to understand as so many in the Eastern hemisphere do that we are all interconnected and what we do to our bodies as well as how we interact with our fellow man and our ecosystem as a whole will dictate how well we will become.