Carpal Tunnel Syndrome
Vitamin B6 (pyridoxine) has been a subject of interest in CTS research for decades. Some studies have found evidence of vitamin B6 deficiency in CTS patients (Fuhr 1989; Folkers 1978). Vitamin B6 supplementation has been effective for CTS in some, but not all trials, which may result partly from differences in patient populations and CTS etiology (Gaby 2011).
A small, uncontrolled trial found that vitamin B6 supplementation for at least 12 weeks greatly improved CTS symptoms in four subjects with laboratory signs of vitamin B6 deficiency (Ellis 1981). The same research team later studied seven CTS subjects, finding that all had significant blood deficiencies of vitamin B6. A double-blind, crossover study of these seven CTS subjects reported that daily supplementation with 100-150 mg B6 for 10-12 weeks resulted in marked improvement in CTS symptoms compared to the placebo phase of the trial (Ellis 1982). Another study found that among 137 men who did not take dietary supplements, a lower blood level of vitamin B6 was associated with a significantly higher prevalence of CTS symptoms such as tingling, wrist/hand pain, and nocturnal awakening (Keniston 1997). Several additional trials have reported that supplementation with 50-200 mg/day of vitamin B6 resulted in fewer CTS symptoms, less pain, and better nerve conduction (Gaby 2011; Bernstein 1993).
A randomized trial treated subjects with mild-to-moderate CTS with either splinting plus 120 mg vitamin B6 daily or splinting alone. After 3 months, the B6-treated subjects had significantly milder CTS symptoms (including less pain, nocturnal awakening, hand numbness, weakness, and tingling) than placebo subjects, as well as significantly faster median nerve conductivity (Talebi 2013).
Supplementation with other B vitamins such as B2 (riboflavin) and B12 (cobalamin) may also be helpful in CTS. Vitamin B2 is critical for energy production, vitamin B6 metabolism, and many other important metabolic functions. A case study reported on a 32-year-old man with longstanding CTS and marked blood deficiencies of vitamins B2 and B6. After five months of treatment with 50 mg B2 daily, the individual’s symptoms were nearly completely resolved. After an additional three months of taking 50 mg B2 and 500 mg B6 daily, his CTS symptoms disappeared entirely and grip strength increased significantly (Folkers 1984).
Vitamin B12 plays a critical role in nerve function and red blood cell formation. Vitamin B12 deficiency is common in older adults, with one study reporting vitamin B12 deficiency in 40.5% of a group of 548 adults aged 67-96 years (Lindenbaum 1994). A randomized, open-label trial of vitamin B12 (1500 mcg daily of methylcobalamin, a highly absorbable form of vitamin B12) treatment for subclinical CTS in stroke patients over age 65 found it was effective compared to no treatment. Sixty-seven stroke patients with asymptomatic CTS evident on nerve conduction studies, on the side unaffected by the stroke, were compared to 68 similar stroke patients who did not receive vitamin B12 treatment. After two years, the methylcobalamin-treated subjects had significantly improved median nerve conduction on their unaffected side compared with untreated subjects. The mechanism by which vitamin B12 may help CTS could be related to improved nerve regeneration and remyelination (myelin is the fatty sheath insulating most neuronal cells) (Sato 2005).
Alpha-Lipoic Acid Combinations
Alpha-lipoic acid (ALA), an anti-inflammatory agent and powerful free radical scavenger, has been studied in both oral and intravenous forms and found to be successful as a treatment for diabetic peripheral neuropathy (Mijnhout 2012; Reljanovic 1999; Ziegler 2004; Ziegler 2006) and other types of neuropathic pain (Memeo 2008). Clinical studies also indicate that ALA decreases inflammatory cytokines including IL-6 (Zhang 2011; Salinthone 2010).
ALA has shown promise for the treatment of CTS. In a study of 112 individuals with moderate CTS, subjects were treated with either 600 mg ALA plus 360 mg gamma-linolenic acid (GLA) (an anti-inflammatory omega-6 fatty acid found in borage seed oil, evening primrose oil, and black currant seed oil) or a combination of three B vitamins (100 mg B1, 150 mg B6, and 500 mcg B12) daily. After 90 days of treatment, the ALA/GLA group improved significantly in both symptoms and functional scores, while those given B vitamins exhibited slightly improved symptoms (Di Geronimo 2009).
Another trial compared a twice-daily regimen of 400 mg of the NSAID dexibuprofen (15 subjects) to dexibuprofen combined with either 400 mg ALA (15 subjects) or 400 mg ALA and 400 mg curcumin (15 subjects). After four weeks, all groups experienced some reduction in pain, with the dexibuprofen/ALA/curcumin group showing the greatest improvement. After eight weeks, pain was significantly improved in the dexibuprofen/ALA/curcumin group and reduced (non-significantly) in the dexibuprofen/ALA and dexibuprofen alone groups (Di Pierro 2013).
A study of two combination regimens that included ALA was conducted in subjects undergoing CTS surgery. Each regimen was tested on 60 subjects. The first group took 300 mg ALA, 500 mg of the anti-inflammatory turmeric derivative curcumin (in phytosome form, a complex of curcumin and phospholipids), and small amounts of B vitamins (1.05 mg B1, 1.2 mg B2, 4.5 mg B5, and 1.5 mg B6) twice daily for 3 months before and after surgery. The second group received the supplements twice daily before surgery only. A third group did not receive supplements. Three months after surgery, the subjects who received the supplements before and after surgery had significantly less pain, numbness, and night-time symptoms compared to the other two groups (Pajardi 2014).
Acetyl-L-carnitine is another compound found to be effective in oral and injectable forms, in both animal and human trials, for a variety of neuropathies (Memeo 2008; Flatters 2006; Chiechio 2006; De Grandis 2002; Youle 2007). Acetyl-L-carnitine promotes peripheral nerve regeneration and has pain-relieving effects in patients with many types of nerve pain of the extremities. Acetyl-L-carnitine improves the efficiency of a number of energy-intensive biochemical processes essential for nerve repair (Memeo 2008; De Grandis 1998). It may also be helpful for CTS, although only limited evidence is available as of the time of this writing. In an uncontrolled study, 1097 subjects with peripheral neuropathies, including 109 subjects with CTS, were treated with 1000 mg intramuscular acetyl-L-carnitine daily for 10 days followed by 2000 mg oral acetyl-L-carnitine daily for an additional 20 days. Symptoms were rated as improved by 83% of investigators and 84% of subjects (De Grandis 1998).
Omega-3 Fatty Acids
Omega-3 fatty acids may also be useful in treating CTS, although the evidence is sparse. A case report told of a 47-year-old auto mechanic whose CTS improved dramatically after being treated with 3000 mg eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) daily for 8 months. The patient was able to avoid surgery and continue full-time work. Omega-3 fatty acids may block pain receptors involved in neuropathic pain (Ko 2010).
Serratiopeptidase is a protease (protein-dissolving enzyme) derived from a bacterium found in silkworms. Serratiopeptidase possesses anti-inflammatory action that has been reported to be comparable to that of the NSAID diclofenac sodium (Voltaren) (Jadav 2010). One study reported that 10 mg of oral serratiopeptidase given twice daily for 6 weeks was associated with significant clinical improvement in 13 of 20 (65%) CTS subjects. Significant improvement in median nerve conduction velocity was also noted. No adverse side effects were reported (Panagariya 1999).
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