Flaxseed oil for carpal tunnel

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Carpal Tunnel Syndrome

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What is carpal tunnel syndrome?
Carpal tunnel syndrome (CTS) develops when the median nerve, which runs from the forearm into the hand, becomes pressed or squeezed at the wrist. The median nerve controls sensations to the palm side of the thumb and fingers (except the little finger), as well as impulses to some small hand muscles involved in the movement of the fingers and thumb. The carpal tunnel is a narrow passageway composed of ligament and bones located at the base of the hand; the median nerve and tendons run through it into the hand. Sometimes, thickening from irritated tendons or other swelling narrows the tunnel and compresses the median nerve, causing sensations of tingling and pain. Carpal tunnel syndrome is the most common and best known “entrapment neuropathy” in which nerves are compressed or traumatized.

The risk of carpal tunnel syndrome is three times higher among women than men, perhaps because the tunnel itself may be smaller in women. Risks are also higher than normal among individuals with diabetes or other metabolic disorders that can affect the body’s nerves and make them more susceptible to injury.

In addition, there is a higher than normal incidence of CTS among those with assembly line jobs whose work includes manufacturing, sewing, finishing, cleaning, and packing meat, poultry, or fish. Carpal tunnel syndrome is three times more prevalent in these lines of work than it is among data-entry personnel.

What are the symptoms of carpal tunnel syndrome?
The first signs are often burning, tingling (or itching) and numbness in the palm and fingers. The dominant hand is usually affected first. Most people begin to notice the sensations in bed at night and, in the morning, feel as if they have to shake their hands or wrists to restore normal feeling. As the condition worsens, symptoms include pain, weakness or numbness in the hand and wrist radiating up the arm. Over time, weakness and atrophy can develop in some of the small hand muscles that control the thumb. You may find it hard to make a fist or pick up small objects and, in some cases, you may not be able to feel the difference between hot and cold with your hands.

What are the causes of carpal tunnel syndrome?
For years carpal tunnel syndrome was believed to be a repetitive stress injury stemming from overuse of the hands, wrists and fingers, particularly from spending long hours at the computer keyboard. But a recent study from Harvard casts doubt on this notion and suggests that most people who develop carpal tunnel syndrome are genetically predisposed to do so, perhaps because of the structure of their hands and wrists

Researchers led by David Ring, M.D., an assistant professor of orthopedic surgery, used the Bradford Hill criteria, a widely accepted method of determining the association between a disease and its cause, to evaluate factors contributing to CTS. They found that biological factors including genetics were three times more powerful than repetitive hand use and other occupational factors. The study was presented at the 74th Annual Meeting of the American Academy of Orthopedic Surgeons.

Another new slant on CTS came from ergonomics researchers at the University of California at San Francisco and McMaster University in Canada, who concluded that the angle of wrist flexion can increase pressure on the median nerve and established limits on how much the wrist can be flexed in each direction before nerve damage sets in. The study was published in the February 2007 issue of Human Factors: the Journal of the Human Factors and Ergonomics Society.

Other contributors to carpal tunnel syndrome include wrist injuries such as sprains or fractures that cause swelling, an overactive pituitary gland, hypothyroidism, rheumatoid arthritis, mechanical problems in the wrist joint, work stress, repeated use of vibrating hand tools, fluid retention during pregnancy or menopause, or the development of a cyst or tumor in the tunnel. In some cases no cause can be found.

What is the conventional treatment of carpal tunnel syndrome?
The conventional treatment for CTS is to rest the affected hand and apply ice packs. Drug treatment begins with nonsteroidal anti-inflammatory drugs and, sometimes, diuretics to reduce swelling. Oral prednisone may be prescribed or lidocaine, a nerve-numbing anesthetic, may be injected into the wrist.

Surgery for carpal tunnel syndrome may be recommended if symptoms last for six months. It involves severing or “releasing” the band of tissue around the wrist to reduce pressure on the median nerve. Surgery is an outpatient procedure, done under local anesthesia. It is performed via a two-inch incision in the wrist or endoscopically through two small incisions in the wrist and palm. A miniature camera is inserted through one of the incisions, through which the surgeon can visualize the tissue on a screen while surgical instruments are inserted through the other incision. Risks of either type of surgery include infection, nerve damage, stiffness and pain at the scar and, sometimes, a loss of strength. Full recovery can take several months, although symptoms may be relieved immediately after surgery.

What therapies does Dr. Weil recommend for carpal tunnel syndrome?
First, be sure to rest the affected hand and discontinue any activity that makes symptoms worse.

Vitamin B-6 (pyridoxine), can act as a natural therapeutic agent for nerve compression injuries when taken in 100 mg doses two or three times a day. (At doses higher than 300 mg daily, B6 has caused nerve damage in a few individuals; discontinue use if your symptoms are progressing.) Yoga has been shown to reduce pain and improve grip strength.

For quick relief, rub on arnica gel and wrap ice packs around your wrists for five minutes every few hours to ease the pain and inflammation.

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October 22, 2012

Shedding Light on Carpal Tunnel Syndrome
By Denise M. O’Neal
For The Record
Vol. 24 No. 19 P. 8

Carpal tunnel syndrome (CTS), a term frequently heard in the medical transcription community, carries a lot of weight within the profession, yet there are misconceptions about its origin, causes, and symptoms.

“This is a syndrome whereby a nerve that goes to the hand is simply pinched or compressed. The layman’s term would be ‘pinched nerve,’” says Mark S. Cohen, MD, an orthopedic surgeon at Rush University Medical Center in Chicago. “In medical terms, it’s a nerve that is being compressed or deformed. In this case, there is impingement or encroachment on the path of the nerve as it travels to the hand. The median nerve, which provides the sensation to the majority of the hand, courses through the palm and wrist within a closed space called the carpal tunnel, an anatomical pathway by which the nerve passes from the forearm to the hand. That pathway has a certain circumference and within that pathway travels the median nerve and the flexor tendons of the fingers. There is a canal with a given diameter that houses tendons and one soft structure, which is the median nerve. Carpal tunnel is simply a condition where the nerve does not have enough room during its passage from the forearm to the hand. It gets pinched, compressed, or flattened, if you will, within this anatomical constraint of the carpal tunnel.”

Fingering a Culprit
The common assumption is that the syndrome mainly affects people who do a lot of typing. Not so, Cohen says. “There is a lot of controversy in our field regarding the association of CTS and typing,” he explains. “It’s now clear that typing activities don’t cause CTS. They may cause symptoms from CTS, meaning that during typing activities your fingers may tingle. This represents a manifestation of symptoms. However, manual labor jobs such as carpentry, meat packing, and people who use heavy vibratory tools are predisposed to the condition.”

If typing brings about only a manifestation of the symptoms, what causes CTS? “It’s the most common condition that leads people to see orthopedic hand surgeons,” Cohen says. “Most cases are what we term ‘idiopathic’ with no identifiable cause, but it’s clearly seen in certain medical conditions, such as diabetes mellitus, rheumatoid arthritis, hypothyroidism, and renal failure. It is not a cause, but it is also associated with smoking and … being overweight or obese. It is seen more commonly in women than in men and also seen in people of middle age and older as opposed to adolescents and individuals in their teenage years. Lastly, there is probably a hereditary component in some cases.”

Symptoms
Medical transcriptionists should be on the alert for various signs of CTS. “Typically, individuals state that they have tingling and numbness in their fingers; their hands fall asleep; and often they wake in the middle of the night with tingling,” Cohen says. “Also, it is not uncommon for people to report that their hands fall asleep when they drive or when they talk on the telephone. This occurs because driving and talking on the phone positions your wrists in an extended or flexed position, which closes down the actual carpal tunnel pathway. When you bend your wrists into flexion, you are essentially adding to the nerve compression. When you drive with your wrists back, again you are manually pinching the nerve. Occasionally, individuals report clumsiness or dropping of objects or difficulty with fine motor skills such as buttoning one’s shirt. These would be seen in more advanced stages of the condition.”

The symptoms would seem to provide telltale signs of something being amiss, yet medical transcriptionists and others will often ignore the messages. “Getting individuals educated about carpal tunnel syndrome is vital,” Cohen says. “Many people are actually scared of the tingling and numbness. Once they know it’s mainly a lifestyle condition and the tingling is not causing any damage when it occurs, it provides them a sense of relief.”

Treatment
Once diagnosed, returning the sufferer to full health depends largely on how advanced the condition is. “There are a lot of conservative treatments that are very useful. The first stage of treating someone with CTS, as long as they don’t have advanced disease, would be wearing a brace during sleep,” Cohen says. “This keeps the wrist in neutral alignment and allows for a maximum diameter of the carpal tunnel, leading to the least amount of nerve compression possible.”

For those who may have waited a bit longer to seek treatment, a shot in the arm may be necessary. “Individuals with significant symptoms can receive a cortisone injection into the carpal tunnel,” Cohen says. “This bathes the tendons and nerves, reducing inflammation and edema, thereby taking some of the pressure off of the nerve. The shot and night splint are curative in about one-third of patients with mild CTS.”

Severe cases may require surgery. A misconception making the rounds in the transcription industry is that choosing surgery may not lead to the desired results. “I think there is a lot of misinformation out there with respect to CTS,” Cohen says. “For people who have documented CTS, this is the most successful surgery that we perform—95% to 100% of the time it is a curative surgical procedure. We diagnose the condition with a history and physical examination, and occasionally one may need a nerve test to confirm the diagnosis. At Rush, many of us perform carpal tunnel surgery under local anesthesia as an outpatient. It takes between five and 10 minutes. You can eat breakfast, come in and have your surgery, and use your hand by the afternoon. I think the stories that you hear where people failed are often in individuals who were misdiagnosed and their symptoms are from other problems or conditions.”

Lend Yourself a Hand
For busy medical transcriptionists striving to earn more money and avoid backlogs, the keyboard is their friend. Although typing isn’t the source of CTS, the activity can exacerbate symptoms. Cohen says that because the syndrome is not something that improves with strengthening, movement, or stretching, there are no real exercises to help prevent CTS.

However, there are helpful measures to limit the condition’s impact. “Make sure your workstation is ergonomically correct. Your keyboard should not be too high or too low, leaving the wrists in a poor position during typing, such as flexion,” Cohen says.

Drugs are usually not much help, Cohen notes. “There are no medications that are helpful other than, although rare, vitamin B12, which can be beneficial for carpal tunnel symptoms in people with a B12 deficiency,” he says.
Nevertheless, employing the necessary lifestyle changes and listening to your body can help prevent CTS from becoming debilitating.

— Denise M. O’Neal is a 15-year veteran of the transcription industry and a freelance writer based in the Chicago area.

Just inside your wrist is a narrow, bony passage called the carpal tunnel. This tunnel contains tendons and a nerve, all encased in a sheath called the synovium. When the tendons become inflamed and swollen, they squeeze the nerve, causing pain and numbness.

Approximately 260,000 carpal tunnel surgeries are performed yearly, but some doctors are opting to add vitamin B6 to their treatment regimens, along with wrist splints and anti-inflammatories. Some experts suggest that around 90 percent of carpal tunnel syndrome (CTS) cases can be cured by B6. (Know what else helps? Eating these pain-fighting foods.)

Prescription for Healing

Some doctors suggest 50-100 mg of Vitamin B6 to ease CTS symptoms. Why? Doctors are divided on why vitamin B6 seems to provide relief from CTS. Some contend that synovium swelling and inelasticity are caused by a B6 deficiency. Other doctors believe that vitamin B6 acts as a diuretic, helping the body to eliminate the excess fluid that may be making wrists swell. Still another theory suggests that vitamin B6 somehow short-circuits an angry nerve’s ability to transmit pain signals.

Medical experts do agree on one thing: No matter how vitamin B6 gets the job done, you have to be careful not to take too much. In studies using lab animals, researchers found that excess B6 can harm the central nervous system.

The average diet provides only about 1.4 mg of vitamin B6 a day, in part because the nutrient is lost in food processing, so many people are just not getting enough. Raw foods are the best sources, because heat destroys this nutrient. Foods containing B6 include potatoes, bananas, chicken breast, top round of beef, fish, brown rice, and avocados.

But be on alert: too much B6 has been linked to serious nervous disorders as well as to oversensitivity to sunlight, which can produce skin rashes and numbness. Amounts above 100 mg should only be taken under the supervision of your doctor. (What other vitamins do wonders for your health? We’re glad you asked.)

More from Prevention: Your Carpal Tunnel Problems, Solved!

ANN ARBOR—Carpal tunnel syndrome sufferers who take vitamin B6 in hopes of improving their condition are wasting their money and may be jeopardizing their health.

The largest and most comprehensive study to date of the relationship between vitamin B6 and carpal tunnel syndrome found no correlation between a patient’s vitamin B6 status and the hand/wrist ailment.

The lead author of the study, Dr. Alfred Franzblau of the University of Michigan School of Public Health, also cautions that excessive doses of vitamin B6 are neurotoxic and can cause sensory nerve damage. According to the U.S. Bureau of Labor Statistics, there were 38,300 cases of carpal tunnel syndrome involving lost work days in 1994—up from 33,000 cases in 1992.

The U-M study is reported in the May issue of the Journal of Occupational and Environmental Medicine.

“Unfortunately, a number of small studies and some anecdotal evidence have convinced many physicians to routinely prescribe supplementation with vitamin B6 as part of the clinical management of carpal tunnel syndrome,” says Franzblau.

However, those studies were flawed, he notes, adding that they included “small samples of non-randomly selected subjects” and frequently relied on subjective measures of outcome.

The U-M study is the first to measure blood levels of vitamin B6 with two different laboratory tests, assess ulnar and median nerve function in the wrists and hands, and obtain carpal tunnel syndrome symptoms among a large sample—125 employees in two auto parts plants. Carpal tunnel syndrome symptoms include numbness, tingling, burning or pain in the wrists, hands or fingers.

The U-M researchers found that 40 employees (32 percent) reported symptoms consistent with carpal tunnel syndrome, 31 employees (24.8 percent) had median nerve dysfunction as determined by nerve function tests, and 10 employees (8 percent) had a vitamin B6 deficiency. However, there was no relationship between the vitamin deficiency, symptoms of carpal tunnel syndrome, or impaired nerve function.

“Our primary concern is that patients may be overdosing on vitamin B6 as prescribed by their physicians, some of whom are prescribing 300 milligrams a day or more,” Franzblau says. “While most reported cases of sensory neuropathy related to vitamin B6 supplements involve dosages of more than 1,000 milligrams a day, some cases involve dosages as low as 200 milligrams a day. The USRDA (United States Recommended Dietary Allowance) for vitamin B6 for adults, incidentally, is just 1.6- 2.0 milligrams a day.”

Franzblau’s colleagues on the U-M study were Cheryl L. Rock, associate professor of human nutrition, School of Public Health; Dr. Robert A. Werner, School of Public Health, Veterans Administration Medical Center in Ann Arbor, and Department of Physical Medicine and Rehabilitation , Medical School; Dr. James W. Albers, School of Public Health and Department of Neurology, Medical School; and Matthew P. Kelly and Elizabeth C. Johnston, graduate students, School of Public Health.

U-M News and Information ServicesUniversity of Michigan

Carpal tunnel syndrome is a painful disorder that occurs when pressure is placed on the median nerve in the wrist. Symptoms include numbness, tingling, weakness and pain in the hand.

The carpal tunnel refers to a small space in the wrist where the median nerve and several other tendons run through to the hand.

The median nerve controls movement and feeling in your thumb and in all fingers, excluding the pinkie and half the ring finger. This pressure can be caused from fluid-retention in pregnancy, repetitive stress or a broken wrist.

Natural therapies and splints can help to reduce pain and inflammation and prevent long-term damage to the nerve.

Carpal tunnel symptoms

The symptoms of carpal tunnel syndrome include:

  • Pins and needles
  • Numbness
  • Pain in the fingers or hand, particularly at night
  • Radiated or referred pain into the arm and shoulder
  • Weakness of the hand

Causes of carpal tunnel

Pressure on the median nerve is what causes carpal tunnel syndrome. This pressure comes from swelling or anything that makes the carpal tunnel narrower. Sometimes an exact cause cannot be identified. In some cases, there is a combination of factors including:

  • Repetitive stress – overuse of the tendons in the carpal tunnel from repetitive movement in the wrist and hand can lead to irritation and inflammation.
  • Pregnancy – the hormones during pregnancy can cause oedema in the wrist leading to compression of the median nerve. After birth, this issue is usually resolved.
  • Congenital factors – some people simply have a smaller carpal tunnel than others.
  • Conditions or illnesses – obesity, rheumatoid arthritis and arthritis can all contribute to joint swelling, reduced blood flow and arm pain.

Carpal tunnel is commonly work-related and may be caused by work that requires:

  • Hand-arm vibration
  • Working for long periods in the same awkward position
  • Repetitive or forceful hand movements

If you are experiencing these work-related, repetitive hand/wrist movements and you also have one of the conditions listed above you are at higher risk of developing carpal tunnel syndrome.

Acute home-care

Symptoms that are mild can be treated at home. Firstly, it is recommended that you discontinue the repetitive activities that are causing numbness and pain. Resting your wrist between activities that do cause discomfort is a good idea.

Wearing a splint at night can help take the pressure off the median nerve—many people find this method very helpful. It’s also ideal to warm-up and stretch regularly before commencing any strenuous activity.

Ice packs can be applied to the area to help relieve pain and reduce swelling. Ice for 15 minutes at a time with breaks in between.

Treatment options

The aim of carpal tunnel syndrome is to start treatment as soon as possible to prevent long-term complications and damage to the nerve. This can include a combination of natural therapies aimed to reduce pain and inflammation, protect the median nerve and reduce fluid in the area.

Anti-inflammatory diet

Foods that promote inflammation such as sugar, refined carbohydrates and fried foods should be avoided.
Foods that reduce inflammation in the body include fresh fruit, vegetables and foods high in omega-3, including linseeds, chia seeds, fish, nuts and seeds.
Consider avoiding nightshade family vegetables which includes capsicum, white potato, tomatoes and eggplant. Some people have found they respond dramatically when their diet is free of these foods.
Following a low sodium diet may also be helpful in combating fluid retention in the wrist.

Alpha lipoic acid and GLA

Alpha lipoic acid is an antioxidant, well known for its protective effect on the myelin sheath and nerves. The myelin sheath is a covering that wraps around the nerve, just like the plastic covering around electrical cables. A study published in the European review for medical and pharmacological sciences journal found alpha lipoic acid when combined with gamma-linolenic acid (GLA) caused a significant reduction in both symptoms scores and functional impairment. They concluded that this combination of nutrients is a useful tool for controlling the symptoms of carpal tunnel syndrome and decreasing its progression to a more severe state, especially if taken in the early stages.

B vitamins

In this same study, an improvement was also found in the group taking a B vitamin preparation consisting of B6, B1 and B12. Although, the results were not as significant as the alpha lipoic acid and GLA group, there was still marked improvement in the participant’s symptoms. There have also been studies just on supplementation with vitamin B6. A 2013 study published in the advanced pharmaceutical bulletin found that B6 treated patients had reduced pain during the day and at night—reducing the average times the person woke-up at night. There was also reduced hand numbness, weakness and tingling and an increase in hand strength when handling objects. Other sensory tests performed on the median nerve had also improved

Herbal medicine

Curcumin, a constituent extracted from turmeric has potent anti-inflammatory properties and can significantly reduce pain and inflammation. Although it is yet to be proven helpful for sufferers of carpal tunnel it has been demonstrated effective for a variety of other inflammatory disorders such as arthritis.

Curcumin can be combined with other anti-inflammatory herbs such as boswellia, ginger and white willow. Herbs that support nerve health include St John’s wort and Jamaica dogwood, the latter is specifically indicated for people with nerve pain.

Herbal diuretics could also be useful in removing some of the fluid in the wrist and includes dandelion leaf, celery seed and stonebreaker.

Talebi M, et al. Effect of vitamin b6 on clinical symptoms and electro diagnostic results of patients with carpal tunnel syndrome. Adv Pharm Bull. 2013;3(2):283-8

Jurenka JS. Anti-inflammatory properties of curcumin, a major constituents of curcuma longa: a review of preclinical and clinical research. Altern Med Rev. 2009 Jun;14(2):141-53

Natural home remedies to relieve carpal tunnel syndrome

What causes carpal tunnel syndrome?

There are a number of factors that can lead to carpal tunnel syndrome such as arthritis, diabetes, repetitive strain injury, and pregnancy. Any activity, injury, or illness that puts pressure on the median nerve can contribute to carpal tunnel syndrome.

Keep it in neutral

Keeping your wrist in a neutral position, that is not extending or flexing it, can help to relieve symptoms of CTS by relieving pressure on the median nerve. One common method of treating carpal tunnel syndrome is to wear a wrist splint. Wearing a wrist splint at night when symptoms are most prevalent can help to keep your wrist in a neutral position.

Herbal remedies

Natural pain relief can often be more beneficial to us than ploughing our way through stacks of pain medication. Natural pain relief remedies often have little or no side effects whereas conventional medication can often come with a whole bunch of other complaints.

The great news is that natural pain relief remedies can be found by simply opening your spice cupboard. Turmeric has traditionally been used to help relieve arthritis and inflammation and this action is thought to be due to a chemical called curcumin. Similarly, ginger is also thought to have anti-inflammatory properties as well as helping to soothe and support the digestive tract.

Devil’s Claw, a South African herb that can help reduce inflammation and muscle and joint stiffness and soreness, could also be beneficial in helping to relieve CTS pain. Devil’s Claw is a good alternative to those who either can’t take pain killers or wish to take a more natural approach to pain management. You can find Devil’s Claw in our natural pain relief remedy Atrosan.

Take breaks

Pushing through activities that are causing you discomfort in your wrist such as numbness, tingling or pain probably won’t help much in relieving symptoms of carpal tunnel syndrome. Instead look to your body for signs that it wants to change its position, posture or pattern of movement. Take regular breaks especially when your wrist, hand, or fingers feel fatigued or achy. Get up and walk around, stretch out your arms, adjust your position and shake out your hands.

Wrist exercises

Simple wrist exercises can help relieve pain caused by carpal tunnel syndrome. First try bending the wrist forwards and backwards, taking the finger tips down towards the ground then up towards the ceiling. Then try gently circling the wrists in one direction and then the other way. Finally, open the fingers as wide as you can and then clench them into a fist, repeat this 5-10 times.

Stay in shape

If your body’s circulatory and repair systems work efficiently you’ll be less likely to suffer carpal tunnel syndrome symptoms. Making sure your circulation is healthy will help to make sure that the extremities – being the hands and the feet – get the blood and nutrients they need circulated to them. For some handy tips on how to boost your circulation check out Helen’s blog for natural ways to boost your blood circulation.

Being overweight will put an excess strain on your body and make it harder for your heart and circulation system to work effectively. This strain can then aggravate carpal tunnel symptoms so losing a couple of pounds could also be beneficial.

How you sleep

In most cases symptoms of carpal tunnel syndrome are most apparent at night, some doctors believe this is because the fluid in the body is redistributed when you lie down, so more of it accumulates in the wrist. However, your sleeping position may be another contributing factor, sleeping with your wrist bend or tucked underneath your head or pillow can cause compression of the median nerve.

Our sleeping position can have a massive impact on our body and also the quality of sleep that we achieve. Don’t be afraid to try several sleeping positions to find the one that best suits you, try to avoid any sleeping positions which compresses the median nerve.

Use ice

Applying an ice pack onto your wrist and forearm for around 10 minutes 2 to 3 times a day can help to reduce inflammation and swelling. It can be tricky to know whether ice or heat is best for your pain but in this case ice should win out over heat. While ice can reduce inflammation and swelling, heat can worsen a carpal tunnel problem because it causes the tissues in the narrow passageway to swell.

Eat foods that can help reduce inflammation

Another way you can reduce inflammation is through your food, try including more antioxidant-rich foods, such as bell peppers, that have the effect of reducing inflammation. Walnuts are another good inclusion to consider as they are rich in omega-3 fatty acids which can also work to decrease inflammation. Pineapple contains an enzyme called bromelain that is thought to help break down inflammation, which can, in turn, aid carpal tunnel symptoms.

Consume more vitamin B6

Vitamin B6 is an important mineral involved in hormonal regulation, as well as reducing tiredness and fatigue. It is also important for protein metabolism and brain health.

Although more research needs to be done in this area some studies have found that taking vitamin B6 could potentially help with carpal tunnel syndrome. There is much debate around this area though with some experts claiming that deficiency in this vitamin could be a culprit factor in leading up to carpal tunnel syndrome, whilst others believe that vitamin B6 helps promote pain relief due to its antinociceptive properties (which reduce sensitivity to pain).

Although vitamin B6 is available in supplement form we don’t need large quantities of it which is why I would recommend attempting to get it through your diet. While vitamin B6 is essential for our body’s function overconsumption of this vitamin can lead to nerve toxicity and negatively impact the nervous system. There are many natural food sources of vitamin B6 including bananas, spinach and sunflower seeds, so I would recommend including more of these in your diet if you can.

What else can I do?

If you find that your symptoms are getting worse I would suggest getting a doctor to check out your symptoms. If you find that home and herbal remedies haven’t helped you there are still a variety of options out there that could help relieve symptoms such as acupuncture and surgery.

7 Ways to Help Prevent Carpal Tunnel Syndrome

When most people think about carpal tunnel syndrome (CTS), they associate it with years of heavy typing, computer use, and other office related tasks. But the truth is it can affect any person who performs repetitive movements with their hands.

That’s evidenced by the roughly 500,000 people who undergo surgery every year to treat CTS. It’s one of the most common hand operations.

There isn’t currently a proven way to prevent CTS, but there are things you can do to reduce the amount of pressure you put on your hands and wrists. Below is information to help you understand CTS and what you can do to reduce your chances of getting it.

What Is Carpal Tunnel Syndrome

Your carpal tunnel is located on the palm side of your wrist. It’s made up of bones, ligaments, and tendons. CTS happens when the median nerve that runs through your carpal tunnel gets put under pressure or squeezed by swollen tendons in your wrist.

Arthritis and years of repetitive hand movements can cause the tendons to swell. When this happens, you start to feel symptoms of CTS.

What Are the Symptoms

According to the American Academy of Orthopaedic Surgeons (AAOS), the most common symptoms of CTS include:

  • Numbness or tingling in the hand
  • An electric shock-like feeling mostly in the thumb, index, and long fingers
  • Unusual sensations and pain that travels up the arm toward the shoulder

It’s common for symptoms to appear slowly and at any time. Many people report they feel it most on the thumb side of their hand. When symptoms are recognized and treated early, CTS can be helped without surgery.

Who Is at Risk

There are a variety of factors that make some people more likely to get CTS than others, like:

  • Heredity: A trait that causes the carpal tunnel to be smaller can run in families.
  • Sex: It’s more common in women than men. They have narrower wrists making it easier to put pressure on the median nerve. Hormone changes from pregnancy can also increase women’s risk.
  • Age: People who are older experience it more often, usually from years of wear and tear.
  • Health conditions: Illnesses like hypothyroidism, rheumatoid arthritis, and diabetes can also play a role.
  • Hand usage: Those who work with their hands often, like heavy laborers, musicians, and office workers, have increased risk. Past hand injuries can be a cause too.

What You Can Do To Help Prevent It

Here are some things you can try to prevent CTS from happening:

  1. Maintain a healthy lifestyle.
    • Don’t smoke: It interferes with blood flow and makes CTS worse
    • Keep your weight down: Obesity can slow down the speed of nerve messages to the hand and can contribute to a lack of physical activity, which can increase CTS risk
  2. Avoid sleeping in positions that cause your wrists to bend or curl.
  3. Keep your hands warm to prevent stiffness. If you work in a place that’s cold, consider wearing fingerless gloves.
  4. Loosen your grip and force when you’re working with your hands. Chances are when you write, you hold the pen or pencil too tight, or when you type, you push the keys hard.
  5. Take frequent, quick breaks from repetitive activities to rest your hands or change their position.
  6. Stretch your hands, fingers, and wrists often, rotating them in circles and flexing and extending your palms and fingers.
  7. Improve your posture and body mechanics at your work station. Pay attention to your use of the computer monitor, chair, keyboard, and mouse or other equipment and tools. .

What To Do If You’re Already Experiencing Symptoms

If you’re already having some problems with CTS, here are things you can do to help it and reduce pain or discomfort:

  • Apply cold packs to your wrists to reduce pain and inflammation.
  • Use nonsteroidal anti-inflammatory drugs like aspirin, ibuprofen (Advil, Motrin IB, others) or naproxen (Aleve).
  • Wear a wrist splint at night. You can find them at most drugstores and you don’t need a prescription.

If you try these options, or any others, and find they’re not working for you, don’t hesitate to talk to your doctor. Physical therapy, occupational therapy, or cortisone injections may be an option.

The decision to have surgery is based on the severity of your symptoms. Many people who undergo surgery have an improvement in their CTS symptoms, but recovery can be a slow process.

Signs and Symptoms

Carpal tunnel syndrome

Table of Contents > Conditions > Carpal tunnel syndrome

Signs and Symptoms What Causes It? Who’s Most At Risk? What to Expect at Your Provider’s Office Treatment Options Prognosis/Possible Complications Following Up Supporting Research

Carpal tunnel syndrome (CTS) is an injury caused by a pinched nerve in the wrist. The injury causes pain and numbness in the index and middle fingers and weakness of the thumb. Carpal tunnel receives its name from the eight bones in the wrist, called carpals, which form a “tunnel” through which the nerve leading to the hand extends.

Signs and symptoms of CTS include:

  • Nighttime painful tingling in one or both hands, frequently causing sleep disturbance.
  • Feeling of uselessness in the fingers.
  • A sense that fingers are swollen even though little or no swelling is apparent.
  • Daytime tingling in the hands followed by a decreased ability to squeeze things.
  • Loss of strength in the muscle at the base of the thumb near the palm.
  • Pain shooting from the hand up the arm as far as the shoulder.

What Causes It?

The carpal tunnel is filled with tendons (bundles of collagen fibers that attach muscle to bone) that control finger movement. Tasks requiring highly repetitive and forceful movements of the wrist can cause swelling around the tendons, resulting in a pinched nerve and producing CTS. Trauma, certain diseases, and pregnancy may also trigger CTS. On rare occasions, CTS may be genetic (some patients with CTS have carpal canals that are narrower than average). People who have short and wide hands with square wrists may also be at increased risk of CTS.

Who’s Most At Risk?

People working with small hand tools in manufacturing, and those using a computer keyboard on a regular basis, are at highest risk.

Women are 2 to 5 times more likely than men to develop CTS. It most commonly occurs in people ages 30 to 60. CTS is associated with health conditions, such as diabetes, hypothyroidism, rubella, pregnancy, connective tissues diseases, obesity, and menopause. High caffeine, tobacco, or alcohol intake are other contributing risk factors.

What to Expect at Your Provider’s Office

If you have symptoms of CTS, you should see your health care provider. Your provider can help determine which treatment or combination of therapies will work best for you.

Your provider will perform a physical examination and some simple tests to determine if you have lost any sensation, or if you have weakness in your thumb or fingers. Your provider may also perform more sophisticated diagnostic procedures ranging from a nerve conduction study to electromyography (EMG). You may also get x-rays or magnetic resonance imaging (MRI), or ultrasound imaging to reveal the cause and the nature of the injury.

Treatment Options

Management of CTS is based on severity. Your health care provider may put your wrist in a splint or brace to keep your wrist from bending, and to minimize or prevent pressure on the nerve. You will probably need to wear the splint full time for 3 to 4 weeks, then at night only. Putting ice on your wrist, massaging the area, and doing stretching exercises may also help.

Prevention

You can help prevent CTS or alleviate symptoms by making some simple changes in your work and leisure habits, such as:

  • Stretch or flex your arms and fingers before beginning work and at frequent intervals.
  • Alternate tasks to reduce the amount of repetitive movements.
  • Modify or change daily activities that put pressure on your wrists.
  • Modify your work environment. If you use a computer, have an adjustable keyboard table and chair, and a wrist rest.

Drug Therapies

Your provider may prescribe the following medications:

  • Anti-inflammatory drugs, such as ibuprofen, to reduce inflammation (swelling, pain, and redness).
  • Corticosteroids. A type of steroid, injected at the site of the carpal tunnel to reduce tendon swelling.
  • Diuretics, if needed.

Surgical and Other Procedures

Patients who do not improve with medication and splinting may need surgery. Surgery provides complete relief in 95% of patients.

Complementary and Alternative Therapies

A comprehensive treatment plan for CTS may include a range of complementary and alternative therapies.

Nutrition and Supplements

You should only use supplements and complementary therapies under the supervision of a qualified practitioner. Some dietary supplements, herbs, or CAM treatments can potentially interfere with conventional medicines. Keep all providers informed regarding any therapies you may be considering.

Following these nutritional tips may help reduce symptoms:

  • Eliminate all suspected food allergens, including dairy (milk, cheese, eggs, and ice cream), wheat (gluten), soy, corn, preservatives, and chemical food additives. Your provider may want to test you for food allergies.
  • Eat foods high in B-vitamins and iron, such as whole grains (if no allergy), dark leafy greens (such as spinach and kale), and sea vegetables.
  • Eat antioxidant-rich foods, including fruits (such as blueberries, cherries, and tomatoes), and vegetables (such as squash and bell pepper).
  • Avoid refined foods, such as white breads, pastas, and sugar.
  • Eat fewer red meats and more lean meats, cold-water fish, tofu (soy, if no allergy) or beans for protein.
  • Use healthy oils in foods, such as olive oil or coconut oil.
  • Reduce or eliminate trans fatty acids, found in commercially-baked goods, such as cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine.
  • Avoid coffee and other stimulants, alcohol, and tobacco.

You may address nutritional deficiencies with the following supplements:

  • A multivitamin daily. Containing the antioxidant vitamins A, C, E, D, the B-complex vitamins and trace minerals such as magnesium, calcium, zinc, and selenium.
  • Omega-3 fatty acids. Such as fish oil, 1 to 2 capsules or 1 tablespoonful (15 mL) of oil daily, to help reduce inflammation. Fish oils may increase bleeding in sensitive individuals, such as those taking blood-thinning medications (including aspirin).
  • B-complex vitamin. 1 tablet daily, for symptoms of carpal tunnel. Some studies suggest low levels of riboflavin in the blood is associated with carpal tunnel syndrome and other inflammatory diseases.
  • Vitamin C. 500 to 1,000 mg daily, as an antioxidant. Vitamin C can interact with some medications, including blood-thinning medications and chemotherapy agents. Speak to your doctor.
  • Alpha-lipoic acid. 25 to 50 mg twice daily, for antioxidant support. Make sure you are not thiamine deficient if you take alpha-lipoic acid. Alpha-lipoic acid may interfere with certain thyroid medications and chemotherapy agents.
  • Methylsulfonylmethane (MSM). 3,000 mg twice a day, to help reduce inflammation.

Herbs

Herbs are a way to strengthen and tone the body’s systems. As with any therapy, you should speak with your provider before starting treatment. You may use herbs as dried extracts (capsules, powders, or teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, make teas with 1 tsp. (5 g) herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups per day. You may use tinctures alone or in combination as noted.

  • Green tea (Camellia sinensis). Standardized extract, 250 to 500 mg daily, for inflammation and antioxidant and immune effects. Use caffeine-free products. You may also prepare teas from the leaf of this herb.
  • Bromelain (Ananus comosus). Standardized, 40 mg, 3 times daily, for pain and inflammation. Bromelain may interfere with certain medications, including some antibiotics. Bromelain may increase bleeding in sensitive individuals, such as those taking blood-thinning medications, including aspirin. People who are allergic to latex, pineapple, wheat, papain, and grass pollen may be sensitive to bromelain.
  • Turmeric (Curcuma longa). Standardized extract, 300 mg, 3 times per day, for pain and inflammation. Turmeric may increase bleeding in sensitive individuals, such as those taking blood-thinning medications, including aspirin.
  • Cat’s claw (Uncaria tomentosa). Standardized extract, 20 mg, 3 times per day, for inflammation. Cat’s claw can interact with certain medications, including blood pressure medications. Cat’s claw may worsen autoimmune conditions and leukemia.

Homeopathy

Although few studies have examined the effectiveness of specific homeopathic therapies, professional homeopaths may consider remedies for the treatment of carpal tunnel symptoms based on their knowledge and experience. Before prescribing a remedy, homeopaths take into account your constitutional type, includes your physical, emotional, and psychological makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for you.

An experienced homeopath can prescribe a regimen for treating CTS that is designed especially for you. Some of the most common acute remedies are listed below. An acute dose is 3 to 5 pellets of 12X – 30C every 1 to 4 four hours until symptoms clear up.

  • Apis mellifica. For joints that are red, hot, or swollen.
  • Arnica montana. 4 times per day, for a bruised, beat up feeling, soreness, achy muscles after trauma or overuse. This treatment may be especially effective if the gel or cream form is used topically.
  • Guaiacum. For CTS that is improved by the use of cold applications.

Physical Medicine

Contrast hydrotherapy. Alternating hot and cold water applications — may offer relief from CTS symptoms. This approach decreases inflammation, offers pain relief, and enhances healing. Immerse your wrists fully in hot water for 3 minutes, followed by 1 minute in cold water, and repeat 3 times. Do this 2 to 3 times daily.

Castor Oil Packs. Apply castor oil to a cloth, loosely wrap around wrist, and then cover with Saran Wrap. Apply a heating pad for a half hour, or without using a heating pad, sleep with the application on the wrist. Do this for 4 to 5 nights per week until improvement occurs.

Massage. Studies show that massage and trigger point therapy may help ease symptoms of CTS. Researchers recommend 30 minutes of massage twice a week.

Acupuncture

According to the National Institutes of Health, acupuncture may help treat CTS. Studies suggest that acupuncture restores normal nerve function and can provide long-term relief of pain associated with CTS. Acupuncturists treat people with CTS based on an individualized assessment of the excesses and deficiencies of qi located in various meridians. In the case of CTS, acupuncturists often target the liver, gallbladder, and kidney meridians.

Chiropractic

CTS is commonly treated by chiropractors. The methods most chiropractors use to treat CTS include manipulation of the wrist, elbow, and upper spine, ultrasound therapy, and wrist supports.

In one study, 25 individuals diagnosed with CTS reported significant improvements in several measures of strength, range of motion, and pain after receiving chiropractic treatment. Most of these improvements were maintained for at least 6 months.

A second study compared the effects of chiropractic care with conservative medical care (wrist supports and ibuprofen) among 91 people with CTS. Both groups experienced significant improvement in nerve function, finger sensation, and comfort. The researchers concluded that chiropractic treatment and conservative medical care are equally effective for people with CTS.

Massage

Massage may help prevent or relieve symptoms, especially in combination with rosemary or St. John’s wort oil.

Prognosis/Possible Complications

Most people’s symptoms clear up within a few months with conventional treatment. If left untreated, CTS in advanced stages can become serious, involving a loss of sensation, muscle deterioration, and permanent loss of function.

Following Up

If your wrist is placed in a splint or you receive corticosteroids, you will be monitored by your health care provider until treatment is completed. If you have surgery for CTS, you may need only a single follow up visit.

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Review Date: 11/19/2016
Reviewed By: Reviewed by Steven D. Ehrlich, NMD, Solutions Acupuncture, a private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network. Also reviewed by the A.D.A.M. Editorial team.

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What is Carpal Tunnel Syndrome?

Carpal tunnel syndrome (CTS) is a common, painful disorder caused by compression of the median nerve that passes between the bones and ligaments of the wrist.

What are the Signs and Symptoms of Carpal Tunnel Syndrome?

Compression of the median nerve causes weakness; pain when gripping; and burning, tingling or aching that may radiate to the forearm and shoulder. Symptoms may be occasional or constant.

What Causes Carpal Tunnel Syndrome?

Carpal tunnel syndrome is caused most frequently by repetitive, minor injury. This injury occurs most commonly in people who perform repetitive, strenuous work with their hands (e.g., carpenters), but may also occur in people who do light work (e.g., typists and keyboard operators). It may also follow more serious injuries of the wrist. In addition, carpal tunnel syndrome can be caused by anything that produces inflammation or swelling of the tissues of the wrist, such as rheumatoid arthritis, diabetes and hypothyroidism.

What Dietary Factors are Important in Carpal Tunnel Syndrome?

The increased frequency of carpal tunnel syndrome since 1950 parallels the increased presence of compounds that interfere with vitamin B6 in the body. Particularly incriminating is tartrazine (FD&C yellow dye #5). Tartrazine is added to almost every packaged food. In the United States, the average daily per capita consumption of certified dyes is 15 mg, of which 85 percent is tartrazine. Elimination of tartrazine from the diet may help carpal tunnel syndrome.

Which Nutritional Supplements Should I Take for Carpal Tunnel Syndrome?

Vitamin B6 (pyridoxine) supplementation appears to be quite helpful in many cases of carpal tunnel syndrome, based upon several double-blind studies. However, it may take as long as three months to produce a benefit. Take 25 mg of vitamin B6 three to four times daily.

Vitamin B2 (riboflavin) and other B vitamins may increase the effectiveness of vitamin B6 in the treatment of carpal tunnel syndrome. In one study, vitamin B2 was shown to be useful in the treatment of the disorder on its own, but an even greater effect was seen when it was combined with vitamin B6. B2 helps convert B6 into its more active form, pyridoxal 5′-phosphate. Take 10 mg of vitamin B2 daily. Note: There is no need to supplement with B2 if you are taking a MultiStart formula.

Celadrin is an all-natural matrix of special cetylated, esterifed fatty acids that reduce inflammation. The unique features of Celadrin include an ability to reduce inflammation and pain quickly with no side effects, as demonstrated in clinical trials published in the internationally acclaimed Journal of Rheumatology. Available in cream and capsule form, Celadrin is clinically proven to produce results. Celadrin cream can be applied to affected areas on an as-needed basis. If taken orally, the dosage is three soft gelatin capsules daily.

How Do I Know if the Recommendations are Working?

While B6 therapy will often takes a few months to produce results, Celadrin cream can produce results within 30 minutes.

How to Reduce Carpal Tunnel Syndrome Through Diet and Healthy Habits

Carpal tunnel syndrome (CTS) is a rising concern as more people take on jobs working on computers, which require repetitive motion. In addition to office workers, people working assembly line jobs, janitors, painters and cashiers are often at risk for symptoms of carpal tunnel (CT) due to the repetitive nature of their work. Fortunately, symptoms and pain may be reduced or cured by changing the diet and adjusting habits or work activities.

What Is Carpal Tunnel Syndrome?

A CTS condition is typically created by excessive fluid retention or any sort of movement, which may be repeated frequently such as writing, driving, sewing or keyboarding. These activities could affect or compress the median nerve (MN). The nerve runs through a narrow opening in the wrist, known as carpal tunnel. Any type of swelling or pressure can affect carpal bones or tendons in this region, which ultimately affect the use of wrists and some fingers.

Symptoms

Because tendons and the MN extend from the forearm to the hand, symptoms may occur anywhere in the elbow, forearm, hand or the fingers. Most people with this condition may experience pain, weakness, numbness or a tingling sensation in any of these areas. In many cases, patients have complaints with the middle or index fingers, thumbs or sometimes a portion of their ring fingers.

Treating Mild Symptoms of Carpal Tunnel

If you begin to notice any types of these symptoms, it might be wise to evaluate if certain activities or movements may be causing problems. These simple solutions may be helpful for resolving or providing relief from pain or tingling:

  • Discontinue physical activities, which cause you pain or numbness.
  • Take breaks throughout the day from activities like keyboarding that add additional stress to the wrist or fingers.
  • Apply ice to the wrist a few times per hour for a minimum of 10 minutes to reduce swelling.
  • Wearing wrist splints reduces pressure on nerves.
  • Keep your muscles strong with plenty of exercises and maintain an ideal weight.
  • Incorporate foods into meals that may work well to reduce or cure symptoms.
  • When keyboarding, alternate hands when possible. Shoulders should be relaxed and wrists should be held straight with hands just a bit higher than wrists.
  • Take anti-inflammatory drugs to reduce puffiness or inflammation.

Foods to Prevent or Alleviate Carpal Tunnel

Adding some of these foods may help to reduce symptoms of carpal tunnel or could even prevent carpal tunnel.

Vegetables With Bright Colors

Several vegetables that are bright green or red often contain large amounts of antioxidants, which work well for reducing swelling. Dark leafy greens, red or yellow peppers, healthy carrots, red tomatoes and bell peppers are great sources of healthy antioxidants.

Salmon

Adding salmon to your diet or increasing your intake of other types of fatty fish have been quite effective in reducing CT symptoms and decreasing inflammation. Consider sardines and tuna, which are high in healthy fatty acids.

Pineapple

Tropical pineapple is an ideal fruit to eat that contains bromelain enzymes, which work well for reducing swelling. In addition, you might also add coconut, cherries and blueberries to meals, which contain large amounts of antioxidants to fight inflammation.

Walnuts

Walnuts contain omega fatty acids just like some types of fish. Adding a handful of walnuts to your diet is not only healthy, but they can reduce wrist swelling. If you enjoy various types of seeds in your diet, try to cook more meals utilizing chia seeds or flax seeds for additional fatty acid intake.

Spinach

Research has shown that vitamin B6 is extremely effective at fighting CT symptoms. Spinach is rich in vitamin B6, and it is also found in many other foods like cantaloupe, nutritious cauliflower, bananas, sweet oranges and chicken.

Drinks or Foods to Avoid

Unfortunately, some foods only add to inflammation and pain. Consider reducing or avoiding these foods and drinks:

  • Salt causes more fluid retention, which affects swelling that may increase pain. Decreasing salt intake is recommended.
  • Consuming alcohol increases swelling and reduces the effectiveness of B vitamins needed for healing.
  • Sugar also increases puffiness and swelling, which adds to pain problems.
  • Reducing grains and gluten may help to decrease any inflammation.
  • Consider decreasing foods containing large amounts of saturated fats like processed meats, cheese, sausage and bacon that slow circulation.

Supplements

Whenever possible, it is always best to get vitamins and antioxidants through fresh foods that you consume. However, if you can’t eat certain foods or dislike the taste, you could consider purchasing supplements. For example, vitamin B6 and omega-3 (in fish oil) are both available as supplements and are sold over the counter.

The best way to reduce symptoms of carpal tunnel is to recognize the signs of the condition and make changes to your diet. Make sure you evaluate physical activities that may be repetitive and ensure you have an ergonomic computer workstation to prevent carpal tunnel.

Q: I believe my friend has carpal-tunnel syndrome from doing repetitive work at his job. Is there anything he can take for it that’s a natural anti-inflammatory?

A: Carpal-tunnel syndrome occurs when the median nerve in the wrist is pinched, often from repetitive motions. Symptoms can include numbness, tingling, burning and weakness in the hand or arm.

Doctors often recommend anti-inflammatory drugs, like ibuprofen. Acupuncture was shown in one small study to be as good or better than ibuprofen for relieving pain, numbness and tingling at night (Journal of Acupuncture and Meridian Studies, October 2015).

Vitamin B-6 (pyridoxine) has been a controversial treatment for carpal-tunnel syndrome. Some clinicians maintain that it is ineffective (American Family Physician, Dec. 15, 2016). Others say it works to ease symptoms (Advanced Pharmaceutical Bulletin, online, Aug. 20, 2013).

We offer a word of caution about this nutrient, though. Large doses or prolonged treatment can cause nerve damage, as this reader discovered: “I found out 30 years ago that taking vitamin B-6 helped me get rid of carpal-tunnel syndrome. However, I made the mistake of continuing to take it for decades.

“I eventually developed B-6 toxicity. By then it was having the opposite effect of making my hands AND feet numb. It took me a long time to figure out what was going wrong, since my doctor insisted there was no such thing as B-6 toxicity. By trial and error, I found that stopping the B-6 made the numbness go away.”

Q: My husband is controlling his blood sugar with supplements, diet and exercise. The supplements work for a while, but then his numbers go up in spite of a good diet. Do you have any natural suggestions that could help?

A: A low-carb diet and regular exercise can be beneficial in helping control blood sugar, especially if these strategies lead to weight loss. Adding a water-extracted cinnamon (cinnamomum) product may help, though this approach remains controversial. Other dietary supplements that have been shown to facilitate blood sugar control include fenugreek, nopal (Opuntia), psyllium and ginger (Frontiers in Pharmacology, online, July 6, 2017).

Whatever tactics you employ to control your husband’s blood sugar require careful coordination with his physician. Daily glucose monitoring is essential. For more details on these and other approaches, we are sending you our “Guide to Managing Diabetes.”

Q: I have had a plantar wart for almost 20 years, which eventually turned into a cluster. I’ve tried everything: duct tape, vinegar soaks, banana peel, wart remedies, etc. The doctor even performed surgery, but the warts returned.

I was desperate. I read about Tagamet and gave it a try. Within two months of taking one pill in the morning and one in the evening, my warts are GONE! I am in disbelief. It’s amazing.

A: The heartburn drug cimetidine (Tagamet) has produced conflicting results against warts (Annals of Pharmacotherapy, July 2007). That said, we have heard from many readers that this drug seems to work when most other approaches have failed.

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