Originally appeared as a contribution to the " Clinical Perspectives: Carpal Tunnel Syndrome" article in the December 2009 edition of "In Good Hands" © Colin Rossie 2009/ AMT 2009. Not to be printed or used without permission of the copyright holders and acknowledgement of original publication.
By Colin Rossie
Description
Carpal Tunnel Syndrome (CTS) is an occupational overuse syndrome of the wrist. The tunnel is formed by the carpal bones on the dorsal aspect and by the transverse carpal ligament (and to a lesser extent the flexor retinaculum) on the volar aspect of the wrist. The tendons of the wrist, finger flexor and thumb muscles pass through this tunnel along with the median nerve. The tendons can become inflamed and swell through overuse, thereby compressing the median nerve.
CTS is a mono-neuropathy in that only a single nerve is affected. Muscles that are affected would include the palmaris longus, flexors carpi radialis and ulnaris, flexors digitorum superficialis and profundus, and flexor pollicis longus.
Many references state that CTS is more prevalent in middle-aged females. This could perhaps be partially attributed to physiological changes occurring around menopause, but could also be the result of long-term keyboard use. In practice, I find the condition presenting in both genders, and across a wide range of ages and occupations. In addition to assembly line workers and keyboard operators, CTS also commonly affects any occupation where power or precision grip is constantly required such as musicians, waiting staff, chefs and drivers.
Initially, symptoms are low level and of insidious onset, starting with numbness and tingling in the thumb (I digit), index (II digit) and middle (III digit) fingers, the radial half of the ring finger (IV digit) and possibly the wrist, gradually becoming chronic.
After several months this becomes an acute pain in the wrist and forearm, described as “burning”, “itching” and “throbbing” by those with it. Clients will also report that their fingers feel swollen and numb, even though there will be no visible swelling. In fact, after prolonged periods the forearm muscles and fingers atrophy. Power and precision grips weaken, fine motor skills diminish and the ability to distinguish temperature variations can become difficult. Symptoms are not relieved by rest and actually worsen with sleep, especially where there is a tendency to clutch the hand and fingers in flexion.
Differential Diagnosis
Differential diagnosis would include medial epicondylitis, neuropathies of the ulnar and radial nerves, cervical radiculopathies, thoracic outlet syndrome, sub-acromial impingement, osteoarthritis of either the carpal bones, metacarpals or distal radius and ulna, and tenosynovitis. Also, active trigger points from the scalenes, infraspinatus, subscapularis, brachialis, supinator, pectoralis major and minor, serratus anterior, pronator teres, palmaris longus, flexors carpi ulnaris and radialis, and digitorum profundus and superficialis, adductor pollicis and opponens pollicis all refer pain in patterns that mimic CTS.
In closed kinetic chains, I believe that myofascial trigger points are tertiary considerations - more a symptom of stability and core dysfunction than a primary factor (essentially, they are a local symptom of a poor global relationship to gravity). However, in open kinetic chains such as the upper limb, trigger points play a more significant role as manifestations of purely local dysfunctions, occupying a more central role in the treatment protocols employed.
Assessment
Pain from the median nerve can originate anywhere along the length of the nerve, not just the carpal tunnel. Although symptoms may appear the same between individuals, the cause may be completely different. True CTS is over diagnosed, being a convenient catch-all for any wrist pain or pain of median nerve origin. Therefore accurate assessment is vital before commencing treatment.
What follows are assessment protocols I use and a brief rationale for their use. This is followed by a description of some treatment approaches, which would vary according to the specific findings of the assessment. Fuller descriptions of the tests can be found in the references provided. Kerry Hage has already described Tinel’s Sign and Phalen’s test in her contribution earlier in this article:
• Active Quick Test of the median nerve to determine that it is the median nerve involved (Butler, 2008, p34).
• Tinel’s Sign to determine median nerve involvement at the carpal tunnel (Magee, p441).
• Phalen’s Test (Magee, p442) to determine carpal tunnel involvement.
• Upper Limb Neurodynamic Test 1 (median nerve), another test to determine median nerve involvement (Butler, 2008, p35-6 and accompanying DVD).
• Upper Limb Neurodynamic Test 2 (median nerve), again to determine median nerve involvement (Butler, 2008, p37-8 and accompanying DVD).
• Adson’s Manoeuvre or Halstead Manoeuvre to determine whether thoracic outlet syndrome is involved in the wrist symptoms (Magee, p322),
• Apley’s Scratch Test to determine if there is gleno-humeral joint involvement (Magee, p254-255).
I would perform the following to rule out involvement of structures other than the median nerve and to determine what structures to work:
• Passive, active and resisted testing of elbow flexion/extension
• Passive, active and resisted testing of forearm supination/pronation
• Passive, active and resisted testing of wrist in flexion/extension, ulnar and radial deviation
• Passive, active and resisted testing of finger flexion/extension, abduction / adduction
Assessment of power and precision grip (Magee, p422) - in addition to determining how these are affected by the CT - is also a good pre- and post-session yardstick for both the client and practitioner.
Treatment
Commence by decreasing the hypertonicity of the myofascial structures of the forearm starting with gentle, myofascial release to the forearm flexors. Follow this with deep transverse frictions to the common flexor tendon, then deep connective tissue massage along the length of the muscles from the distal tendon at the wrist through to the epicondyles, and broadening, transverse compressions across the muscle fibres.
A good series of techniques similar to the above can be found at:
http://www.massagemag.com/Magazine/2004/issue107/assess107.5.php
Another good source of techniques that could be employed, along with excellent illustrations of the anatomy, can be found in Clay & Pounds ‘Basic Clinical Massage Therapy’. The technique illustrated for working with the Flexor Retinaculum is particularly useful. A word of caution though – unfortunately, the photo in the 1st edition of this book looks like the therapist is crushing the nerve. I’m sure this isn’t actually the case! Always keep in mind that your intent isn’t to crush the nerve (which would exacerbate the client’s symptoms) but to
a) free it from the surrounding structures that it might be adhered to
b) lengthen shortened structures that could be impinging it and
c) decrease the swelling of other soft tissue structures within the carpal tunnel that affect the nerve.
Next, deactivate trigger points that may be present in the forearm myofascia and tendons. Kerry Hage has already addressed this aspect in her contribution. If it is a genuine case of Carpal Tunnel Syndrome, there will likely be active TrPs in the shoulder girdle that will need deactivation as well.
Follow TrP deactivation with stretching and a ‘flushing’ effleurage, starting gently but with depth, gradually decreasing the depth and slowing the rate to create a flushing effect on any soft tissue swelling.
I would then use direct myofascial technique with active movement participation (DMFT w/AMP) to the forearm flexors and inter-osseous membrane (IOM) of the forearm.
For more information on this style of work, see Smith (2005), Stanborough (2004), Riggs (2007) and Schleip (www.somatics.de).
Many of the forearm flexor muscle fibres attach directly to the Inter-osseous membrane (IOM)of the forearm (Stecco 2004); working it can have a profound effect on CTS symptoms.
Have the client supine and their hand and forearm supinated, have them form a soft fist and flex the wrist. as you apply pressure to the appropriate depth at the wrist and move slowly up the forearm toward the common flexor tendon. At the same time, ask the client to slowly bring the wrist into extension, gradually opening the fingers so that at maximum wrist extension the fingers are fully extending as well (see photos 1-3). Work up the arm like this several times, paying attention to the feel of the tissue being worked. Also pay attention to the different slips of muscle/fascia you contact, always seeking to differentiate the tissue (see photo 4). To work in a second plane, have the client vary their movement by medially and laterally deviating their wrist. As the radius and ulna move you will affect the IOM, especially if you focus your intent on it.
Other techniques I might incorporate into a session for CTS could include:
• DMFT w/AMP to the forearm extensors, client supine, arm beside the torso again with the intention of affecting the IOM (see photo 5), this time from the dorsal side (client supine, forearm pronated). Ask for medial and lateral deviation of the wrist as you work the forearm (figure 1).
Again, to get a second plane of movement, request the client to slowly lift their hand up and down (extend and flex the wrist –figure 2). Alternatively, ask them to gradually press their palm into the table and slowly release it as you work on it.
Another variation would be to have the client anchor their hand by pressing their palm into the table and then actively move the elbow medially and laterally as you work the forearm distally to proximally (figure 3 – see Maupin, 2005, pp80-81).
• DMFT w/AMP to the palmar fascia. Client's forearm and hand supinated. Apply direct pressure to the client's palm with either your thumb or finger pads, and slowly work up the palm to past the wrist as the client flexes and extends their digits.
• DMFT w/AMP to the flexor retinaculum. With the client’s forearm supinated, I hold the outsides of the client’s hand with both my hands, thumbs on the centre of the flexor retinaculum. I ask the client to extend their wrist at the same time opening (abducting) their fingers as I slowly and deeply drag both thumbs out to the sides.
I may also perform a series of neural mobilisations for the median nerve. These are fully described in Butler (2000) pp314-325, (2008) pp41 -43, and Barral (2007), pp161- 169. They are also demonstrated in the relevant section of the DVD accompanying Butler (2008). These mobilisations can be used as pre- and post- assessment tools or at any stage during the treatment session.
If the client has tested positive to the median nerve tests, the nerve may be impinged at sites other than the carpal tunnel. Neural massage of the median nerve at more proximal locations might be required.
In the upper arm, the median nerve is about the width of a window sash cord and is on the medial aspect of the arm between the biceps brachii and triceps brachii. Here it can be easily palpated and treated for restrictions (Barral, p162 and figure 6.58), also at the ligament of Struthers in the elbow (Barral, p164 and figure 6.59, Hammer, p165), in the forearm (Barral, p165 and figure 6.60), at the wrist (Barral, p165-6 and figure 6.62) and in the hand. The intent of this style of work is to release the nerve from the surrounding structures it could be adhered to. Basically, it is working epineurium. Nerves themselves have the consistency of blancmange and the intent should not be to crush them.
Tom Myers discusses the arm in his ‘Anatomy Trains’ model of the body, according it 6 myofascial meridians. Of special note in terms of working with CTS in his myofascial meridians paradigm would be the Deep Front Arm Line, which roughly corresponds to the lung meridian in Traditional Chinese Medicine (Myers, 2009, pp151-155) and more importantly the Superficial Front Arm Line, which approximates the pericardium meridian in TCM (Myers, 2009, pp155-158). Myers’ model is worth consideration and further study if you are seeing a large number of CTS clients (Myers, 2009, pp 149-169).
Homework
Wearing a wrist splint to bed to prevent wrist and finger flexion during sleep is one option that will help prevent the nocturnal exacerbation of CTS. Stretching the forearm flexors in conjunction helps reduce symptoms and speeds recovery. Butler (2008) shows a series of exercises in both his book (pp 44- 48) and DVD. I play the relevant median nerve self-management section of the DVD to clients, who have found it particularly useful.
CTS shouldn’t be considered from just a local, remedial perspective but in the global context of the whole being. From a structural Integration perspective, this would involve the body’s relationship to its centre of gravity. Previous trauma or unbalanced, repetitive work habits affect this relationship. Poor posture will affect the brachial plexus, thoracic outlet and sub-acromial region. Re-education regarding seated posture, shoulder girdle and upper limb usage (relating these to the body’s centre of gravity) would be essential in this paradigm, as well as modifying the workstation layout to improve its ergonomic efficiency.
Acknowledgments
My sincere thanks to Ed Maupin for generously allowing me to re-print his diagrams from “A Dynamic Relationship to Gravity: Volume 1-The Elements of Structural Integration”. Thanks also to Tania Lambert for her photography.
Bibliography
Barral J.P. 2007 Manual Therapy for the Peripheral Nerves Churchill Livingstone/Elsevier Edinburgh
Butler, David, 2000 The Sensitive Nervous System Noigroup Publications Adelaide
Butler, David 2008 The Neurodynamic Techniques Noigroup Publications Adelaide
Clay, J.H. & Pounds, D.M. 2003 Basic Clinical Massage: Integrating Anatomy & Treatment 1st edition, Lippincott Williams & Wilkins, Baltimore MD
Hammer, Warren 1999 Functional Soft-Tissue Examination and Treatment by Manual Methods 2nd edition, Aspen Publications, Gaithersburg MD
Lowe, W. 2004 “Assess and Address: Carpal Tunnel Syndrome” in Massage Magazine, issue 107. Available online: http://www.massagemag.com/Magazine/2004/issue107/assess107.5.php
Magee D.G. 2008 Orthopedic Physical Assessment, 5th Edition, Saunders/Elsevier St Louis Missouri
Maupin, E 2005. A Dynamic Relation To Gravity, Vol 1—The Elements of Structural Integration. Dawn Eve Press
Myers, T.W. 2009 Anatomy Trains, Myofascial Meridians for Manual and Movement Therapists 2nd edition, Churchill Livingstone/Elsevier Edinburgh
Riggs, A 2007 Deep Tissue Massage: A Visual Guide to the Techniques Revised Edition, North Atlantic Books, Berkeley California
Schleip, R. Put more AMPs into your sessions: Advantages & Tips for Active Movement Participation (AMP) of the client during
the hands-on myofascial work sighted 10/9 2009 at www.somatics.de
Smith, J. 2005, Structural Bodywork Churchill Livingstone/Elsevier Edinburgh
Stanborough, M. 2004, Direct Release Myo-Fascial Technique Churchill Livingstone/Elsevier Edinburgh
Stecco, L 2004 Fascial Manipulation for Musculoskeletal Pain Piccin, Padova, Italy
Colin Rossie has over 25 years experience as a bodyworker—initially as a shiatsu practitioner, then as a remedial and sports massage therapist, before becoming a Certified Rolfer® and Rolf® Movement practitioner. His work is firmly grounded in a sound knowledge of anatomy and physiology and Western science. Colin also brings a strong awareness and exploratory approach to kinaesthetics when treating clients. He works mainly from his Lilyfield, Sydney clinic and occasionally in the Tweed Heads/Byron region.
PHOTO DESCRIPTIONS:
Photo 1 - DMFT of the forearm flexors & IOM using the proximal phalanges
Photo 2 - AMP: extending the wrist and fingers from a soft fist
Photo 3 - DMFT w/AMP of the forearm flexors & IOM using re-enforced fingers
Photo 4 - DMFT w/AMP of the forearm flexors & IOM using thumbs of both hands
Photo 5 - DMFT w/AMP of the forearm extensors using the palm
FIGURE DESCIPTIONS:
Figure 1 (©2005 Ed Maupin used with permission)
Figure 2 (©2005 Ed Maupin used with permission)
Figure 3 (©2005 Ed Maupin used with permission)
Thursday, February 25, 2010
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