Tuesday, 7 February 2017

Treatment of Carpal Tunnel Syndrome

What is Carpal Tunnel Syndrome?

Simply put, carpal tunnel syndrome is the inflammation or entrapment of nerves within the carpal tunnel of the anterior wrist, which can cause pain and numbness. “Most of my clients see me presenting with the classic symptoms,” explains Richard Garcia, a massage therapist in private practice in Peyton, Colorado. “These symptoms include numbness and tingling in the hand, difficulty grasping or carrying objects and, sometimes, hand pain.” Some clients, too, report the pain is worse in the evening, and sleep can be interrupted.
 
The causes of carpal tunnel syndrome are often associated with repetitive motion, such as working at a computer all day, for example, though other factors can come into play, as well. “Carpal tunnel is most often considered a repetitive strain or overuse injury, but genetics and disease processes can contribute to the symptoms, too,” explains Mary Bennett, owner of Alleviate LLC in Bloomington, Indiana. “Excessive flexion and extension of the wrist seem to be the most popular theory as to cause of carpal tunnel syndrome. However, heredity, those with smaller carpal tunnels, diabetes and rheumatoid arthritis, to name a few, can all play a part.”

What You Need to Know

Necessary knowledge. Everyone we talked to agreed that a better-than-average understanding of anatomy and physiology was necessary when working with clients with carpal tunnel syndrome. “You must know the anatomy of the area,” Bennett explains. “There are specific structures involved; you should know what they are so you help your client and not hurt them.”
 
Also, according to Kanoa General, owner of Blue Turtle Healing in New York, having sound critical thinking skills is a must, as well as knowing how to apply current massage therapy techniques to help resolve the problem. “Having a strong professional relationship with a variety of health care professionals should be a given,” adds Garcia. “This gives the massage therapist the opportunity to use the health care professionals as a ‘sounding board’ to privately confirm their assessments, and it shows the health care professionals that you take your work seriously and are actively striving to improve your own knowledge.”
 
One other critical skill mentioned by the massage therapists we spoke with: know your own limitations. Whether you need to consult with other massage therapy colleagues or refer the client to another health care professional, understanding what you can and cannot do for the client is imperative, especially if there are additional underlying health conditions. “Don’t be afraid to reach out to colleagues or therapists who know more than you and ask for help,” General says. “Also, don’t be afraid to refer out to other health care providers.”
 
Assessment. Some of your clients will come to you with a diagnosis from their health care provider—and some won’t—making your initial assessment critical. “The initial assessment includes a detailed health history form and an interview,” explains Bennett. “I ask about their medications, general health issues and specific information about the  carpal tunnel syndrome, such as the location of the pain and/or numbness, the initial onset and duration of symptoms, activities that exacerbate the symptoms and prior treatment.”
 
Along with medical history, evaluative tests like Phalen’s or Tinel’s for the wrist can be helpful in developing a comprehensive treatment plan, says General. “I also assess the pronator teres, the shoulder and cervical region for compression along the median nerve, especially if they have a history of neck or shoulder injuries or perform repetitive movements on a daily basis,” he adds.
 
Because these clients are going to likely need a series of massages to get real relief, reassessing how massage therapy sessions are working is also going to be important. “I assess before and after treatment and ask questions related to the clients activities of daily living,” General says. “For example, were they able to sleep at night with less pain or have they been able to lift and drink a glass of water without feeling like they were going to drop the glass.”
 
Garcia, too, asks general questions about the client’s condition, as well as if they are seeing any relief from their symptoms or have experienced any changes in lifestyle or stress levels, for example. “I also ask them if they feel we need to make any changes to how the massage is carried out,” he adds. “Do they want or need more or less pressure, more or less oil, as well as what stretches worked, what stretches didn’t, and if there was any discomfort or soreness afterwards.”
 
Communicate clearly. The same can be said of any consumer demographic you’re working with, but you need to be able to tell your clients what they can expect. First, says Bennett, develop a treatment plan yourself. “Ask yourself ‘what is my objective and how am I going to accomplish that?’” she explains.
 
From here, make sure you can properly explain the treatment plan to the client in a way that is easily understandable. “The client should know your plan,” she says. “They should know what to expect as far as discomfort and expected results.” Also, be sure you don’t promise results you can’t deliver. Be very clear about the benefits massage therapy will provide so your clients aren’t expecting results you might not be able to achieve.

How Massage Can Help

Techniques used. There are a variety of ways you can work with clients who have carpal tunnel syndrome. Though much of the focus may be on the wrist area, as with other problems, more than one structure may be involved. Garcia does a full-body session with a concentration on the wrist, believing that carpal tunnel is very rarely strictly a wrist problem. “My opinion is that if the client has carpal tunnel syndrome, the probability of other muscles being out of balance is approximately 100 percent,” he says.
 
Bennett agrees. “The arm is usually in a torsion pattern that is present in the rest of the body,” says Bennett. “Typically carpal tunnel syndrome clients will present with an internal rotation of shoulder and arm. Because the nerve that supplies the sensation in the carpal tunnel originates in the neck and shoulder area, I feel it is important to release possible ‘kinks’ along the entire nerve pathway.”
 
Using detailed deep tissue work that releases tension, adhesions and trigger points in the soft tissue of the shoulder, full arm and hand, Bennett works to bring the shoulder and arm out of internal rotation. General uses orthopedic massage techniques like myofascial release through stripping, compression and active engagement.
 
Typical session. Bennet begins by releasing the internal rotation of the shoulder, specifically the pectoral muscles and subscapularis. “Then, starting at the upper arm, down to the elbow, forearm and hand, I feel for adhesions and fibrous tissue, especially along the nerve pathways, releasing them systematically,” he says.
 
General typically works on clients for an hour, using heat and compression to reduce hypertonicity in the flexor muscles. “This is followed by myofascial release techniques and stretching of the muscle tissue,” he says. “The entirety of the session is not devoted to releasing the forearm but the whole arm, shoulder girdle and cervical region."
 
Time it takes. The number of sessions a client needs to find relief will vary of course, and most often is dependent on how severe the problem is. “I’ve had clients improve in one 60-minute session,” General says. “Others have improved in six, 60-minute sessions, after addressing primary, secondary and tertiary reasons for carpal tunnel syndrome.”
 
Most agree, however, that clients should see some relief after the first session. “Most clients experience some relief after the first session,” explains Bennett. “Typically it takes three to five sessions to get long-term results, sometimes more, sometimes less.”
 
Garcia uses deep tissue and neuromuscular therapy, saying clients usually begin to see relief almost immediately. He’s careful to temper this statement, however. “Note that relief does not mean complete resolution of symptoms,” he cautions.
 
One of the biggest factors concerning the time it takes for clients to find relief revolves around the time they’ve spent suffering from the symptoms. According to Bennett, the longer a person goes without treatment, the longer it takes for them to recover, generally speaking.



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