Carpal tunnel syndrome (CTS) plagues those who work with computers or jobs that involve repetitive motion. The numb fingers, tingling, & weakness in the hand are common signs of CTS. The lifetime risk of CTS is approximately 10% of the adult population. Women are three times more likely to develop CTS, compared with men, perhaps because the tunnel itself may be smaller. The dominant hand is usually affected and produces the most severe pain in cases of bilateral CTS.

Carpal tunnel syndrome is compression of the median nerve within the carpal tunnel causing numbness, tingling, and other symptoms in the hand and arm. The carpal tunnel is formed by the flexor retinaculum (transverse carpal ligament) as it connects to bones on the anterior wrist. The tendons of some wrist flexors and the median nerve pass through the tunnel into the hand. The median nerve serves the palm (anterior) side of the thumb and to the index, middle, and lateral half of the ring fingers; it also controls small muscles at the base of the thumb. Because the tunnel is inflexible, it cannot accommodate swelling, which causes compression of its contents.

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Double crush syndrome is compression at multiple sites along a single peripheral nerve. For example, the combination of carpal tunnel syndrome and neck pain from cervical radiculopathy is a common complaint, especially among individuals with osteoarthritis. Cohen et al (2016) questioned this traditional, but narrow, definition stating many systemic pathologic processes (diabetes mellitus, drug-induced peripheral neuropathy such as can occur during chemotherapy, neurologic, vascular, and autoimmune diseases) can have deleterious effects on peripheral nerve function. Multiple crush syndrome and double crush syndrome are used interchangeably.

Common causes of CTS are occupational repetitive use of the wrist, direct trauma, and some structural abnormalities (carpal tunnel is narrower than average). Some conditions, such as rheumatoid arthritis and the fluid retention often experienced during pregnancy, can cause CTS. In some cases, the cause is unidentified.

Symptoms include pain and paresthesia in the anterolateral side of the affected hand and fingers. The person often experiences muscle weakness and weak grip. Atrophy is seen in severe or chronic cases. Initial treatment choices are the use of a wrist brace or splint to stabilize the area and ergonomic devices such as special keyboards and cushioned mouse pads. NSAIDs and injectable corticosteroids help reduce swelling and inflammation. Analgesics are used to decrease pain. In some cases, surgery is needed to release the compressed nerve..

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Massage Therapy and CTS – Massage the forearm muscles and muscles in the palm of the hand, below the client’s pain tolerance. PROM of the anterior and posterior forearm muscles also may be helpful. Recommend self-massage and self-stretching to help clients maintain or improve their treatment goals. Do not use massage techniques over the anterior neck (anterior and posterior triangles) as this area is an endangerment site. Massage to this area caused neurologic adverse events including brachial plexus injury and spinal accessory neuropathy. Orthopedic physical tests such as the Phalen test and the Tinel sign test can be used to evaluate the presence or absence of CTS in clients who present with symptoms of this condition, but do not currently have a diagnosis. A positive result may warrant referral to the client’s healthcare provider for medical evaluation.

327973_1_En_26_Fig3_HTMLPhalen Test. The Phalen test may identify carpal tunnel syndrome (CTS). Ask the client to maximally flex both wrists and press the dorsi of the hands together so the forearms form a straight line with elbows pointing laterally; hold this position for 1 minute. If pain, numbness, tingling, or paresthesia develops or increases in median nerve distribution (thumb, index, middle, and lateral half of ring fingers), the test is positive and may warrant referral to the client’s healthcare provider for medical evaluation.

Tinels-at-Wrist-TestTinel Sign Test. The Tinel sign may identify carpal tunnel syndrome (CTS). Ask the client to flex the elbow on the affected side, and supinate the forearm so the palm faces upward, and wit the wrist slightly extended. Lightly tap the anterior surface of the wrist in the location of the median nerve with one or two fingertips 4 to 6 times. If pain, numbness, tingling, or paresthesia develops or increases in median nerve distribution (thumb, index, middle, and lateral half of ring fingers), the test is positive and may warrant referral to the client’s healthcare provider for medical evaluation. The Tinel sign test can be used on other areas of the body such as the medial elbow (ulnar nerve), the lateral neck (brachial plexus), and the medial ankle (tibia nerve). A positive result may warrant referral to the client’s healthcare provider for medical evaluation.

research iconResearch. A 15-minute daily self-massage to the affected forearm and hand combined with weekly massage from a clinician to the same area administered for 4 weeks decreased pain, anxiety, and depression and improved nerve conduction velocity in persons diagnosed with CTS (Field et al, 2004). Six weeks of daily self-applied hand massage and wrist-hand stretching combined with wrist-hand resting splint worn during night sleep reduced pain and improved grip strength compared with the splint only group (Madenci et al, 2012). Hand massage consisted of 30-seconds of effleurage, 60-seconds of friction, 30-seconds of petrissage, 30-seconds of shaking or vibration, and ended with 30-seconds of effleurage (totally 3 minutes). The wrist-hand stretching included movements which lengthen the tendons and the median nerve within the carpal tunnel. Participants were asked to repeat each position 10 times at least 3 times a day.

Six weeks of twice-weekly general massage or CTS-targeted massage improved function and grip strength and these improvements persisted for 4 weeks post-treatment (Moraska et al, 2008). Targeted massage has greater gains in grip strength compared with general massage, but these gains did not reach statistical significance. A 30-minute massage administered twice weekly for 6 weeks combined with trigger point work decreased CTS symptoms and improved function (Elliott & Burkett, 2013). Twice weekly sessions of manual therapy (massage and wrist mobilizations) and electrophysical therapy (laser and ultrasound) administered over 10 weeks had a positive effect on nerve conduction, pain reduction, functional status, and subjective symptoms in individuals with CTS (Wolny et al, 2017). However, the manual therapy group had greater improvements in pain reduction, subjective symptoms, and functional status compared with the electrophysical therapy group.

Piper et al (2016) conducted a systematic review of soft tissue therapies used to manage musculoskeletal disorders and found localized relaxation massage combined with multimodal care helpful for CTS.

Picture Credits:

http://www.rothmanortho.com/stories/blog/Carpal-Tunnel-Syndrome-Treatment-In-Freehold

http://www.wildermanphysicaltherapy.com/

http://www.link.springer.com/chapter/10.1007/978-3-319-50512-1_26

http://www.medisavvy.com/tinels-wrist-test/

References:

Cohen, B.H. Gaspar, M.P., Daniels, A.H., Akelman, E., Kane, P.M.. (2016). Multifocal neuropathy: expanding the scope of double crush syndrome. J Hand Surg Am, 41(12), 1171-1175.

Elliott R, Burkett B. (2013). Massage therapy as an effective treatment for carpal tunnel syndrome. J Bodyw Mov Ther, 17(3), 332-338.

Field, T., Diego, M., Cullen, C., Hartshorn, K., Gruskin, A., Hernandez-Reif, A., Sunshine, W. (2004). Carpal tunnel syndrome symptoms are lessened following massage therapy. J Bodywork Mov Ther, 8(1), 9-14.

Madenci, E., Altindag, O., Koca, I., Yilmaz, M., Gur, A. (2012). Reliability and efficacy of the new massage technique on the treatment in the patients with carpal tunnel syndrome. Rheumatol Int, 32(10), 3171–3179.

Moraska, A., Chandler, C., Edmiston-Schaetzel, A., Franklin, G., Calenda, E.L., Enebo, B. (2008). Comparison of a targeted and general massage protocol on strength, function, and symptoms associated with carpal tunnel syndrome: a randomized pilot study. J Altern Complement Med, 14(3), 259-267.

Piper, S., Shearer, H.M., Côté, P., Wong, J.J., Yu, H., Varatharajan, S., Southerst, D., Randhawa, K.A., Sutton, D.A., Stupar, M., Nordin, M.C., Mior, S.A., van der Velde, G.M., Taylor-Vaisey, A.L.. (2016). The effectiveness of soft-tissue therapy for the management of musculoskeletal disorders and injuries of the upper and lower extremities: A systematic review by the Ontario Protocol for Traffic Injury management (OPTIMa) collaboration. Man Ther, 21, 18-34.

Wolny, T., Saulicz, E., Linek, P., Shacklock, M., Myśliwiec, A. (2017). Efficacy of manual therapy including neurodynamic techniques for the treatment of carpal tunnel syndrome: a randomized controlled trial. J Manipulative Physiol Ther, 40(4), 263-272.

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Dr. Susan Salvo is a massage therapist, author, educator, researcher, explorer, and perpetual student. To learn more, check out the “About Susan” tab. You can contact Susan at susansalvo@hotmail.com.