Carpal Tunnel Syndrome

Carpal Tunnel Syndrome is compression of the median nerve as it passes through the bony canal (or carpal tunnel) of the wrist.  Symptoms are very similar as those found in Pronator Teres Syndrome, where the median nerve is compressed between the heads of the pronator teres muscle.

Causes of Carpal Tunnel Syndrome
Carpal tunnel syndrome is often seen in people with occupations that require repetitive movements of the wrist.  Some of these professions include massage therapists, check-out clerks, office workers who type a lot, and string musicians.  The median nerve passes through the carpal tunnel of the wrist with various other tendons and vessels. The carpal tunnel may be narrowed by bony callus formations or other bony changes that may occur with system conditions like rheumatoid arthritis.  Space occupying lesions like cysts or ganglia may also cause the carpal tunnel to narrow.  The structures that pass through the carpal tunnel may increase in size due to inflammation or irritation, swelling (as often seen in pregnant women), fibrosis, or scar tissue due to wrist related trauma.  In addition, carpal tunnel syndrome can be acute in nature when secondary to trauma, with infection, during an acute episode of rheumatoid arthritis, or a new activity requiring repetitive wrist movements.  Sometimes, there is no known cause of Carpal Tunnel Syndrome.

Signs & Symptoms
Carpal Tunnel Syndrome patients often complain of numbness and tingling felt in the palm of the hand, through the thumb, pointer and middle fingers.  Pain and burning sensations may also present.  The symptoms are often worse at night or in the early morning and will increase with repetitive use of the hand and wrist.  There may be heat and inflammation, tenderness and a boggy feel to tissue at the wrist.  The muscles of the forearm may be hypertonic and fascial restrictions may be present.  With Carpal Tunnel Syndrome, the pain may wake the patient from sleep and relief from all symptoms is usually sought out by elevating and shaking the hand or immersing them in warm water.  In chronic conditions there may be autonomic losses like sweating, redness and dryness of the skin and the muscles of the thumb may appear to have wasted.

Orthopedic Assessment
Some of the typical orthopedic assessment techniques a massage therapist may use are:

• The patient may be asked to perform active & passive resisted ranges of the wrist.
• The patient may be asked to perform resisted muscle strength testing of the muscles that cross the wrist joints.
• Phalens and Reverse Phalens testing may be performed. This is where the patient is asked to hold their hands in a flexed position (for Phalens) against each other, or an extended or prayer position (for Reverse Phalens) for 60 seconds and report on symptoms.
• Tinel’s test may also be performed. This is where the therapist taps along the nerve path to try and determine where the compression site is.

Massage Treatment Goals
Massage therapy can be used as a tool to help decrease sympathetic nervous system firing, pain, numbness, tingling and burning sensations. In addition, it can be used to help reduce swelling and inflammation while preventing tissue adhesions.  Therapeutic massage should be aimed at maintaining or improving joint and tissue health as well as muscle strength and preventing cyanosis.

Typical Massage Treatment
The entire upper limb and neck may be treated in instances of Carpal Tunnel Syndrome. The double crush theory suggests that in cases of Carpal Tunnel Syndrome there may be multiple areas of compression, none of which on their own are causing the symptoms, but instead symptoms are caused by the collective effect of each compression site combined.  Manual Lymph drainage techniques may be used to help reduce edema. General Swedish massage and fascial techniques may be used on the arm, pectoralis muscles and neck to help maintain tissue health and prevent tissue adhesions. Attachments release may be performed and trigger points may also be addressed in the arm, shoulder girdle and neck.  Passive and active stretching of the wrist may also be incorporated into therapeutic massage treatments.

Massage Contraindications & Precautions
Patients suffering Carpal Tunnel Syndrome may have sensory impairments. No extreme hydrotherapies or pressure depths should be used.  If muscle atrophy is present the treatment will have to be modified accordingly.  Blood flow to the hands and fingers may be impaired which may lead to tissue fragility in extreme cases. If edema is present the patient should be positioned for proper drainage.  And the therapist should not use any techniques that would cause further compression of the median nerve.

Typical Suggested Homecare
The patient may be asked to perform pain free passive stretches to the wrist, shoulder or neck, as well as squeezing and gripping exercises of the hand as necessary.  Contrast arm baths may help increase circulation while warm arm baths and/or heating pads on the forearm flexor muscles may help reduce symptoms. The patient may be asked to refrain from or reduce certain activities that overuse the wrist and hand.  It may be suggested that the patient wear a splint while sleeping or doing things that require a lot of hand movement, and/or perform self massage. If edema is present, it may be suggested that the patient use a cold compress to help reduce swelling.

Intercostal Neuralgia (Shingles)

Intercostal neuralgia is a neural pain along the nerves that travel between the ribs.  A common example of intercostal neuralgia is caused by the herpes zoster virus, known as Shingles or Post Herpetic Neuralgia.

Causes of Intercostal Neuralgia
One of the more common causes of intercostal neuralgia is the herpes zoster virus. This is the same virus that causes Chicken Pox in children.  Any person, who has contracted the virus by contracting Chicken Pox or through receiving the vaccine, has the herpes zoster virus dormant in their system and is at risk of contracting Shingles.  Rheumatism, fibromyalgia or diabetes may also cause intercostal neuralgia.  Trauma, including vertebral or rib subluxation, and prolapsed thoracic discs are other potential causes.

Signs & Symptoms
Patients presenting with intercostal neuralgia will have a sharp, stabbing pain along the affected nerve. This is usually a unilateral pain.  They may or may not have nodules along the ribs near the affected nerve.  They may be hypersensitive to pressure, and they may be suffering a reflex spasm of muscles because of the pain.  Pain will inhibit active range of motion that may lead to consequential atrophy (wasting) of muscles.  Patients may also present with shallow, apical breathing as deep breaths may also increase pain.

Orthopedic Testing
Some of the typical orthopedic assessment techniques a massage therapist may use are:

• Active range of motion of the thorax within pain-free ranges.
• Rib expansion test – the therapist will measure multiple areas of the rib cage as the patient is asked to breath in and out.
• Breath count – the therapist will monitor the number of breaths per minute the patient takes.

Massage Treatment Goals
Massage therapy can be used to help reduce the sympathetic nervous system firing, increase circulation, reduce muscle spasm and hypertonicity of affected musculature, including the diaphragm, all of which will in turn help reduce pain.  Massage can be aimed at increasing thoracic mobility, avoiding further neural irritation, and maintaining pain-free passive ranges of motion as well as progressively restoring pain-free active ranges of motion and strength.

Typical Massage Treatment
During the acute stage local massage is contraindicated. General Swedish or relaxation massage may be performed to other areas of the body.

During the chronic stage General Swedish techniques may be used to stimulate circulation. Compressions, stroking and fine vibrations may be used to help relieve muscle spasm.  Diaphragmatic breathing, diaphragm release, and abdominal massage may be implemented to help decrease the hypertonicity of the diaphragm.  Myofascial release techniques, rib springing and/or rib raking and vertebral mobilization may be used to help maintain thoracic mobility if there is no muscle spasm present.  The massage therapist may use attachment release, or address trigger points when these modalities are within the patient’s pain tolerance.  Functional strength may be assisted with stimulating ROOD’s techniques, and muscle spasm may be reduced using sedating ROOD’s techniques.

Massage Contraindications & Precautions
Local massage during the acute stages is contraindicated.  The patient may be on strong pain medications and there is a potential for sensory impairment and/or easy bruising.  Pressure should be monitored and no extreme temperatures should be used.  The patient may also be intensely sensitive to cold.  The massage therapists should avoid stretching or dragging an inflamed nerve as this may aggravate the condition.  Trophic skin changes may be present.  Massage treatment should be discontinued if the pain increases instead of decreases.

Typical Suggested Homecare
It may be suggested that the patient apply mild heat to the ribcage to help increase circulation and reduce pain.  When the nerve is not inflamed, the massage therapist may suggest diaphragmatic breathing and or intercostal stretching.

Huntington’s Disease

Huntington’s Disease (HD) sometimes called Huntington’s Chorea or just Huntington’s, is a genetic brain disorder that is inherited by a person. The Huntington’s gene is a dominant gene, which means only one parent must carry the gene in order for it to be passed on. The child of a parent who has the Huntington’s gene will have a 50% chance of inheriting the same gene. And 100% of all people who have the Huntington’s gene will eventually show symptoms. The disease is fatal; death is generally due to other health complications and not Huntington’s itself. Death usually occurs 15-20 years after the onset of the symptoms.

Cause of Huntington’s Disease
This is a genetic disorder, which means that each child of a parent who has Huntington’s has a chance of getting it. It occurs equally between males and females and in all races. Symptoms usually occur between 30 and 50 years old, however the disease can appear in children and in senior citizens.  1 out of every 10,000 American’s has Huntington’s Disease.

Signs & Symptoms
The Huntington’s gene causes parts of the brain to progressively die, and as this occurs a person with Huntington’s becomes less able to control physical movements and emotions, and less able to remember events or make decisions.

A familial history of Huntington’s Disease is important for diagnoses. Gene testing, prior to symptoms present, is now also available. While there are significant variations in symptoms and not all patients present with the same symptoms, there is potential for Huntington’s patients to suffer emotional turmoil including depression and anxiety, cognitive impairment and physical deterioration.

During the early stages of the disease the cognitive symptoms are often subtle. The patient may have difficulty organizing routine details, or coping with new situations and as such these activities may become more time consuming. There is often difficulty in recalling information, decision-making and a lack of attention to details. Combined, these symptoms may also lead to and include general irritability. There may be slight physical changes also developing in the early stages, including fidgeting or twitching of the hands and/or feet, changes in handwriting, and difficulty with other daily tasks.

During the intermediate stages of this disease, the symptoms become worse. The physical symptoms gradually develop into more obvious involuntary movements such as jerking and twitching of the head, neck and arms. These movements (known as chorea, thus the name Huntington’s Chorea) interfere with walking, talking and swallowing. During this stage a person with Huntington’s Disease will walk with a stagger and their speech may become slurred.

During the advanced stages of Huntington’s Disease there are generally fewer involuntary movements and more rigidity. Outside care is required as a person is no longer able to communicate, has difficulty swallowing and maintaining weight.

Death usually occurs 15-20 years after the onset of the disease. It is often due to health complications such as choking, heart failure, infection or aspiration pneumonia.

Orthopedic Assessment
Some of the typical orthopedic assessment techniques a massage therapist may use when treating a Huntington’s patient are:

• Postural assessment
• Gait assessment
• Active and passive range of motion testing
• Pulse & Blood Pressure monitoring

Massage Treatment Goals
Therapeutic Massage is palliative care for patients with Huntington’s Disease. Massage therapy may be aimed at reducing sympathetic nervous system firing, which leads to a reduction in physical and emotional stresses. This can help reduce choric movements and spastic musculature as well as create a perception of decreased overall pain. Individual tissues may be assessed and treated to help ease areas of specific tension and/or pain. Postural dysfunction may be assessed and treated with the goal of slowing the progression of the disease – though there is no evidence that states massage therapy slows Huntington’s symptom progression. Quality of life may be enhanced by a regular regime of palliative care techniques, including massage therapy for patients with Huntington’s Disease.

Typical Massage Treatment
While massage treatment for patients with Huntington’s Disease can be incredibly variable and individual depending on the symptoms presenting, some things may be typical. The massage focus may be relaxation based, with the therapist offering a calming, rhythmic session focusing on reducing the sympathetic system firing. General Swedish Massage strokes may be combined with rhythmic kneading and tapotement to help relax tense tissue, increase circulation and reduce overall stress. Deep tissue techniques may be applied to areas of intense tension and stiffness, while the patient is asked to concentrate on deep breathing and relaxation. ROOD’s techniques may be used to help stimulate weakened muscles and sedate hypertoned muscles.

Massage treatment for patients with Huntington’s Disease may be palliative and relaxing.

Massage Contraindications & Precautions
In later stages of this disease communication may be difficult. The therapist must ensure that they have the patients consent to treat prior to treatment. In addition, a Huntington’s patient may be on strong pain-killers and/or anti-inflammatory medications. Health history should be detailed and include a list of medications. Side effects of these medications should be taken into consideration. Co-morbidities may exist with Huntington’s patients and may be contraindicated. Treatment depth and techniques may need to be modified accordingly. A massage therapist may want a doctor’s approval prior to treating the patient.

Typical Suggested Homecare
Diaphragmatic breathing may be recommended, in order to help reduce sympathetic nervous system firing and reduce stress. Active range of motion with the cardinal planes of any joint may also be suggested to help maintain joint and tissue health.

Brachial Neuralgia

Brachial neuralgia denotes pain in the nerves of the brachial plexus.  If prolonged it may progress to brachial neuritis.

Causes of Brachial Neuralgia
Brachial neuralgia may be caused by posture, a hyperkyphotic curve of the thoracic spine, a lowered shoulder girdle or shoulder compression.

Signs & Symptoms
Intermittent pain, often described a lancinating ‘zing’ along the nerve pathways.  There may be muscle hypotonicity, spasm and possible twitching. Brachial neuralgia may also present with parasthesia, especially of the fingers.

Orthopedic Assessment
Some of the typical orthopedic assessment techniques a massage therapist may use are:

• Active and passive range of motion testing of the neck, arm, elbow, wrist and fingers.
• Sensation may be tested with two-point discrimination or deep and light touch.

Massage Treatment Goals
Therapeutic massage is used to help eliminate the cause, correcting postural dysfunction including hyperkyphosis (if functional in nature) and/or shoulder compression. Massage Therapy aides in reducing muscle spasm, helping strengthen and improve muscle tone in the shoulders, especially the upper and middle trapezius and the rhomboid muscles, which in turn helps raise the levels at which the shoulders are normally carried.  In addition therapeutic massage is used to help relieve pain by reducing the sympathetic nervous system firing, decreasing pressure over the brachial plexus, preventing further compression, treating the compensatory structures and preventing further compensations by helping improve circulation and maintaining tissue health.

Typical Massage Treatment
During the acute stage of brachial neuralgia the patient is positioned for comfort and General Swedish massage techniques may be used along with vibration and stroking. Diaphragmatic breathing may be encouraged, and gentle passive range of motion of the neck and shoulders may be performed.

During the chronic stage of brachial neuralgia Myofascial and General Swedish massage techniques may be used and trigger points may be addressed in the neck, shoulder, anterior chest and thoracic spine muscles.  Attachment release may be used in these areas as well. Diaphragmatic breathing may be encouraged with passive and active stretching of the neck and chest. Stimulatory techniques may be performed on the rhomboids and lower/middle trapezius muscles.

Massage Contraindications & Precautions
The more prolonged brachial neuralgia persists the more likely it is to develop into brachial neuritis a more serious, pathological condition that includes inflammation if the neural tissues.  A patient suffering brachial neuralgia may be taking strong pain medications and may also present with sensory impairment due to the condition itself. Caution must be taken as to massage pressure so that the tissues are not damaged. During acute stages, rhythmic mobilizations and local massage is contraindicated as aggressive massage over the brachial plexus will aggravate the condition.  In addition, full stretches of the cervical spine (neck) or the glenohumeral (shoulder) joint may cause aggravation and should be avoided.

Typical Suggested Homecare
During the acute stage the patient may be asked to perform passive relaxed range of motion within the pain-free ranges.  This may progress with a chronic condition to active range of motion exercises with or without isometric resistance.  Relaxation and respiratory exercises including diaphragmatic breathing may be encouraged. Postural awareness correction and exercises to raise the shoulder girdle, like shoulder shrugs may be taught.  Ice or mild heat may help reduce pain, and contrast washes or baths help increase circulation and maintain tissue health.

Bells Palsy

Bell’s palsy is a flaccid paralysis of the face caused by inflammation or damage to the cranial nerve VII (CNVII), the facial nerve.  The facial nerve leaves the brain stem and passes through the geniculate ganglion, the stylomastoid foramen and the parotid gland before is separates into two divisions, a motor division and a sensory & autonomic division. It then innervates the muscles of facial expression and the functions of taste sensations from the anterior two-thirds of the tongue. It also supplies some preganglionic parasympathetic fibers to several of the head and neck ganglia.

Causes of Bells Palsy
Bell’s palsy is caused by nerve compression from edema and swelling either as a primary complaint or secondary to trauma, or by conditions affecting the parotid gland, or in some cases by exposure to a chill or draft.

Signs & Symptoms
Bell’s palsy presents with a rapid onset of unilateral facial weakness followed by flaccid paralysis of the muscles of facial expression.  This includes symptoms like the inability to raise the eyebrow or completely close the eye, the loss of the blinking reflex and the inability to flare the nostrils or raise the corner of the mouth, whistle or pucker lips. Patients often have difficulty eating, articulating some sounds and holding their lower lip to drink out of a glass.

There is also sensory and autonomic involvement which may present as loss of tear production, decreased salivation, reduced taste from the anterior two-thirds of the tongue and a heightened sense of hearing.

Orthopedic Assessment
Some of the typical orthopedic assessment techniques a massage therapist may use are:

• Visually inspect the patient’s face in a neutral expression and/or the patient may be asked to perform a number of different facial expressions.
• Sensation may be tested on the posterior portion of the auditory canal (ear).
• The therapist may tap of the patient’s glabella in order to test the Corneal (blink) reflex.
• The patient may be asked to perform active ranges of motion of the neck, eyes and/or mouth

Massage Treatment Goals
Massage therapy should be used as a tool to increase circulation and maintain tissue health of the affected areas, to stimulate the muscles affected by flaccid paralysis and to prevent fibrosis and contracture, and to over all maintain ranges of motion.  In addition, massage therapy can be used as a tool to decrease sympathetic nervous system firing which in turn reduces stress.  Therapeutic massage can also be used to treat the compensatory structures like the neck and shoulders for hypertonicity, pain and stiffness, and to decrease any edema.

Typical Massage Treatment
The patient is treated supine (face up) and the unaffected side is treated first from lateral to medial.  The affected side of the face will be treated after from the midline to the lateral side.  The treatment may consist of compressions, vibrations, stroking and fingertip kneading. General Swedish massage techniques may be used on the anterior chest and neck, and the posterior neck and shoulders.  The Platysma muscle (on the anterior of the neck) may be treated from the direction of the clavicle (collar bone) to the mandible (jaw) using segmental stroking and fingertip kneading. The massage therapist may passively raise the patient’s eyebrows, draw the eyes together, close the eye or shape the patients mouth.  Manual lymph drainage and/or gentle stimulatory techniques such as ROODs brushing or quick stretches may also be incorporated in the massage.

Massage Contraindications & Precautions
The patient should not be positioned prone (face down), and palpation should be performed lightly due to potential sensation changes caused by Bell’s palsy.  The patient may have difficulty articulating some words and as such the therapist needs to be mindful of this to ensure that the patient’s needs are met.  Edema may be present and if that is the case, local heat should be avoided.  The patient may have difficulty closing the eye and as such the area around the eye should be avoided by the massage therapist in order to prevent damage or infection.  Flaccid muscles should never be stretched and no long strokes or fascial work should be done on the affected side.

Typical Suggested Homecare
The patient may be asked to perform passive movements in front of a mirror, even if only one side of the face is working  In addition they may be asked to try imagining or visualizing the paralysed side of the face as moving properly along with the unaffected side.  The patient may also be asked to apply mild heat, like a facial steam, an infrared sauna or even contrast bathing in order to assist with circulation.

Sciatica & Piriformis Syndrome

Sciatica may be in the form of neuralgia (nerve pain) or neuritis (nerve inflammation).  True Sciatica is inflammation of the sheaths or connective tissue surrounding the axons of the sciatic nerve.  The pain in this instance is often a constant dull ache.  Sciatic neuralgia is often caused by nerve root compression, a herniated intervertebral disc at L4, trauma, or lumbar spondylosis (degeneration of the intervertebral discs), or spondylolisthesis (one segment of the spine is moved).  Pain is often paroxysmal, shooting, throbbing and intermittent.  Pseudo Sciatica is a term used for sciatic-like symptoms created by a contracted iliotibial band, sacroiliac lesions, Piriformis Syndrome, Fibromyalgia or a number of other conditions which aggravate the sciatic nerve. Read more “Sciatica & Piriformis Syndrome” →