4.17: Carpal Tunnel Syndrome

Carpal tunnel syndrome is a condition characterized by tingling, numbness and pain in the hand and fingers (particularly the thumb, index, middle and ring fingers). These symptoms are often the result of median nerve irritation in the wrist or forearm.

Carpal tunnel syndrome is a condition characterized by tingling, numbness, and pain in the hand and fingers (particularly the thumb, index, middle, and ring fingers).

Pathophysiology

The median nerve passes through several anatomical structures and it may be exposed to mechanical irritation at many different points. Prolonged irritation of a peripheral nerve triggers the release of inflammatory mediators, known as “neurogenic inflammation”; this noxious substance can disrupt the normal function of nerves. Ongoing tissue hypoxia or inflammatory responses lead to molecular signaling that promote the development of fibrosis, this may contribute to further peripheral nerve dysfunction (Barbe et al., 2020; Bove et al., 2019).

Clinical Examination

A thorough health history intake can be done to gather information about patients’ limitations, course of pain, and prognostic factors for delayed recovery (e.g., low self-efficacy, fear of movement, ineffective coping strategies, fear-avoidance, pain catastrophizing) and answers to health-related questions. Screen patients to identify those with a higher likelihood of serious pathology/red flag conditions. Then undertake a physical examination: neurological screening test, assess mobility and/or muscle strength.

Outcome Measurements

Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:

• Self-Rated Recovery Question
• Patient Specific Functional Scale
• Brief Pain Inventory (BPI)
• Visual Analog Scale (VAS)
• DASH Outcome Measure
• CTS-6 Evaluation Tool
• Kamath and Stothard Questionnaire
• Katz and Stirrat hand symptom diagram
• Upper Extremity Functional Index
• Brigham and Women’s Carpal Tunnel Questionnaire
• Boston Carpal Tunnel Questionnaire (BCTQ)
• Patient-Rated Wrist Evaluation (PRWE)
• Patient-Rated Wrist/Hand Evaluation (PRWHE)

Physical Examination

Incorporate one or more of the following physical examination tools to determine the likelihood of carpal tunnel syndrome and interpret examination results in the context of all clinical exam findings.

• Spurling’s Test (Foraminal Compression Test)
• Cervical Distraction Test
• Cervical Compression Test
• Scalene Cramp Test
• Adson’s Test
• Halstead Maneuver (Reverse Adson’s Test or Wright’s Test or Hyperabduction Test)
• Costoclavicular Test (Military Brace)
• Upper Limb Tension Tests (1, 2, 3, & 4)
• Phalen Test
• Tinel Sign
• Carpal Compression Test

Treatment

Education

Provide reassurance and patient education on condition and management options and encourage the use of active approaches (lifestyle, physical activity) to help manage symptoms.

Manual Therapy

The responses to massage therapy are complex and multifactorial – physiological and psychological factors interplay in a complex manner. Systematic reviews have also shown that manual therapy combined with multimodal care can improve symptoms, decrease disability, and improve function for patients who suffer from carpal tunnel syndrome (Huisstede et al., 2018). Research has looked at both peripheral and central responses elicited by massage therapy treatments, by working within the patients’ pain tolerance, massage therapy may help modulate nociceptive barrage into the central nervous system (peripheral drive) and activate endogenous pain networks (central drive).

Central Drive

Massage has a modulatory effect on peripheral and central processes via input from large sensory neurons that prevents the spinal cord from amplifying the nociceptive signal. This anti-nociceptive effect of massage therapy can help ease discomfort in patients who suffer from carpal tunnel syndrome.

Peripheral Drive

Carpal tunnel specific work may also involve specific soft tissue treatment to optimize the ability of mechanical interfaces to glide relative to the median nerve. The application of appropriate shear force and pressure impart a mechanical stimulus that may attenuate tissue levels of fibrosis and TGF-β1 (Bove et al., 2016; Bove et al., 2019). Furthermore, passive stretching may help diminish intraneural edema and/or pressure by mobilizing the median nerve as well as associated vascular structures (Boudier-Revéret et al., 2017).

Myofascial trigger point: Infraspinatus

The etiology of myofascial trigger points is still not well understood, but that does not deny the existence of the clinical phenomenon. From a clinical perspective, myofascial trigger points describe an observable phenomenon that may help clinicians investigate common pain patterns. An international panel of 60 clinicians and researchers was recently consulted to establish a consensus for identification of a myofascial trigger point. The panel agreed on two palpatory and one symptom criteria: a taut band, a hypersensitive spot, and referred pain (Fernández-de-Las-Peñas & Dommerholt, 2018). For patients with carpal tunnel syndrome studies have demonstrated that assessing and treating the infraspinatus muscle may be an effective treatment option for a sub-group of patients (Meder et al., 2017).

Structures to be Aware of When Treating Carpal Tunnel Syndrome

A massage therapy treatment plan should be implemented based on patient-specific assessment findings and patient tolerance. Structures to keep in mind while assessing and treating patients suffering from carpal tunnel syndrome may include neurovascular structures and investing fascia of:

• Costo-Clavicle Space
• Scalene Muscle Group (anterior scalene, middle scalene, and posterior scalene)
• Pectoral Region (pectoralis major, pectoralis minor, serratus anterior and subclavius)
• Rotator Cuff (subscapularis, infraspinatus, teres minor, supraspinatus)
• The Upper Arm (biceps brachii, brachialis, coracobrachialis, triceps brachii)
• Superficial Anterior Compartment of the Forearm (pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, flexor carpi ulnaris)
• Deep Anterior Compartment of the Forearm (flexor digitorum profundus, flexor pollicis longus, and pronator quadratus)
• Anterior Interosseous Membrane
• Carpal Bones (trapezium, trapezoid, capitate, hamate, scaphoid, lunate, triquetrum, pisiform)
• Palmar Aponeurosis & Transverse Carpal Ligament
• Lumbricals

Self-Management Strategies

Massage therapists not only provide hands-on treatment they can also develop self-management programs to help patients manage symptoms. Simple home-care recommendations such as stretching, splinting and home exercises have been shown to be useful for carpal tunnel syndrome (Lewis et al., 2020; Shem et al., 2020).

Prognosis

Massage therapy as a therapeutic intervention is being embraced by the medical community, it is simple to carry out, economical, and has very few side effects. Randomized clinical trials have demonstrated that for some patients who suffer from carpal tunnel syndrome there is no significant differences in pain and functional outcomes at a six month, twelve month, and four year follow up when surgical and conservative care are tested (Fernández-de-Las Peñas et al., 2017; Fernández-de-Las-Peñas et al., 2019; Fernández-de-Las-Peñas et al., 2020).

Massage Sloth: Massage Tutorial: Carpal Tunnel Syndrome

Key Takeaways

Contemporary multimodal massage therapists are uniquely suited to incorporate several rehabilitation strategies for carpal tunnel syndrome based on patient-specific assessment findings including, but not limited to:

• Manual Therapy (soft tissue massage, neural mobilization, joint mobilization)
• Education that is Person-Centered (e.g., biopsychosocial model of health and disease, self-efficacy beliefs, active coping strategies)
• Stretching & Loading Programs (e.g., concentric, eccentric, isometric exercises)
• Hydrotherapy (hot & cold)
• Self-Management Strategies (e.g., engaging in physical activity and exercise, social activities, and healthy sleep habits)

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