This week’s guest blog is from Richard Lebert
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.
As peripheral nerves pass through the body they may be exposed to mechanical or chemical irritation at different anatomical points. Prolonged compression or fixation of a nerve may result in a reduction of intraneural blood flow. This then triggers the release of pro-inflammatory substances (calcitonin gene-related peptide and substance P) from the nerve. This by-product is referred to as neurogenic inflammation and it can disrupt the normal function of nerves even without overt nerve damage, it can also contribute to the initiation and propagation of chronic pain. 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., 2021; Bove et al., 2019).
Massage Therapy for Carpal Tunnel Syndrome
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).
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.
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).
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
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).
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).
Barbe, M. F., Harris, M. Y., Cruz, G. E., Amin, M., Billett, N. M., Dorotan, J. T., Day, E. P., Kim, S. Y., & Bove, G. M. (2021). Key indicators of repetitive overuse-induced neuromuscular inflammation and fibrosis are prevented by manual therapy in a rat model. BMC musculoskeletal disorders, 22(1), 417. https://doi.org/10.1186/s12891-021-04270-0
Boudier-Revéret, M., Gilbert, K. K., Allégue, D. R., Moussadyk, M., Brismée, J. M., Sizer, P. S., Jr, … Sobczak, S. (2017). Effect of neurodynamic mobilization on fluid dispersion in median nerve at the level of the carpal tunnel: A cadaveric study. Musculoskeletal science & practice, 31, 45–51. doi:10.1016/j.msksp.2017.07.004
Bove, G. M., Harris, M. Y., Zhao, H., & Barbe, M. F. (2016). Manual therapy as an effective treatment for fibrosis in a rat model of upper extremity overuse injury. Journal of the neurological sciences, 361, 168–180. doi:10.1016/j.jns.2015.12.029
Bove, G. M., Delany, S. P., Hobson, L., Cruz, G. E., Harris, M. Y., Amin, M., … Barbe, M. F. (2019). Manual therapy prevents onset of nociceptor activity, sensorimotor dysfunction, and neural fibrosis induced by a volitional repetitive task. Pain, 160(3), 632–644. doi:10.1097/j.pain.0000000000001443
Bueno-Gracia, E., Ruiz-de-Escudero-Zapico, A., Malo-Urriés, M., Shacklock, M., Estébanez-de-Miguel, E., Fanlo-Mazas, P., … Jiménez-Del-Barrio, S. (2018). Dimensional changes of the carpal tunnel and the median nerve during manual mobilization of the carpal bones. Musculoskeletal science & practice, 36, 12–16. doi:10.1016/j.msksp.2018.04.002
Dilley, A., Harris, M., Barbe, M. F., & Bove, G. M. (2021). Aberrant Neuronal Activity in a Model of Work-Related Upper Limb Pain and Dysfunction. The journal of pain, S1526-5900(21)00386-2. Advance online publication. https://doi.org/10.1016/j.jpain.2021.12.004
Erickson, M., Lawrence, M., Jansen, C., Coker, D., Amadio, P., & Cleary, C. (2019). Hand Pain and Sensory Deficits: Carpal Tunnel Syndrome. The Journal of orthopaedic and sports physical therapy, 49(5), CPG1–CPG85. doi:10.2519/jospt.2019.0301
Fernández-de-Las Peñas, C., Ortega-Santiago, R., de la Llave-Rincón, A. I., Martínez-Perez, A., Fahandezh-Saddi Díaz, H., Martínez-Martín, J., Pareja, J. A., & Cuadrado-Pérez, M. L. (2015). Manual Physical Therapy Versus Surgery for Carpal Tunnel Syndrome: A Randomized Parallel-Group Trial. The journal of pain: official journal of the American Pain Society, 16(11), 1087–1094. https://doi.org/10.1016/j.jpain.2015.07.012
Fernández-de-Las-Peñas, C., Cleland, J., Palacios-Ceña, M., Fuensalida-Novo, S., Pareja, J. A., & Alonso-Blanco, C. (2017). The Effectiveness of Manual Therapy Versus Surgery on Self-reported Function, Cervical Range of Motion, and Pinch Grip Force in Carpal Tunnel Syndrome: A Randomized Clinical Trial. The Journal of orthopaedic and sports physical therapy, 47(3), 151–161. doi:10.2519/jospt.2017.7090
Fernández-de-Las-Peñas, C., & Dommerholt, J. (2018). International Consensus on Diagnostic Criteria and Clinical Considerations of Myofascial Trigger Points: A Delphi Study. Pain medicine (Malden, Mass.), 19(1), 142–150. doi:10.1093/pm/pnx207.
Fernández-de-Las-Peñas, C., Ortega-Santiago, R., Díaz, H. F., Salom-Moreno, J., Cleland, J. A., Pareja, J. A., & Arias-Buría, J. L. (2019). Cost-Effectiveness Evaluation of Manual Physical Therapy Versus Surgery for Carpal Tunnel Syndrome: Evidence From a Randomized Clinical Trial. The Journal of orthopaedic and sports physical therapy, 49(2), 55–63. doi:10.2519/jospt.2019.8483
Fernández-de-Las-Peñas, C., Arias-Buría, J. L., Cleland, J. A., Pareja, J. A., Plaza-Manzano, G., & Ortega-Santiago, R. (2020). Manual Therapy Versus Surgery for Carpal Tunnel Syndrome: 4-Year Follow-Up From a Randomized Controlled Trial. Physical therapy, 100(11), 1987–1996. https://doi.org/10.1093/ptj/pzaa150
Hamzeh, H., Madi, M., Alghwiri, A. A., & Hawamdeh, Z. (2020). The long-term effect of neurodynamics vs exercise therapy on pain and function in people with carpal tunnel syndrome: A randomized parallel-group clinical trial. Journal of hand therapy: official journal of the American Society of Hand Therapists, S0894-1130(20)30144-7. Advance online publication. https://doi.org/10.1016/j.jht.2020.07.005
Huisstede, B. M., Hoogvliet, P., Franke, T. P., Randsdorp, M. S., & Koes, B. W. (2018). Carpal Tunnel Syndrome: Effectiveness of Physical Therapy and Electrophysical Modalities. An Updated Systematic Review of Randomized Controlled Trials. Archives of physical medicine and rehabilitation, 99(8), 1623–1634.e23. doi:10.1016/j.apmr.2017.08.482
Lewis, K. J., Coppieters, M. W., Ross, L., Hughes, I., Vicenzino, B., & Schmid, A. B. (2020). Group education, night splinting and home exercises reduce conversion to surgery for carpal tunnel syndrome: a multicentre randomised trial. Journal of physiotherapy, 66(2), 97–104. https://doi.org/10.1016/j.jphys.2020.03.007
Shem, K., Wong, J., & Dirlikov, B. (2020). Effective self-stretching of carpal ligament for the treatment of carpal tunnel syndrome: A double-blinded randomized controlled study. Journal of hand therapy: official journal of the American Society of Hand Therapists, 33(3), 272–280. https://doi.org/10.1016/j.jht.2019.12.002
About the Author
Richard Lebert is an educator and health care professional with a focus on digital literacy, interprofessional collaboration and person-centered care. In addition to his training as a Registered Massage Therapist, Richard has certification in Medical Acupuncture from McMaster University and a Certificate of Online and Open Learning from The University of Windsor.
His work has been featured in Canadian Chiropractor Magazine, Massage Magazine and Massage Therapy Today and Massage Therapy Canada.
You can find out more about Richard at https://www.RMTedu.com.