Accelerated Healing with Soft Tissue Release: Part Two; Get a Handle on Carpal Tunnel Syndrome
Accelerated Healing with Soft Tissue Release: Part Two; Get a Handle on Carpal Tunnel Syndrome
REPETITIVE STRAIN INJURIES, CUMULATIVE TRAUMA disorders, repetitive motion injuries and various overuse syndromes -- of which carpal tunnel syndrome is one -- account for up to 50 percent of workplace injuries( 1). Insurance companies Blue Cross and Blue Shield of California assessed that a single case of carpal tunnel syndrome can cost as much as $100,000 in lost work, surgery and retraining( 2). Carpal tunnel syndrome has become one of the major sources of lost productivity and financial drains in this country( 3).
Do you think that you, as a massage therapist, can make a difference? You can.
The medical response to carpal tunnel syndrome
Having researched, since 1995, numerous studies on cumulative trauma disorders, I have found that there is a rather depressing response by allopathic physicians to carpal tunnel syndrome.
Treatment of carpal tunnel syndrome usually focuses on one of four approaches: rest; immobilization with braces or splints; corticosteroid injections; physical therapy, stretching and biomechanical modification (ergonomics); and, if symptoms persist after one or more of these approaches, surgery( 4).
Rest can help with carpal tunnel syndrome, but is not viable as a treatment because people can't simply stop working.
Bracing and splinting not only have little effect; after one week, statistics have shown( 5), the problem gets worse. And we can conjecture that if bracing and splinting did help, there would not be such an overwhelming number of surgical procedures. The reasoning behind splints and braces seems sound, but the results are not: Movement is the answer, fixation is not.
In the case of cortisone injections, again, the reasoning seems sound: Cortisone inhibits the bradykinins that initiate the inflammation response, but cortisone is as corrosive as battery acid if overused. I have known athletes from Finland and Sweden who have had their Achilles tendon detach from the heel bone because of cortisone overuse by their team doctor for simple heel pain. The other problem is that a needle injection is like trying to throw a dart across a room to hit the bull's-eye on a dart board: The actual success rate is very low.
Physical therapy, stretching and biomechanical modification are all effective adjuncts to bodywork, but, in my opinion, do not address carpal tunnel syndrome as quickly or effectively as massage therapy.
The final approach is surgery. Although surgery is generally successful in treating carpal runnel syndrome, in my estimation it need never be an option. In the last 10 years I have worked with hundreds of clients who have been diagnosed with carpal tunnel syndrome, who never needed surgery. Finding an alternative to surgery not only means saving time and expense, but also saves the client from undergoing this invasive procedure.
The nature of carpal tunnel syndrome
There is a great ancient Sufi tale about Mulla Nasrudin, who was given permission by the king to transport precious gems and herbs across the border into Persia (now known as Iran) -- but who, when the border guards would ask his purpose of travel, would reply that he was a smuggler. The guards would search him and his horse, and find nothing. His papers were correct, so they would have to let him pass by. After many years, when Nasrudin was very rich, a retired border guard met him in a social situation, and asked, "Now that I am retired, and there is no danger to you, what were you smuggling?" Nasrudin replied, "Horses." The moral of the tale is that you can spend years looking in the wrong place for the wrong thing. This is the case with soft-tissue dysfunction and referred pain. In the case of carpal tunnel syndrome, the problem is not in the carpal tunnel. The problem is actually as big as a horse.
Repetitive stress disorders produce microtrauma, which in turn creates scar tissue. Over time, as the intensity of the microtrauma increases, the autonomic nervous system receives the message of injury and initiates the inflammation response.
The eight carpal bones in the wrist make up the three sides of the carpal tunnel. A band across these bones, the transverse carpal ligament, forms the remaining side. Normally, nine tendons and the median nerve have enough room to pass through this tunnel from the forearm to the hand. But when the pressure increases in the tunnel, the nerve does not get enough oxygen. This makes the hand tingle or feel numb, or become so weak that you can't grip things as you used to.
The pressure increases because one of the side effects of the inflammation response is shortening of muscle length. Normally, tendons easily glide in their sheaths -- but any change in tension of the musculature will create inflammation in the tendons, and they then become irritated and swollen, and may squeeze the median nerve. But if a physician looks only at the point of pain and recommends surgery as the intervention, she's missed something as big as a horse. The "horse" being, in this case, the powerful muscles in the forearm that create movement at the wrist.
Going up-river to remove the problem
The answer to carpal tunnel syndrome is to help the client quickly regain muscle memory in the flexors and extensors of the hand, the supinators and pronators-everything to do with rotation at the wrist.
This approach to healing must quickly address all the forces of movement -- both agonist and antagonist -- at the same time, to re-establish the integrity of movement at the wrist. If you subdivide every muscle movement into a separate protocol, as some have done, then you miss the innate intelligence of the body's own healing power.
How do we regain muscle memory and proper resting length of any muscle? By realigning scar tissue so that the autonomic nervous system perceives a thinner and more elastic scar, no matter how tiny that scar tissue may be, and automatically provides proper resting length. This in turn immediately reduces the tension in the tendons as they glide in their sheathes. Pressure on the median nerve is then quickly reduced, and in about one day relief is on the way.
The massage/stretching protocol described in this article is called Soft Tissue Releaser(R6), a technique developed to address sports injuries that has been used by some of the world's fastest sprinters. This technique addresses chronic pain and repetitive strain injuries in 15 to 30 minutes, including the five or 10 minutes the therapist takes to show the client stretches to do as homework.
Remember, the goal is to restore the total integrity of movement at the wrist. It is not concerned with individual muscles and their actions. We can be transfixed with the site of pain: Whenever someone says "this is where it hurts," then that is where we work. Wrong conclusion.
Think of any great river that you know. If there is toxic waste in the water and the fish are dying, the livelihood of a generation of fishermen is in jeopardy. The government can spend millions of dollars cleaning up this waste, every year, if they so choose. Instead, why not go up-river, find out who is dumping the waste and close them down? That is the goal with Soft Tissue Release. We go up-river to the source of the problem, and shut it down so quickly that life down-river responds immediately.
In the case of carpal tunnel syndrome, "up-river" is the wrist and finger flexors. These include the flexor carpi radialis, ulnaris and flexor digitorums.
We use multiple compressions, changing the plane or angle of the stretch after every compression. The therapist effects a release without knowing which was exactly the correct stretch or where exactly the scar tissue was. This pressure-and-stretch component is at the center of accelerated healing.
Please pay attention to these points: 1) Pressure is always used during the stretch; 2) When the stretch is over, then the pressure is released; 3) We start at the fully shortened muscle length and go to an extreme stretch; 4) When the stretch is over we go back to the shortened position to start again; and 5) Each time we finish the stretch, the pressure point changes.
The stretches used in Soft Tissue Release are based on Active Isolated Stretching, developed 30 years ago by Aaron Mattes (see sidebar, "Active Isolated Stretching"). If you are not incorporating this work, you will not get the same results.
Although pressure is a component of the technique, it is not key. The rhythmic extent of the repeated stretch, in various planes of the stretch, is more important than the amount of pressure applied. Pressure through a movement appeals to muscular reeducation, the re-organization of scar tissue and subsequent electrical reprogramming of muscle memory through the repetitious nature of the stretches( 7).
The technique in action
Begin the technique with the client's elbow locked out and the wrist in full flexion with the palm upward. Press down with your thumb just above the carpal tunnel (see Photo 1). As you take the wrist into full extension, with firm pressure, glide over the carpal tunnel and into the palm (see Photo 2). At the end of the stretch, release the pressure. Next, find a new starting position with a different pressure location and repeat the pressure/stretch technique at another angle. This means that you apply gliding pressure, using lotion or oil, proximally from just below the elbow crease, moving distally over the carpal tunnel into the palm. At the same time, you move the hand from flexion to extension. Create this stretch with your fingers over the tips of the client's fingers. This is a great stretch. Every time you repeat this stretch, change the plane of movement at the wrist to abduction or adduction, changing the plane of movement in a rapid, random movement. Remember, the key is movement in various planes. We need to appeal to all the muscles involved in flexion and extension.
Also remember that the amount of pressure is not as important as the full nature of the rhythmic stretch, going from flexion to extension, changing the plane of the stretch and the location of the pressure each time. Do not do this slowly. There is something in the rapidity of this pressure-and-stretch combination that distracts clients and is therefore more tolerable to them.
Next, starting proximally at the crease of the forearm, using the same amount of pressure, glide down all the wrist flexors during extension, firmly passing over the carpal tunnel (see Photo 3). Again, as you take the wrist into full extension, glide over the carpal tunnel and into the palm (see Photo 4). At the end of the stretch, release the pressure. Next, find a new starting position with a different pressure location and repeat the pressure/stretch technique at another angle.
Next, turn the client's arm over and glide downward over the wrist extensors (see Photo 5); with your other hand, take the client's wrist into full flexion (see Photo 6). At the end of the stretch, release the pressure. Next, find a new starting position with a different pressure location and repeat the pressure/stretch technique at another angle.
Lastly, place your thumb on the extensors and your fingers on the flexors, holding the client's arm in a "double lock." As though in a handshake, with your other hand rotate the wrist into radial-ulnar pronation and supination, going back and forth very quickly (see Photos 7a and 7b). While rotating the wrist, quickly change the position of your double lock, and glide up and down the forearm. As you glide up and down the flexors, put the wrist in extension. As you glide up and down the extensors, put the wrist in flexion.
Homework for the client
An important component of this work is educating the client of the importance of stretching on their own. An effective way to communicate this is to tell the client that you are going to re-educate the resting length of their muscles during the session, and that if they stretch their muscles correctly on their own, they can continue doing the work that they do now -- without pain. I tell my clients that if they don't do their stretches, they might have to come see me again.
The stretches (See Photos A, B, C and D) need to be done as long as the client has a job that creates thc repetitive stress. The client should do the stretches two or three times per day, at a minimum, and can do them as often as everry 20 or 30 minutes (they can do one or two of the stretches at a time rather than performing all of them at once).
Now the best part
The client's hands have been numb, they've been losing their grip, and have been waking up at night in pain. Wrist splints didn't work, nor did the strengthening exercises given to them by their physical therapist. The pain-killers upset their stomach, the specialist says that the only alternative is surgery and then retraining for a new job. This has been their nightmare for a year or so. But you can say, "Tomorrow you'll feel much better. Do these homework exercises and in one week you'll be fine."
They don't believe you, but guess what? The next day they do feel better. Then they do the Active Isolated Stretches you showed them how to do as homework. And their lives can be back to normal in just a few weeks.
(1.) Bureau of Labor Statistics, Report on Survey of Occupational Injuries, 1990.
(2.) Leahy, P. Michael, D.C. Chiropractic Sports Medicine, Vol. 9, Number 1, 1995.
(4.) Bell, Russell Terry. Findings of Robert Schwartz, M.D., and Stuart Weinstein, M.D., Patient Care Magazine, Feb. 15, 1996.
(5.) Bureau of Labor Statistics, Report on Survey of Occupational Injuries, 1990.
(6.) For additional information about the theory behind Soft Tissue Release, see "Accelerated Healing with Soft Tissue Release, Part One: Relief from Pain Between the Shoulder Blades," Issue #78, March/April 1999.
(7.) When you provide movement at the same time you disrupt the scar tissue, collagen fibers are re-laid in an organized fashion. Scar tissue then becomes thinner and more elastic. The autonomic nervous system perceives this as first-intention healing instead of second-intention healing, and allows a release of muscle memory and proper resting length. (In first-intention healing the autonomic nervous system responds to a slight wound with invisible scarring. In second-intention healing heavier scarring occurs. Soft Tissue Release disrupts the scar through movement -- i.e., stretching -- tricking the autonomic nervous system into first-intention healing even in the case of serious muscle injuries.)
Massage Magazine, Inc.
By Stuart Taws