By Zhenya Kurashova Wine
Originally published in Massage & Bodywork magazine, April/May 2000.
Some time back I received a request from a reader to cover treatments for violinists. Although violin-playing is not a sport, these clients are athletes — each day undergoing continuous use of their upper extremities, especially the hands. Let’s cover some of the common dysfunctions seen in violinists, as well as preventive treatments to help keep these athletes’ upper extremities in good shape. We will start with the condition I’ve seen afflict quite a few professional and amateur violinists — Carpal Tunnel Syndrome.
Carpel Tunnel Syndrome (CTS) falls into a category of peripheral neuropathy and is one of the fastest-growing dysfunctions affecting the American population today. Peripheral neuropathy is the dysfunction of a single nerve that produces a variety of neurological and general symptoms such as pain, muscle weakness and atrophy, vasomotor (i.e., calibre of the blood vessels) problems, and sensory loss. CTS results from compression on the median nerve by the structures which surround it. In order for us to understand the cause of this dysfunction, we have to take a closer look at the structure in which it occurs.
The tunnel through which the median nerve runs is created by the flexor retinaculum (or transverse carpal ligament) and the carpal bones. The canal is created for the flexor tendons (which lie directly beneath the median nerve) and for the median nerve itself to run through. The median nerve supplies five muscles in the hand which are found in the thumb, index, middle and part of the ring finger. The median nerve being one of the brachial plexus nerves (it originates at the C6-T1) runs through the medial side (inside) of the arm, through the medial part of the elbow and ends at the above mentioned fingers. It is a sensory nerve and provides innervation for most flexors of the forearm, elbow joint, and many joints of the hand, thumb muscles and skin of the hand. Another structural aspect which makes the median nerve so prone to involvement is its make-up — it is created from large diameter fibers which will react to even slight pressure.
As you can see from the structural analysis of the components of the wrist, it is not designed for repetitive tasks or for heavy use because it is made from fine structures intended for fine motor functions which are non-repetitive in nature. The wrist is prone to dysfunction if it is required to perform functions for which it is not built.
Causes of CTS
Seldom will we see CTS develop due to a single injury of the wrist (although it does happen). More often it occurs because of Cumulative Trauma Disorder (CTD) or continuous overuse of the wrist while performing a repetitive activity. As you can imagine, the continuous finger “flex-and-hold” motion violinists enact for hours on end as a part of practice and performance is that kind of repetitive motion that creates CTS.
The motion of repetitive, forceful wrist flexion causes the forearm muscles and wrist tendons to be overused and strained. This leads to contraction of the muscles and tendons, as well as swelling of these structures, which in turn produces pressure on the median nerve. Other conditions seem to contribute to CTS as well. Diabetes, Guillain-Barré syndrome, rheumatoid arthritis and pregnancy seem to be some of the common factors leading to CTS. These conditions increase fluids in the tissue (especially in the extremities) and cause secondary production of deposits in the limited space. A note of interest — women seem to be affected more often than men, and especially if they are overweight.
Persons who use motion of pronation repetitively may affect the median nerve at the elbow, causing its irritation and producing symptoms associated with and leading to CTS. Whatever the reason for the median nerve compression, the symptoms of CTS will cause a significant amount of pain and often total disability.
Symptoms of CTS
CTS patients most often suffer the following:
1. Numbness (or cold fingers), tingling, and burning sensations of the thumb, index, middle and part of ring finger (also known as paresthesia). Often patients wake up at night due to the above described sensations.
2. Sensory deficit in the radial-palmar aspect of the hand.
3. Pain in the wrist, palm and forearm, which seems to be worse at night.
4. Weakness and atrophy of the thumb abductors.
The pain, although originating at the wrist, can radiate to the elbow and shoulder (along the passage of the median nerve), and can be temporarily relieved by shaking out the hands. Although today there are complex nerve conduction tests that can evaluate the nerve’s condition, two simple tests can detect if the median nerve is involved. Tinel’s sign involves a physician tapping over the median nerve at the wrist and detecting paresthesia in the fingers innervated by the nerve. The other test determines if the patient can oppose his/her thumb without pain. I provide you with these diagnostic tools not to diagnose, but to know the tests performed by doctors. Please make sure your client has a diagnosis of CTS before treating them for CTS.
Standard Treatment for CTS
Standard treatment involves splinting the forearm/wrist (especially during the night) and surgery. Surgical procedures are performed to section (cut) the transverse carpal ligament in order to decompress the nerve. As I see it, certain complications can result from surgery, mainly scar tissue formation in the sectioned ligament that once again will produce compression on the median nerve. In fact, in a 1990 Journal of Hand Surgery the results of a study on 60 patients showed that only 27 percent reported good outcome of surgery, whereas 32 percent said symptoms persisted or worsened; 42 percent considered symptoms mostly improved.
A couple of years ago I had a chance to work with an area chiropractor — one of the leaders of CTS treatment in the chiropractic field. He manipulates the wrist so the carpal bones, which are involved and often are moved to contribute to the compression on the median nerve, are placed back in their right place. In doing so, the chiropractor enlarges the size of the carpal tunnel and eliminates compression on the median nerve. This treatment seems to be very effective and is quickly becoming one of the standards of CTS treatment protocol. Often ultrasound is used along with manipulation, which seems to provide relief to patients.
What Can Russian Neuro-Muscular Treatment Do?
Russian Neuro-Muscular Re-education treatment goals for CTS will differ from patient to patient according to the severity of the condition and symptoms that are present. They can include:
1. Decrease edema at the wrist.
2. Decrease muscle contraction of the forearm flexors.
3. Decrease tension of the wrist flexor tendons.
4. Increase elasticity of the tendons compressing on the median nerve.
5. Break up and eliminate pathological deposits (if edema was present and is absent now.)
6. If post-surgical, increase elasticity of the transverse ligament scar.
7. Decrease irritation of the median nerve.
8. Decrease pain and paresthesia (numbness, tingling, burning, cold sensations).
9. Normalize muscle tone and strength of the forearm and the thumb.
Let’s start again at the beginning. As mentioned, swelling is one of the conditions that not only accompanies CTS, but also contributes to the nerve compression. By decreasing edema in the wrist you will decrease pain and prevent development of pathological deposits in the carpal tunnel. In order to eliminate edema you have to drain the edema from the area by vasodilating the proximal vessels in order to create a “pump-like” effect. To do that, clasp the upper arm with two hands (make sure the fingers are spread for comfort) and glide in the direction of the underarm. Once edema is decreasing in the forearm, you may follow this “pumping” in the proximal area with continuous gliding moves over the forearm. Note: Make sure you don’t compress down on the tissues, since this will cause vasoconstriction and production of edema. Once edema is dealt with (or in case of its absence) you can progress to the other goals.
Whenever working with nerve pain the therapist’s work progresses from the area of least pain to the area of most pain along the passage of the nerve. In the case of CTS, the work will start on the forearm and will progress into the wrist. Divide the forearm into two parts, starting at the bulk of the forearm flexors (i.e., closer to the elbow) and after a few strokes of clasping, gliding strokes, begin gentle-pressured stretching with fingers. Your massage should be painless, and your progression to the deeper-pressured stretching strokes (such as cresting hand position and heel of the hand) will depend on the client’s ability to receive them. Pressure stretching should originate in the proximal area moving distally (toward the hand) and should stop half-way down. Besides increasing pliability of the muscle, this stroke will also calm the nerve. The client should report a decrease of pain in the wrist and fingers before you move to the next half of the forearm.
Another stroke that calms the median nerve is gentle vibration. Place all four fingers in the area of the nerve projection and while moving your hand side to side (creating shaking movement), progress downward in the distal direction. Use a few strokes of pressure stretching followed by a few strokes of vibration and then repeat the combination. On the second half of the forearm you will continue with the same treatment as described above, but you will more likely use pressure stretching with fingers more than any other technique. Once again do not fight the tissue, but rather repeat your pressure stretching and vibration combinations until the client reports a decrease of pain and you feel increased pliability of the tendons. This progression to the next area might take a few treatments to accomplish — remember to be guided by the client’s ability to receive the treatment, rather than by this protocol. As the client’s tissue continues to respond, you should see progressive improvement in the muscle’s pliability. This will allow you to spend less time on that area and more time on the more distal area. In a few treatments (it will vary from client to client depending on the severity of the condition) you should be able to progress to the wrist. Before any treatment is done on the wrist itself, make sure there is no swelling. If edema is present, use the gliding strokes above it to resolve the swelling.
On the wrist itself, start with superficial pressure stretching with fingers and vibration combination. After a few minutes, move on to more proximal areas with the same treatment you were doing on that area and work there for a few minutes before returning to the wrist. A note of caution: Whenever you work with the irritated nerve you are walking a thin line between decreasing irritation of that nerve and actually causing more irritation. It is better to underwork the irritated nerve than to overwork it. As the clients progress through the treatments they should report the following improvements: less paresthesia sensations occurring in the fingers; a significant decrease of pain in the forearm and wrist; and ability to resume some of the activities requiring the use of the forearm, wrist and hand. As the nerve irritation becomes absent, you may progress to the final stage of treatment to increase elasticity of the wrist tendons/ligaments and prevent compression on the nerve in the future.
Deeper pressure stretching with fingers and “hatching” stretching is used to accomplish this goal. Please remember that the pain should be totally absent before you can graduate to deeper treatment. At that time you may also want to include treatment of the thumb and encourage the client to begin an exercise program to strengthen his/her wrist and hand flexors (theraband and theraputty exercises are the standard ones for accomplishing this goal). The Russian Neuro-Muscular Re-Education treatment schedule is done every day for 10 to 15 minutes per treatment. Depending on the condition, the client may be seen between 12 to15 times. If more treatments are needed to accomplish the above listed goals, take at least 10 days off before resuming the next set of treatments.