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94 m a s s a g e & b o d y w o r k j a n u a r y / f e b r u a r y 2 0 1 5 technique CLINICAL APPS Helping Dustin Play By Whitney Lowe The practice of clinical massage provides wonderful opportunities to learn new things about the body and help people who are looking for relief from their pain and injury complaints. In this installment, we follow the case of Dustin, a professional piano player whose pain in his arm and hand is impairing his preparation for an important audition. Dustin began having significant forearm and hand pain about three weeks prior to his first visit. His family doctor diagnosed his condition as medial epicondylitis, with possible early stage carpal tunnel syndrome (CTS). He was prescribed anti- inflammatory medication to address the epicondylitis and given stretching exercises to perform at home. As a professional musician, Dustin spends a great deal of time at the piano, both in practice and performance. In the last two months, he has greatly increased the amount of time he practices every day in order to prepare for an upcoming audition. Unfortunately, Dustin's pain is interfering with this preparation. The anti-inflammatory medication and treatment regimen from his doctor has not helped very much, so he is exploring other options. BACKGROUND AND KEY CONSIDERATIONS After performing a comprehensive intake history, there are several key factors that are important to note: • The pain is predominantly in his right hand. • There is discomfort in his forearm, but the primary pain is felt in his hand. • He reports the pain in his hand as sharp and penetrating. • He also experiences significant loss of coordination in his right hand while playing. • There are times when it feels like his fingers freeze up. • He's been playing piano professionally for many years. • He recently increased his daily practice time. There are key findings in the history that indicate likely involvement of epicondylitis and/ or nerve entrapment. Yet, other conditions can produce similar symptoms, so it is always important to perform a thorough assessment to make sure all the existing signs and symptoms are consistent. When evaluating the information derived from any part of the assessment process, it should fit the pattern of the condition(s) of the diagnosis. While most of the elements from Dustin's history are consistent with the diagnosis he was given, there are some factors that warrant further investigation. INITIAL PHYSICAL EVALUATION A comprehensive series of range of motion and resistance tests were performed for Dustin's elbow, forearm, and hand region. None of the active, passive, or resisted tests/motions reproduced the primary pain Dustin was experiencing. These tests evaluate dysfunction in the local tissues that produce the movements being tested. Sometimes, if a condition is not very severe, it won't be painful with range-of-motion testing because the tissues are not significantly stressed. However, if the root cause of the problem is in fact epicondylitis Phalen's test. 1

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