Issue link: https://www.massageandbodyworkdigital.com/i/434495
F r e e m u s i c d o w n l o a d s f o r C e r t i f i e d m e m b e r s : w w w. a b m p . c o m / g o / c e r t i f i e d c e n t r a l 95 and/or carpal tunnel syndrome, and given the severity of the pain he described, some of these procedures should be reproducing that pain. In order to gather more information, three commonly used special orthopedic tests were also employed. The golfer's elbow test helps identify the likelihood of medial epicondylitis. In this test, the practitioner applied pressure to the common flexor tendons just distal to the medial epicondyle of the humerus while simultaneously resisting the client's wrist flexion. Dustin reported mild discomfort with this procedure, but said it did not reproduce his primary pain. Phalen's test is one of the best-known procedures for evaluating carpal tunnel syndrome (Image 1). In this procedure, the client placed the back side of the hands together and held them in that position for about 60 seconds. If this position reproduces neurological pain in the hand, there is a good likelihood of median nerve compression in the carpal tunnel. However, this test did not reproduce any of Dustin's pain. The tethered median nerve stress test is also considered accurate for identifying median nerve compression in the carpal tunnel (Image 2). In this procedure, the index or middle finger is pulled in hyperextension while the wrist is also fully extended. Pain reproduced with this procedure is indicative of median nerve pathology. Dustin reported some mild discomfort with this procedure, but nothing that significantly reproduced the primary pain he experiences when playing the piano. Based on client history and characteristics of the reported pain, Dustin appeared to have a pretty severe form of neurological impairment in his hand. He also reported loss of coordination in many of his movements, pointing to motor nerve dysfunction. If there was a local nerve compression in the carpal tunnel, it would likely reproduce Dustin's symptoms during some of the assessment tests, but none reproduced his pain. Passive and active wrist hyperextension, which would stretch the affected nerve, would also likely increase pain if Dustin had carpal tunnel syndrome. Passive or active flexion might also cause discomfort, as the contents of the carpal tunnel are further compressed at the end of wrist flexion movements. If there are indicators of neurological involvement, but none of the tests that stress local neurological tissues reproduce pain, the condition may not be a local nerve compression at all. There may be a systemic neurological problem that should be considered. During the evaluation, there were two key pieces of information in Dustin's history that warranted deeper inquiry. He mentioned a loss of coordination and a feeling that the fingers in his right hand were freezing up as he was playing the piano. These characteristics indicate some type of motor nerve involvement, but are not commonly described symptoms of local nerve compression in the wrist. Because of these ambiguities in the symptom pattern, Dustin was encouraged to see a neurologist to perform more detailed diagnostic studies of these apparent neurological symptoms. There was no apparent contraindication to massage and it was still possible that his soft- tissue pathology would benefit, so there was mutual agreement to proceed with an initial treatment session. Initial treatment was aimed at addressing chronic overuse in his forearm muscles and corresponding nerve entrapment that might be occurring in the upper extremity. Dustin was pleased with how he felt after the session and agreed to make an appointment to return after he consulted the neurologist. DUSTIN'S RETURN Dustin returned three weeks later after having had a successful consultation with the neurologist. He was very thankful for the detailed initial evaluation in the first massage appointment and the recommendation to see the neurologist. The neurologist informed him that while many of his symptoms were quite similar to medial epicondylitis and carpal tunnel syndrome, he was actually suffering from a condition that is common in musicians called focal dystonia or musician's cramp. The tethered median nerve stress test. 2