Massage & Bodywork

MAY | JUNE 2016

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100 m a s s a g e & b o d y w o r k m a y / j u n e 2 0 1 6 presentation. For example, if there is compression on the ulnar nerve branch of the brachial plexus near the thoracic outlet region, it will take less pressure in the cubital tunnel to cause symptoms to appear. Client history is very important in uncovering the presence of ulnar nerve compression in the cubital tunnel. Determine if there is repeated upper extremity use, especially if it involves repetitive elbow flexion or prolonged periods of holding the elbow in a flexed position. Also important is identifying external compression on the posterior elbow that may aggravate symptoms. For example, if a person's occupation requires long periods of leaning on elbows, ulnar nerve compression may result from both elbow flexion and external compression on the nerve. The ulnar nerve carries a large number of sensory fibers. Therefore, nerve compression may produce common sensory symptoms such as pain, paresthesia, or numbness. The symptoms will usually be felt in the hand where the ulnar nerve provides sensory innervation (Image 5). Symptoms can also be 5 Sensory distribution of the ulnar nerve. Mediclip image copyright (1998) Williams & Wilkins. All rights reserved. Ulnar nerve distribution be used to investigate the possibility of nerve compression in this region is the upper limb neurodynamic test #4 (Image 7). In this procedure, the arm is put in a position that places the greatest amount of tensile (pulling) stress on the ulnar nerve. If symptoms increase with this position, there is an increased likelihood of ulnar nerve involvement somewhere along its path. Gently palpating the area on the posterior side of the elbow while the client is in this position may reveal additional sensitivity and reproduction of symptoms. That response would strengthen suspicion of ulnar nerve compression in the posterior elbow region. TREATMENT CONSIDERATIONS When a nerve is compressed, it often develops an increased degree of sensitivity. Consequently, it is a bad idea to do anything that further aggravates the nerve compression symptoms. Soft-tissue treatment in the region of the cubital tunnel, where the nerve is very superficial, could easily aggravate symptoms and prolong the condition. It is also a good idea to avoid deep compressive work near the proximal attachment sites of the flexor tendons near the medial epicondyle, as this is where the ulnar nerve may be compressed between adjacent muscle structures. However, just because the nerve may be compressed in this region does not mean massage is contraindicated. Tightness throughout the flexor muscles of the forearm, and especially the flexor carpi ulnaris, can play a role in aggravating nerve compression problems. In this case, working the wrist and hand flexor muscles in the forearm can be beneficial as long as it does not produce neurological sensations. It may be advantageous to work lightly around the elbow and reserve other more specific and deep pressure applications for the middle and distal portion of the forearm. Nerve compression problems are notoriously slow to heal. The most important factor in addressing the felt along the forearm, but are more common in the hand. The motor fibers in the ulnar nerve can be affected as well. Sensory symptoms generally appear first, but if the condition is more severe, motor symptoms such as atrophy or weakness may occur later. The primary reason sensory symptoms appear first has to do with the arrangement of fibers inside the nerve. Image 6 shows a schematic representation of the cross section of the nerve. Generally, there is a greater concentration of sensory fibers around the periphery, while in the center there are more motor fibers, such as those supplying the flexor carpi ulnaris and flexor digitorum profundus muscles. 3 Because pressure will be experienced first on the outer periphery of the nerve, those sensory fibers that are most superficial and closest to the edge are the ones initially affected by compression. Some of the motor fibers that innervate the adductor pollicis muscle in the hand are also closer to the periphery of the nerve. As a result, atrophy and weakness in this muscle can often occur at the same time as the increased sensory symptoms in the hand. The adductor pollicis muscle makes up part of the fleshy bundle of muscles on the thenar eminence of the hand. When this muscle is not getting adequate nerve supply, there may be apparent atrophy or even a concave appearance to this portion of the hand. A comprehensive picture established through detailed clinical history and physical examination methods mentioned previously is essential for recognizing this problem. Another method that can

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