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In this order, each joint-positioning component is added until mild pain is provoked. Therapeutic nerve fl ossing occurs as the therapist slowly releases the client's elbow extension (slackening the nerve) while the client sidebends her head to the opposite side (tractioning the nerve). As the routine is repeated, the client's head returns to neutral (slackening the nerve) while the therapist extends the elbow to stretch the nerve back through the tunnel. Play with this maneuver until you determine the best angle for maximum tractioning. SUMMARY Nerve and carpal mobilizations form a powerful team for treating CTS pain. Improved signal conduction to the muscles, increased sensory perception, and greater hand function are just a few of the therapeutic benefi ts derived from these stretching modalities. Remember to be very gentle when working in areas of nerve infl ammation. If your state laws allow, advise your clients how to perform these simple nerve and carpal gliding techniques at home. Notes 1. C. Fernández-de-Las Peñas et al., "Manual Physical Therapy Versus Surgery for Carpal Tunnel Syndrome: A Randomized Parallel-Group Trial," The Journal of Pain 16, no. 11 (November 2015): 1087–94. 2. Eren Cansü et al., "Neglected Lunate Dislocation Presenting as Carpal Tunnel Syndrome," Case Reports in Plastic Surgery and Hand Surgery 2, no. 1 (January 2015): 22–24, doi:10.3109/23320885.2014.993397. Erik Dalton is the executive director of the Freedom from Pain Institute. Educated in massage, osteopathy, and Rolfi ng, Dalton has maintained a practice in Oklahoma City, Oklahoma, for more than three decades. For more information, visit www.erikdalton.com. Editor's note: Massage & Bodywork is dedicated to educating readers within the scope of practice for massage therapy. This column is based on this author's years of experience and education. The column is meant to add to readers' knowledge, not to dictate their treatment protocols. 3 With the client's elbow and wrist slightly fl exed (palm up), the fi ngers of therapist and client interlace. The therapist's thumbs glide superiorly until they bump into the radius and ulna bones, and move slightly medially to contact the triquetrum and scaphoid. Holding mild sustained pressure, the client palmar-fl exes the wrist against the therapist's resistance to a count of fi ve and then relaxes. The therapist gently extends the client's wrist while his thumbs spread the triquetrum and scaphoid laterally to open the tunnel and drag the lunate away from the median nerve. Repeat 3–5 times. To create space between the proximal carpal row and the radius/ulna, the therapist extends and gently tractions the elbow and wrist up to, but not entering, the painful barrier. With the therapist's thumbs positioned on the proximal carpal row, the client slowly palmar-fl exes the wrist against the therapist's resistance to a count of fi ve, and then relaxes. The therapist's fi ngers extend the wrist and traction the arm with the intent of spreading the tunnel, gliding the carpals free of the radius/ulna, and stretching the median nerve. Repeat 3–5 times, and then retest the ability of the third and fourth digits to oppose the thumb. C h e c k o u t A B M P 's l a t e s t n e w s a n d b l o g p o s t s . Av a i l a b l e a t w w w. a b m p . c o m . 103 4 5 To mobilize the median nerve distally, the therapist supinates the client's arm and slowly extends her fi ngers, wrist, and elbow until slight CTS discomfort is felt. To glide the nerve proximally, the client left sidebends her head while the therapist fl exes her elbow to allow the nerve to glide headward. Repeat this gentle back-and-forth nerve fl ossing maneuver 3–5 times each session until symptoms improve.