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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 . 87 Schematic representation of the cross section of the median nerve at the carpal tunnel showing distribution of sensory and motor nerve fibers. Sensory fibers are blue and motor fibers are red. 1 there is a higher percentage of sensory fibers in the median nerve. The sensory fibers are also distributed more dominantly in the periphery of the nerve (Image 1). As a result, compression pathology tends to produce sensory symptoms (pain, paresthesia, numbness) earlier than motor symptoms (atrophy and weakness) because the sensory fibers are closer to the periphery of the nerve. This fiber distribution pattern also indicates that if there is significant grip-strength weakness along with sensory symptoms, the condition may be more advanced because a greater number of motor fibers are affected. VARIATIONS ON COMMON EVALUATION METHODS Despite the frequency and prevalence of CTS, there are no high-tech diagnostic procedures that produce a definitive diagnosis for the condition. Nerve conduction velocity is still used frequently as a means for identifying median nerve impairment. However, early sensory symptoms can occur without a significant change in nerve conduction velocity. Because the neural pathology and sensory symptoms may occur without significant impairment of conduction velocity, there is even greater importance placed on the physical examination to identify potential neural involvement in the early stages. Another potential complication that often clouds the picture of CTS involvement is locating the precise region of median nerve entrapment. While the carpal tunnel is certainly the most researched and well- gather about the median nerve involvement, the greater our chance of being accurate to set an effective course for our treatment. There are a number of special orthopedic tests that are routinely used to evaluate CTS. Some of them are more accurate than others. Any evaluation procedure has two key components to determine how accurate it is at identifying a particular type of tissue involvement: sensitivity and specificity. Sensitivity refers to how accurate that test is at determining everyone who has the particular problem being investigated. Specificity refers to how accurate the test is at ruling out everyone who does not have that problem. Ideal accuracy for any evaluation procedure comes when you have a high degree of both specificity and sensitivity. One of the problems that occurs, especially in the early onset stages of CTS, is that many of the standard orthopedic testing procedures are not sensitive enough to pick up sensory symptoms that indicate nerve pathology. Modifications can be made to some of the standard CTS orthopedic assessment tests to make them more sensitive, and consequently more versatile, for evaluating nerve compression pathologies. Variations on standard carpal tunnel evaluation procedures are suggested here. When performing any of these procedures, remember that exaggerated neural sensations may be indicative not only of mechanical compression neuropathy, but could involve other facets of neural sensitivity, such as excess neural tension or systemic neurological disorders like diabetes. Appropriate contraindications for proper treatment should be carefully weighed after gathering evaluation information. Phalen's Test Phalen's test is the most common special orthopedic test for evaluating CTS. To perform this test, the client presses the back of the hands together so the wrists are flexed close known region of median nerve pathology, there are numerous locations throughout the upper extremity where the median nerve can be compressed. These locations include the region between the scalene muscles and beneath the clavicle in the thoracic outlet, beneath the pectoralis minor muscle, under the bicipital aponeurosis in the elbow, and between the two heads of the pronator teres muscle in the forearm. Compression of median nerve fibers in any of these locations could mimic the symptoms of compression at the carpal tunnel in the wrist. For that reason, detailed physical examination is, again, even more important. Massage therapists are in an ideal position to address not only carpal tunnel compression, but also the numerous sites of nerve compression throughout the upper extremity. However, it takes skilled clinical reasoning and sharply honed physical examination skills to identify the most likely site(s) of nerve compression. I cannot emphasize enough how important skillful clinical reasoning is for making some of these determinations. All too often I hear massage practitioners say they don't use any type of formal assessment process but let their hands tell them where to work. While your palpation skills are unquestionably valuable for identifying hypertonicity in muscles, they are notably limited for identifying nerve compression pathology. Nerve compression and tension symptoms are notoriously tricky and can often deviate from simple evaluation guidelines. So, the more information we can