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86 m a s s a g e & b o d y w o r k j u l y / a u g u s t 2 0 1 7 technique SCIENCE OF NERVES Carpal Tunnel Syndrome Assessment Tests Suggested Variations on Standard Protocols By Whitney Lowe Mention upper extremity nerve entrapment problems and the first thing that comes to most people's minds is carpal tunnel syndrome (CTS). It is the most commonly occurring and well-studied peripheral nerve entrapment condition. Women develop the condition more often than men, and the incidence of the condition is much higher in certain occupations—especially those with significant upper extremity overuse. Workers whose jobs involve high- velocity and high-force manual labor are far more susceptible to CTS, and it is especially common when the occupation involves vibrating tools, assembly-line work, or other types of challenging upper extremity repetitive motion. 1 Massage therapists are also susceptible to this problem because of the significant hand and finger grasping involved in daily work. Clients are increasingly looking for nonsurgical treatments for this chronic condition, as there is still a moderately high number of unsuccessful carpal tunnel surgeries. One study noted that the failure rate for CTS surgery can sometimes run as high as 25 percent. 2 Because traditional treatment is often unsuccessful, many people seek the care of complementary treatment approaches such as massage therapy to address this problem. As a result, massage therapists have a much more important role in evaluating the nature and severity of nerve pathology in these cases. Massage therapists must rely on a physical examination to evaluate potential nerve-related injury. Thus, the results from assessment are even more important. In this installment, we'll take a look at the biomechanical and physiological factors that lead to carpal tunnel problems and then explore some innovative ways to make standard physical examination procedures even more effective for identifying potential problems. PHYSIOLOGICAL EFFECTS OF NERVE COMPRESSION CTS and other peripheral entrapment neuropathies result from numerous causes. The most common are pressure on the nerve from adjacent muscles, tissue fluid accumulation from swelling, fibrosis, space-occupying lesions, direct compression of the nerve from outside forces, and neural ischemia. These factors can be interrelated and an increase in one routinely affects the others. An example is the relationship between pressure on nerves and the reduction in neural blood flow (neural ischemia). Pressure on nerves reduces circulation of blood through very small blood vessels directly to the nerve tissue. In some cases, the alteration in blood flow can produce an inflammatory response that increases pressure on the nerve due to local tissue fluid accumulation. The pressure-neural, ischemia-inflammatory response becomes a vicious cycle that increases neurological symptoms. Intraneural blood-flow problems can also cause pain in nerves without causing significant changes in the nerve conduction velocity. 3 However, the most preferred high-tech diagnostic tool for validating the presence of CTS is a nerve conduction velocity test. The limitations of these tests suggest that other forms of evaluation, such as a comprehensive physical examination, play a crucial role in accurate identification of nerve compression pathologies. A detailed clinical history is also crucial because physiological changes associated with neural ischemia could be magnified in a client with some other form of circulatory compromise, such as diabetes. CTS is usually described as a condition associated with chronic or long-term compression of the median nerve. However, some of the degenerative processes described above can occur after only a short period of time. The time frame for detrimental impacts may even be as short as minutes or hours, depending on the biomechanical stresses on the nerve. The cumulative effects of time is another challenge. The longer pressure is applied to neural structures, the greater the potential damage and the more sensitive the tissues will become. In fact, very little pressure is needed to elicit symptoms if that pressure is applied for a long period of time. Client symptoms from CTS vary based on a number of factors related to structure and function of the affected nerve. The median nerve is a mixed nerve, meaning it contains both sensory and motor fibers. However, at the level of the carpal tunnel,

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