Carpal Tunnel Syndrome

What is Carpal Tunnel Syndrome?

Carpal tunnel syndrome is a condition characterized by tingling, numbness and pain in the hand and fingers (particularly the thumb, index, middle and ring fingers). These symptoms are often the result of median nerve irritation in the wrist or forearm.

BLAUSEN.COM (2014). "MEDICAL GALLERY OF BLAUSEN MEDICAL 2014". WIKIJOURNAL OF MEDICINE 1 (2). - CC BY 3.0.

BLAUSEN.COM (2014). "MEDICAL GALLERY OF BLAUSEN MEDICAL 2014". WIKIJOURNAL OF MEDICINE 1 (2). - CC BY 3.0.

Why Give Massage Therapy A Try?

Massage therapy as a therapeutic intervention is being embraced by the medical community, it is simple to carry out, economical, and has very few side effects. One area that is being explored is the use of massage therapy for patients who suffer from carpal tunnel syndrome. 

Randomized clinical trials have demonstrated that for some patients who suffer from carpal tunnel syndrome there is no significant differences in pain and functional outcomes at six and twelve months when surgical and conservative care are tested (Fernández-de-Las Peñas et al. 2015Fernández-de-Las Peñas et al. 2017).

Why Does Massage Therapy Work?

The responses to massage therapy are complex and multifactorial - physiological and psychological factors interplay in a complex manner. Research has looked at the bioplastic and neuroimmune responses at both the peripheral and central levels elicited by massage therapy treatments.

Pain Management
Massage has a modulatory affect on peripheral and central processes via input from large sensory neurons that prevents the spinal cord from amplifying the nociceptive signal. This anti-nociceptive effect of massage therapy can help ease discomfort in patients who suffer from carpal tunnel syndrome (Bishop et al. 2015Vigotsky et al. 2015).

Peripheral Response
The median nerve passes through many structures and it may be exposed to mechanical irritation at many different points (Filius et al. 2017). Prolonged irritation may result in a reduction of intraneural blood flow. In turn, local hypoxia of a peripheral nerve leads to a drop in tissue pH that triggers the release of inflammatory mediators, known as “inflammatory soup”, this noxious substance can disrupt the normal function of nerves (Fisher et al. 2015). Massage therapy may diminish intraneural edema and/or pressure by mobilizing the median nerve as well as associated vascular structures (Boudier-Revéret et al. 2017).

Carpal tunnel specific work may also involve specific soft tissue treatment to optimize the ability of mechanical interfaces to glide relative relative to the median nerve. Ongoing tissue hypoxia or inflammatory responses lead to molecular signaling that promote the development of fibrosis, this may contribute to further peripheral nerve dysfunction (Fisher et al. 2015). The application of appropriate shear force and pressure impart a mechanical stimulus that may attenuate tissue levels of fibrosis and TGF-β1 (Bove et al. 2016).

Infraspinatus Test in Carpal Tunnel Syndrome

Identification of the correct location for the infraspinatus provocation test (IsT) on the lateral margin of the infraspinatus muscle, between the tip of the inferior angle of the scapula and the dorsal tip of the acromial angle. Pressure is exerted vertically to the course of the fibrous tissue (Meder et al. 2017).

Identification of the correct location for the infraspinatus provocation test (IsT) on the lateral margin of the infraspinatus muscle, between the tip of the inferior angle of the scapula and the dorsal tip of the acromial angle. Pressure is exerted vertically to the course of the fibrous tissue (Meder et al. 2017).

The etiology of myofascial triggerpoints are still not well understood, but that does not deny the existence of the clinical phenomenon.

A contemporary view of 'myofascial trigger-points' is presented by Shah, this categorizes 'myofascial trigger-points' by the a number of measurable characteristics: local and remote inflammation, local acidic milieu, local sensitization, local regions of hypoxia, local muscle stiffness (Shah et al. 2015). 

Studies have demonstrated that assessing and treating the infraspinatus muscle may be an effective treatment option for a sub-group of patients with suffer from symptoms that present similarly to carpal tunnel syndrome (Meder et al. 2017).

Acupuncture

A recent randomized controlled trial in the journal Brain found that acupuncture improved the outcomes for carpal tunnel syndrome by remapping the brain (Maeda et al. 2017).

Summarizing Points

Systematic reviews have also shown that manual therapy combined with multimodal care can improve symptoms, decrease disability and improve function for patients who suffer from carpal tunnel syndrome (Huisstede et al. 2017Piper et al. 2016).

Structures to be aware of when treating carpal tunnel syndrome

A massage therapy treatment plan should be implemented based on patient-specific assessment findings and patient tolerance. Structures to keep in mind while assessing and treating patients suffering from plantar heel pain may include neurovascular structures and investing fascia of:
• scalene muscles
• costo-clavicle space
• pectoralis minor
• biceps brachii muscle
• bicipital aponeurosis
• pronator teres
• transverse carpal ligament
• anterior interosseous membrane
• palmar aponeurosis
• infraspinatus
• lumbricals

More to Explore

Related Links
• Massage Therapy and Postoperative Care
• Traumatic Muscle Fibrosis:  From pathway to prevention 
• Massage Therapy and Compartment Syndrome 
• The Role of Massage in Scar Management 
• Research on Massage and Cancer 
• Sports Massage - The Science is Emerging 
• Massage Therapy and Dupuytren's Disease 

Research Links
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Bair, M.R., Gross, M.T., Cooke, J.R., Hill, C.H. (2016). Differential Diagnosis and Intervention of Proximal Median Nerve Entrapment: A Resident's Case Problem. J Orthop Sports Phys Ther.
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Baselgia, L.T., Bennett, D.L., Silbiger, R.M., Schmid, A.B. (2017). Negative Neurodynamic Tests Do Not Exclude Neural Dysfunction in Patients With Entrapment Neuropathies. Arch Phys Med Rehabil.
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Basson, A., Olivier, B., Ellis, R., Coppieters, M., Stewart, A., Mudzi, W. (2017). The Effectiveness of Neural Mobilization for Neuro-Musculoskeletal Conditions: A Systematic Review and Meta-Analysis. J Orthop Sports Phys Ther.
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Berrueta, L., Muskaj, I., Olenich, S., Butler, T., Badger, G. J., Colas, R. A., . . . Langevin, H. M. (2016). Stretching Impacts Inflammation Resolution in Connective Tissue. Journal of Cellular Physiology.
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Bishop, M. D., Torres-Cueco, R., Gay, C. W., Lluch-Girbés, E., Beneciuk, J. M., & Bialosky, J. E. (2015). What effect can manual therapy have on a patient's pain experience? Pain Management.
https://www.ncbi.nlm.nih.gov/pubmed/26401979 (OPEN ACCESS)

Boudier-Revéret, M., Gilbert, K.K., Sobczak, S. (2017). Effect of neurodynamic mobilization on fluid dispersion in median nerve at the level of the carpal tunnel: A cadaveric study. Musculoskelet Sci Pract.
https://www.ncbi.nlm.nih.gov/pubmed/28734168

Bove, G., Harris, M., Zhao, H., & Barbe, M. (2016). Manual therapy as an effective treatment for fibrosis in a rat model of upper extremity overuse injury. Journal of the Neurological Sciences.
http://www.ncbi.nlm.nih.gov/pubmed/26810536 (OPEN ACCESS)

Chaitow, L. (2016). Dosage and manual therapies – Can we translate science into practice? Journal of Bodywork and Movement Therapies.
https://www.ncbi.nlm.nih.gov/pubmed/27210835

Chen, L., Michalsen, A. (2017). Management of chronic pain using complementary and integrative medicine. BMJ.
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Coppieters, M.W., Butler, D.S. (2008). Do 'sliders' slide and 'tensioners' tension? An analysis of neurodynamic techniques and considerations regarding their application. Man Ther.
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Elliott, R., Burkett, B. (2013). Massage therapy as an effective treatment for carpal tunnel syndrome. J Bodyw Mov Ther.
https://www.ncbi.nlm.nih.gov/pubmed/23768278

Filius, A., Thoreson, A.R., Wang, Y., Passe, S.M., Zhao, C., An, K.N., Amadio, P.C. (2015). The effect of tendon excursion velocity on longitudinal median nerve displacement: differences between carpal tunnel syndrome patients and controls. J Orthop Res.
https://www.ncbi.nlm.nih.gov/pubmed/25640903 (OPEN ACCESS)

Filius, A., Thoreson, A.R., Ozasa, Y., An, K.N., Zhao, C., Amadio, P.C. (2017). Delineation of the mechanisms of tendon gliding resistance within the carpal tunnel. Clin Biomech (Bristol, Avon).
https://www.ncbi.nlm.nih.gov/pubmed/27939953

Fisher, P., Zhao, Y., Rico, M., Massicotte, V., Wade, C., Litvin, J., . . . Barbe, M. (2015). Increased CCN2, substance P and tissue fibrosis are associated with sensorimotor declines in a rat model of repetitive overuse injury. Journal of Cell Communication and Signaling.
https://www.ncbi.nlm.nih.gov/pubmed/25617052 (OPEN ACCESS)

Fernández-de-Las Peñas, C. F., Ortega-Santiago, R., . . . Cuadrado-Pérez, M. L. (2015). Manual Physical Therapy Versus Surgery for Carpal Tunnel Syndrome: A Randomized Parallel-Group Trial.The Journal of Pain.
https://www.ncbi.nlm.nih.gov/pubmed/26281946

Fernández-de-Las-Peñas, C., Cleland, J., Palacios-Ceña, M., Fuensalida-Novo, S., Pareja, J.A., Alonso-Blanco, C. (2017). The Effectiveness of Manual Therapy versus Surgery on Self-Reported Function, Cervical Range of Motion and Pinch Grip Force in Carpal Tunnel Syndrome: A Randomized Clinical Trial. J Orthop Sports Phys Ther.
https://www.ncbi.nlm.nih.gov/pubmed/28158963

Fernández-de-Las-Peñas, C., Cleland, J.,... Alburquerque-Sendín, F. (2017). Effectiveness of manual therapy versus surgery in pain processing due to carpal tunnel syndrome: A randomized clinical trial. Eur J Pain.
https://www.ncbi.nlm.nih.gov/pubmed/28295825

Gilbert, K. K., James, C. R., Apte, G., Brown, C., Sizer, P. S., Brismée, J., & Smith, M. P. (2015). Effects of simulated neural mobilization on fluid movement in cadaveric peripheral nerve sections: Implications for the treatment of neuropathic pain and dysfunction. Journal of Manual & Manipulative Therapy.
http://www.ncbi.nlm.nih.gov/pubmed/26917940 (OPEN ACCESS)

Govea, R.M., Barbe, M.F., Bove, G.M. (2017). Group IV nociceptors develop axonal chemical sensitivity during neuritis and following treatment of the sciatic nerve with vinblastine. J Neurophysiol.
https://www.ncbi.nlm.nih.gov/pubmed/28701542

Huisstede, B.M., van den Brink, J., Randsdorp, M.S., Geelen, S.J., Koes, B.W. (2017). The Effectiveness of Surgical and Post-Surgical Interventions for Carpal Tunnel Syndrome-A Systematic Review. Arch Phys Med Rehabil.
https://www.ncbi.nlm.nih.gov/pubmed/28577858

Huisstede, B.M.A., Hoogvliet, P., Franke, T.P.C., Randsdorp, M.S., Koes, B.W. (2017). Carpal Tunnel Syndrome: Effectiveness of Physical Therapy and Electrophysical Modalities. An Updated Systematic Review of Randomized Controlled Trials. Arch Phys Med Rehabil.
https://www.ncbi.nlm.nih.gov/pubmed/28942118

Lane, E., Clewley, D., Koppenhaver, S. (2017). Complaints of Upper Extremity Numbness and Tingling Relieved With Dry Needling of the Teres Minor and Infraspinatus: A Case Report. J Orthop Sports Phys Ther.
https://www.ncbi.nlm.nih.gov/pubmed/28257619

Lim, Y.H., Chee, D.Y., Girdler, S., Lee, H.C. (2017). Median nerve mobilization techniques in the treatment of carpal tunnel syndrome: A systematic review. J Hand Ther.
https://www.ncbi.nlm.nih.gov/pubmed/28764878

Louw, A., Nijs, J., Puentedura, E. (2017). A clinical perspective on a pain neuroscience education approach to manual therapy. Journal of Manual & Manipulative Therapy.
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Madenci, E., Altindag, O., ... Gur, A. (2012). Reliability and efficacy of the new massage technique on the treatment in the patients with carpal tunnel syndrome. Rheumatol Int.
https://www.ncbi.nlm.nih.gov/pubmed/21953301 (OPEN ACCESS)

Maeda, Y., Kim, H., Kettner, N., Kim, J., Cina, S., .... Napadow, V. (2017). Rewiring the primary somatosensory cortex in carpal tunnel syndrome with acupuncture. Brain.
https://www.ncbi.nlm.nih.gov/pubmed/28334999

Martínez-Merinero, P., Lluch, E., ... Falla, D. (2017). The influence of a depressed scapular alignment on upper limb neural tissue mechanosensitivity and local pressure pain sensitivity. Musculoskelet Sci Pract.
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Meder, M.A., Amtage, F., Lange, R., Rijntjes, M. (2017). Reliability of the Infraspinatus Test in Carpal Tunnel Syndrome: A Clinical Study. J Clin Diagn Res.
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Padua, L., Coraci, D., Erra, C., ... Hobson-Webb, L.D. (2016). Carpal tunnel syndrome: clinical features, diagnosis, and management. Lancet Neurol.
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Park, D. (2017). Ultrasonography of the Transverse Movement and Deformation of the Median Nerve and Its Relationships with Electrophysiological Severity in the Early Stages of Carpal Tunnel Syndrome.
https://www.ncbi.nlm.nih.gov/pubmed/28433831

Piper, S., Shearer, H. M., Côté, P., Wong, J. J., Yu, H., Varatharajan, S., . . . Taylor-Vaisey, A. L. (2016). The effectiveness of soft-tissue therapy for the management of musculoskeletal disorders and injuries of the upper and lower extremities: A systematic review by the Ontario Protocol for Traffic Injury management (OPTIMa) collaboration. Manual Therapy.
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Pratelli, E., Pintucci, M., Cultrera, P., Baldini, E., Stecco, A., Petrocelli, A., Pasquetti, P. (2015). Conservative treatment of carpal tunnel syndrome: comparison between laser therapy and Fascial Manipulation(®). J Bodyw Mov Ther.
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Schmid, A.B., Elliott, J.M., Strudwick, M.W., Little, M., Coppieters, M.W. (2012). Effect of splinting and exercise on intraneural edema of the median nerve in carpal tunnel syndrome--an MRI study to reveal therapeutic mechanisms. J Orthop Res.
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Vigotsky, A. D., & Bruhns, R. P. (2015). The Role of Descending Modulation in Manual Therapy and Its Analgesic Implications: A Narrative Review. Pain Research and Treatment. (OPEN ACCESS)
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Waters-Banker, C., Dupont-Versteegden, E. E., Kitzman, P. H., & Butterfield, T. A. (2014). Investigating the Mechanisms of Massage Efficacy: The Role of Mechanical Immunomodulation. Journal of Athletic Training.
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Wolny, T., Saulicz, E., Linek, P., Shacklock, M., Myśliwiec, A. (2017). Efficacy of Manual Therapy Including Neurodynamic Techniques for the Treatment of Carpal Tunnel Syndrome: A Randomized Controlled Trial. J Manipulative Physiol Ther.
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Yamanaka, Y., Gingery, A., Oki, G., Yang, T.H., Zhao, C., Amadio, P.C. (2017). Blocking fibrotic signaling in fibroblasts from patients with carpal tunnel syndrome. J Cell Physiol.
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