Orthopedic Massage Essentials

By Whitney Lowe, LMT

Technique Synergy: Blending Unique Combinations for Success

Specific techniques and modalities are the key tools of our profession. But as any artisan or craftsmen will tell you, each tool is only as good as the person using it. Sometimes, we may look to one specific assessment or treatment technique to give us the key results we are looking for. Yet, in reality, the most effective approach might be a unique combination of different methods—technique synergy.

Synergy can be defined as the interaction of elements that, when combined, produce a total effect that is greater than the sum of the individual elements by themselves. So, how do you know which different techniques to combine together for the greatest effect? The key lies in understanding the physiological effects of your treatment or assessment techniques so you can choose the most effective approach. Let's look at an example of how several different assessment strategies were combined together to produce more effective evaluation methods for identifying carpal tunnel syndrome.

Variation on Common CTS Evaluation Procedures

Carpal tunnel syndrome (CTS) is the most common median nerve pathology. Yet, there are still challenges in recognizing it, especially in the early stages before symptoms are prominent. Nerve evaluation tests need to be more sensitive to identify the problem at different stages of severity. The sensitivity of the test refers to how accurate it is at identifying the problem when it is present. Below are several variations on standard carpal tunnel syndrome assessment tests that make them more sensitive, and consequently more able to identify a problem before it is severe. These descriptions are excerpted from an article originally published in the Journal of Bodywork & Movement Therapies.¹

Figure 1: Phalen's Test - Reproduced with permission from Journal of Bodywork & Movement Therapies. Massage therapists routinely treat clients with carpal tunnel syndrome. Yet, they do not have the high-tech diagnostic procedures like nerve conduction tests available for identifying possible median nerve involvement. Therefore, the reliance on physical examination to support (or replace) findings from nerve conduction studies is very important. When performing any of these procedures, the practitioner should remember that exaggerated neural sensations may be indicative not only of mechanical compression neuropathy, but of a host of disorders that cause increased neural sensitivity. 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 carpal tunnel syndrome. To perform this test, the client presses the back of the hands together so the wrists are flexed close to 900 (Figure 1). If the sensory symptoms of pain, paresthesia or numbness in the median nerve distribution are reproduced within about 60 seconds, the test is considered positive for median nerve compression in the carpal tunnel.

Figure 2: Phalen's Test Modification - Reproduced with permission from Journal of Bodywork & Movement Therapies. When this test is performed, the wrist is in flexion, which decreases tension on the median nerve. If there is increased tension on the median nerve, there is a greater degree of sensitivity in the evaluation procedure and it could therefore pick up less severe conditions.² Greater sensitivity would therefore result if the wrist was held in flexion (Phalen's test position) while the upper extremity was held in a position that increases neural tension on the remainder of the median nerve. An upper extremity position that would increase tensile stress on the median nerve, while compressing it at the carpal tunnel region, would include lateral flexion of the neck to the opposite side, shoulder abduction, elbow extension, and wrist flexion (Figure 2). This test would be performed unilaterally, unlike the standard Phalen's test, which is performed on both sides at the same time. Make sure the cervical region is laterally flexed away from the side that is being tested.

Figure 3: Hand Elevation Test - Reproduced with permission from Journal of Bodywork & Movement Therapies. Hand Elevation Test

Another relatively new evaluation procedure that has demonstrated greater accuracy than the Phalen's test is the hand elevation test. In this procedure the client holds the hand as high as comfortably possible overhead (Figure 3). If neurological symptoms in the median nerve distribution of the hand are reproduced within one minute, the test is considered positive.³ Neural tension in the median nerve could be added to the hand elevation test to make it more sensitive. With the arm held overhead, the neck is laterally flexed to the opposite side. Additional tension on the median nerve is added by putting the wrist in extension (Figure 4). Another variation would be keeping the wrist in flexion (as in the Phalen's test wrist position).

Figure 4: Modified Hand Elevation Test - Reproduced with permission from Journal of Bodywork & Movement Therapies. Tethered Median Nerve Stress Test

Increased neural tension is already a component of this test. The wrist is held in extension and supination. While in this position, the index finger is pulled into hyperextension as far as motion allows (Figure 5). The finger movement can be performed by the practitioner or by the client.⁴ If neurological symptoms are felt within about one minute, the test is considered positive. As with several CTS tests, this test is considered more accurate when combined with other procedures to produce a comprehensive clinical picture.⁵

The tethered median nerve stress test already involves tension on the median nerve at the wrist. Additional neural tension can be added to the proximal upper extremity to make this procedure more sensitive. Positions to add include lateral neck flexion to the opposite side, shoulder abduction, elbow extension and forearm supination. Note that not all of these motions need to be added. In some cases symptoms will be exacerbated with addition of just one position.

Figure 5: Tethered Median Nerve Stress Test - Reproduced with permission from Journal of Bodywork & Movement Therapies. Accurate evaluation of soft tissue pathologies is an essential element of effective treatment. No diagnostic procedures have proven to be the gold standard for accurately identifying carpal tunnel syndrome. Electrodiagonstic testing, which is commonly used by medical professionals, has demonstrated limited effectiveness. It is also not available to most manual therapy practitioners. There is, therefore, a need for alternative accurate physical examination procedures for CTS. Common physical examination procedures are not always sensitive enough to identify the pathology when it exists. Some of the variations described in this article could prove to be useful adjunctive evaluation procedures that help the manual therapist gather more precise information about their client's soft-tissue pathology so that appropriate treatment or referral may result. These variations on standard CTS evaluation tests show that applying biomechanical principles to various assessment procedures allows us to combine the different strategies together for more accurate results. And that is the key benefit of technique synergy.

References:

Lowe W. Suggested variations on standard carpal tunnel syndrome assessment tests. Journal of Bodywork & Movement Therapies. 2008;12(2):151-157.
Butler D. Mobilisation of the Nervous System. London: Churchill Livingstone; 1991.
Amirfeyz R, Gozzard C, Leslie IJ. Hand elevation test for assessment of carpal tunnel syndrome. J Hand Surg [Br]. 2005;30(4):361-364.
Raudino F. Tethered median nerve stress test in the diagnosis of carpal tunnel syndrome. Electromyogr Clin Neurophysiol. 2000;40(1):57-60.
Kaul MP, Pagel KJ, Dryden JD. Lack of predictive power of the "tethered" median stress test in suspected carpal tunnel syndrome. Arch Phys Med Rehabil. 2000;81(3):348-350.