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WHAT’S INSIDE
Chapter 1: Carpal Tunnel Syndrome: A Comprehensive Guide for Massage Therapists 1 CEU This course provides a comprehensive overview of carpal tunnel syndrome for massage therapists. This overview allows the reader to gain greater knowledge of anatomy, perspectives on how carpal tunnel syndrome affects individuals, as well as specific bodywork methods to alleviate classic symptoms of the condition. Chapter 2: Ethics for Therapeutic Massage and Bodywork 14 4 CEUs 1 This course emphasizes the principles and standards of ethical practice for massage therapy and bodywork, and ethical issues that impact the professional in daily practice. The course includes steps to identify potential ethical conflicts, and strategies for ethical decision making to avoid and resolve ethical issues before they become problematic. Chapter 3: Massage Therapy and the Stress Epidemic 1 CEU The purpose of this course is to discuss the positive role professional massage therapy can play in the stress epidemic in our modern culture. We will examine the negative physiological and biochemical processes that occur in the body under stress and counterpoint them with the beneficial processes that occur in the body during massage. We will also look at the cultural symptoms that contribute to our collective stress and discuss the statistics that qualify stress as a national epidemic. Chapter 4: Massage Therapy for Sports Injuries 69 4 CEUs 59 This course is designed to familiarize massage therapists with the techniques most commonly used to treat sports injuries, the general terminology associated with sports injuries, the most common sports injuries, the anatomy and physiology involved, and the sports each injury is usually associated with. The course also reviews several tips for helping athletes avoid specific injuries. In several instances, learners will discover that massage therapy is contraindicated given the specifics of an athlete’s condition. Chapter 5: Recognizing Headaches 82 1 CEU Headaches can be warning signs of underlying life-threatening conditions, however most are harmless and respond to basic treatments. Massage therapy has grown in acceptance as a viable treatment
option, and more physicians have been suggesting it. Chapter 6: Treatment Planning for Clinical Massage
95
1 CEU To begin massage treatment planning gather the client information including any medications that could affect the treatment plan, and understand that it is important to document all the information. Final Examination Answer Sheet
108
©2023: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Colibri Healthcare, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge in the areas covered. It is not meant to provide medical, legal or professional services advice. Colibri Healthcare, LLC recommends that you consult a medical, legal or professional services expert licensed in your state. Colibri Healthcare, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation or circumstances and assumes no liability from reliance on these materials.
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MASSAGE THERAPY CONTINUING EDUCATION
Book Code: MLA1224
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Carpal Tunnel Syndrome: A Comprehensive Guide for Massage Therapists
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Ethics for Therapeutic Massage and Bodywork
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Chapter 3:
Massage Therapy and the Stress Epidemic
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Chapter 4:
Massage Therapy for Sports Injuries
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Chapter 5:
Recognizing Headaches
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Chapter 6:
Treatment Planning for Clinical Massage
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How do I complete this course and receive my certificate of completion? See the following page for step by step instructions to complete and receive your certificate. Are you a Louisiana board-approved provider? Yes. Colibri Healthcare, LLC is approved by the Louisiana Board of Massage Therapy (Provider #LAP0291). Are my hours reported to the Louisiana board? Yes, we report your hours electronically to the Louisiana Board of Massage Therapy within one business day. Keep your certificate in a safe place for your records. Is my information secure? Yes! We use SSL encryption, and we never share your information with third-parties. We are also rated A+ by the National Better Business Bureau. What if I still have questions? What are your business hours? No problem, we have several options for you to choose from! Online at EliteLearning.com/Massage-Therapists you will see our robust FAQ section that answers many of your questions, simply click FAQs at the top of the page, e-mail us at office@elitelearning.com, or call us toll free at 866-344-0973, Monday - Friday 9:00 am - 6:00 pm, EST. Important information for licensees: Always check your state’s board website to determine the number of hours required for renewal, mandatory topics (as these are subject to change), and the amount that may be completed through home-study. Also, make sure that you notify the board of any changes of address. It is important that your most current address is on file.
Licensing board contact information: Louisiana Board of Massage Therapy 9619 Interline Avenue, Suite B Baton Rouge, LA 70809
Phone: (225) 756-3488 Fax: (225) 925-7834 Website: https://www.labmt.org/home
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Book Code: MLA1224
MASSAGE THERAPY CONTINUING EDUCATION
Please read these instructions before proceeding. Read and study the enclosed courses and answer the final examination questions. To receive credit for your courses, you must provide your customer information and complete the evaluation. We offer three ways for you to complete. Choose an option below to receive credit and your certificates of completion. How to complete continuing education
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Online • Go to EliteLearning.com/Book . Use the book code MLA1224 and enter it in the example box that pops up then click GO . • If you already have an account created, sign in to your account with your username and password. If you do not have an account already created, you will need to create one now. • Follow the online instructions to complete your final exam. Complete the purchase process to receive course credit and your certificate of completion. Please remember to complete the online survey. By mail • Fill out the answer sheet and evaluation found in the back of this booklet. Please include a check or credit card information and e-mail address. Mail to Elite, PO Box 37, Ormond Beach, FL 32175 . • Completions will be processed within 2 business days from the date it is received and certificates will be e-mailed to the address provided. • Submissions without a valid e-mail will be mailed to the address provided.
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MASSAGE THERAPY CONTINUING EDUCATION
Book Code: MLA1224
Chapter 1: Carpal Tunnel Syndrome: A Comprehensive Guide for Massage Therapists 1 CEU
By: Jimmy Gialelis, LMT Learning objectives Identify anatomical structures involved with carpal tunnel syndrome and similar conditions. Delineate “true” carpal tunnel syndrome from other similar conditions. Implicit bias in healthcare Implicit bias significantly affects how healthcare professionals perceive and make treatment decisions, ultimately resulting in disparities in health outcomes. These biases, often unconscious and unintentional, can shape behavior and produce differences in medical care along various lines, including race, ethnicity, gender identity, sexual orientation, age, and socioeconomic status. Healthcare disparities stemming from implicit bias can manifest in several ways. For example, a healthcare provider might unconsciously give less attention to a patient or make assumptions about their medical needs based on race, gender, or age. The unconscious assumptions can lead to delayed or inadequate care, misdiagnoses, or inappropriate treatments, all of which can adversely impact health outcomes. Addressing The carpal tunnel region contains eight bones articulated in tight proximity; cartilaginous structures, called articular discs , help bind these bones. The average wrist circumference that encompasses the carpal tunnel region is seven inches for the average female body stature and eight inches for the average male body stature. Wrist circumference less than six inches for females and less than seven inches for males make one more susceptible to experience carpal tunnel syndrome. There are numerous joint classifications used to describe the articulations of the carpal bones. Most synovial joint spaces witnessed in this region are gliding joint surfaces, also called “plane joint surfaces.” Since there is no rotation of the bones in this area, the joints are considered nonaxial. The sliding movement is like rubbing one’s hands together for warmth in a straight-line fashion. Of note to manual therapists, the joint articulating the trapezium bone to the first metacarpal bone is a saddle joint. This is a modified ellipsoid joint due to the convex/concave shapes joining together. Because this joint provides rotational movement in two planes, it is considered a biaxial joint. The eight bones can easily be listed by their location in their respective rows, proximal or distal, and by directional placement, medial versus lateral. Medial to lateral: Proximal row ● Scaphoid. ● Lunate. ● Triquetrum. ● Pisiform. Medial to lateral: Distal row
Recognize research that indicates the effectiveness of massage therapy for carpal tunnel syndrome patients. Perform bodywork techniques designed to reduce the signs and the symptoms of carpal tunnel syndrome. implicit bias in healthcare is crucial for achieving equity in medical treatment. Strategies to combat these biases involve education and awareness programs for healthcare professionals. These programs help individuals recognize and acknowledge their biases, fostering a more empathetic and unbiased approach to patient care. Additionally, implementing policies and procedures prioritizing equitable treatment for all patients can play a pivotal role in reducing healthcare disparities. Ultimately, confronting implicit bias in healthcare is essential to creating a more just and equitable healthcare system where everyone receives fair and equal treatment regardless of their background or characteristics.
ANATOMY OF THE REGION
“She Looks Too Pretty, Try to Catch Her. ” Another good mnemonic includes recalling that the carpals are located within the manus region, whereas the tarsals are located within the pes region: “Drive a CAR with your carpals and walk on TAR with your tarsals.” Another easy way to learn the locations of the carpal bones is to divide the bones into functional zones in relation to nearby nerves and bones: ● The radial column, aligned with the radial nerve and radius bone, contains the scaphoid, trapezium, and trapezoid bones. ● The median column, aligned with the median nerve, is bounded by the lunate and capitate bones. ● The ulnar column, aligned with the ulnar nerve and ulna bone, contains the triquetrum, pisiform, and hamate bones. The pisiform bone is referred to as a sesamoid bone , meaning it is a bone without a direct articulation with another bone. In this case, the pisiform bone is embedded into the tendon of flexor carpi ulnaris muscle. An injury to this tendon can result in a deviation in the positioning of the pisiform bone, leading to ulnar nerve compression. Figure 1: Carpal Bones
● Trapezium. ● Trapezoid. ● Capitate. ● Hamate.
Medical school students use a variety of mnemonics (acronym phrases to recall lists) to memorize the eight carpal bones. These include: “So Long to Pinky, Here Comes the Thumb.”
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Interestingly, the carpal bones were named for unique features possessed by each bone. Here are the eight listed below with associated name etymologies: ● Scaphoid: Boat shaped with a scaffold like tubercle on its lateral edge. ● Lunate: Half-moon (lunar) shaped. ● Triquetral: Pyramidal design with an oval facet on the palmar edge. ● Pisiform: Pea-shaped design with an oval facet on the dorsal edge. ● Trapezium: Quadrangular with a concave-convex articular distal surface. ● Trapezoid: Resembles as trapezoid shape. ● Capitate: Resembles a baseball cap design with its round head. ● Hamate: Wedge-shaped bone with a hook at its proximal base. The largest carpal bone is the capitate; the smallest carpal bone is the trapezoid. The overall design of the carpal bone structure is to transfer load force from the hand into the antebrachium. Because they are short bones, there is very little leverage strength allowed; therefore, these bones are not ideal to use to move heavy objects or to perform the same repetitive movements daily. Proper wrist alignment is crucial to avoid injury to the carpal bones when moving heavy objects and performing an occupational task that requires repetitive movements.
Unfortunately, the average client is unaware of their daily wrist alignment: This causes many people to develop carpal tunnel syndrome due to the prolonged, repetitive stress on the carpal bone structures. Carpal tunnel syndrome (CTS) involves median nerve impingement within the carpal tunnel on the anterior aspects of the wrist, through which the flexor muscle tendons travel. When these tendons become enflamed, pressure (due to swelling) is placed on the median nerve. The term “nerve impingement” is synonymous with nerve entrapment and nerve compression. In Figure 2, the red dot indicates the location of true carpal tunnel impingement. Figure 2: Nerves Involved in CTS
ETIOLOGY (CAUSE)
● Ergonomic factors, which include: ○ Workspace set up. ○ Repetitive nature of one’s occupation. ○ Use of tools, especially vibrational or fine machinery. Let us examine each item in greater detail. Because of the proximity of the carpal bones, a buckle fracture is a common occurrence. This type of fracture features two bones that experience excessive compression force as they are driven together. Activities that encourage wrist misalignment, such as typing and manual labor, can create the forces needed to compress bones, thus causing a buckle break. Less common fractures of the wrist region include pathologic, comminuted, oblique, and transverse fractures. Pathologic fractures result from a disease process and often involve a significant bone disease, such as osteoporosis or osteopenia. Certain autoimmune diseases, especially involving the thyroid gland, can also weaken bone structures. Comminuted fractures result in the bone shattering into many pieces. An oblique fracture presents as a bone that breaks at an angle. A fracture line in a transverse fracture is characterized as a ninety-degree angle within the bone. These three fracture types result from a traumatic event to the region, such as bracing for a fall or jamming one’s wrist while punching an object. mellitus, cancer, kidney conditions, infectious disease, myopathic conditions, and hypothyroidism. Additionally, autoimmune diseases, such as Guillian- Barre syndrome and systemic lupus may also cause nerve degeneration. Because the body’s immune system is compromised, bodywork efforts need to remain mild for the autoimmune disease patient regarding the length of session, the depth of pressure, and the intensity of tool and product application.
The most common causes of CTS include: ● Wrist fracture. ● Neurological disease. ● Increased fluid retention. ● Inflammatory arthritis conditions.
Wrist fracture A fracture is a break to a bone. If any of the carpal bones become fractured, several musculoskeletal challenges may result: First, the bones may deviate in placement, thereby narrowing the carpal tunnel region itself. Second, if a bone does not heal properly, a misalignment of skeletal structures may result. This can potentially narrow the carpal tunnel region. Third, the inflammatory response may create a myriad of symptoms that cause median nerve compression. The most notable symptom is swelling. Finally, previously injured bones are now compromised, which makes them more susceptible to future injury – especially if the client continues with repetitive stress to the wrist region. There are numerous types of fractures. A hairline fracture (also called a stress fracture ) features faint cracks that weaken the bone. An open fracture is characterized by damage to the skin, even tearing. This creates complex lesions that must heal—in addition to the bone. A closed fracture is a break in the bone; yet, the skin stays intact. Internal bleeding can be a concern with this type of fracture. Neurological disease Neurological diseases and auto-immune disorders often cause the deterioration of peripheral nerves and may contribute to carpal tunnel syndrome symptoms. Examples of some of these neurological diseases include amyotrophic lateral sclerosis, multiple sclerosis, spinal musculature atrophy, and Huntington’s disease. As the nerves degenerate, conductivity is either partially, or completely, impaired or impeded. This renders the nerve useless; the patient first witnesses the onset of muscle atrophy, and then further complications of CTS results. Be wary of peripheral neuropathy in a patient. Common conditions that cause this phenomenon include diabetes Increased fluid retention Fluid retention within the body can happen due to a variety of reasons. Chronic inflammation, autoimmune disease,
cardiovascular disease, hormonal changes, menstrual cycles, and acute injury are all potential causes of fluid retention within
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the body. These factors can alter the cytokine chemicals emitted by white blood cells to regulate and facilitate healing of injured tissues. As fluid builds within a region, several items may result in the carpal tunnel region: Formation of ganglia cysts, increased edema causing pressure upon carpal tunnel structures, inflammatory responses, and the potential for blocked lymph nodes. Arthritis Arthritis refers to general inflammation in joint spaces. There are numerous types of arthritis, all of which ultimately weaken joint structures. As tension loads change and bones are unable to adapt adequately to new tension loads, neighboring boney structures also weaken. The top four types of arthritis linked with a considerable inflammatory response are: rheumatoid, gout, psoriatic, and arthritis that is linked to systemic lupus erythematosus (SLE). These conditions all result in targeted inflammation within joint Ergonomic factors Individuals who type on computers or who regularly use smart phones to complete work tasks are at higher risk for acquiring carpal tunnel syndrome. The angles and torque produced by using electronic devices is enough to shift carpal bones and place unnecessary stress on the carpal tunnel region structures. Some helpful ergonomic-friendly suggestions to provide to clients include: 1. Changing one’s desktop item arrangement every week to avoid repetitive motions in same direction with desk tasks. This includes the placement of one’s computer keyboard, monitor, desk pads, telephones, and décor. 2. Obtaining a standing desk set-up. Typically, the height of one’s keyboard is adjustable with the standing desk set-up. Further, a client may elect to stand or sit on an exercise ball to encourage healthier posture. 3. Obtaining a computer monitor screen that decreases glare: Not only will this reduce adverse effects of the monitor’s light on the eyes, it will ease myofascial stress of facial muscles, which in turn leads to the softening of myofascial tension of the neck and shoulders. The aggregate effect is then
Certain medications’ side effects contribute in increased fluid retention. These medications include drugs that contain estrogen, such as birth control and hormone replacement therapy, non-steroidal anti-inflammatory drugs (including aspirin, ibuprofen and naproxen), and beta-blockers used to treat heart arrythmias and tachycardia.
spaces. Rheumatoid arthritis and SLE are especially burdensome: These autoimmune diseases tax the body heavily, including bone and joint tissue structures. Anti-inflammatory pain relievers, corticosteroids, and disease- modifying treatments are medications used to treat arthritis conditions and may cause significant side effects that may negatively impact bone. If the carpal bones are affected, their smaller stature makes these bones more prone to fracture. experienced with freedom of myofascial tissue along the upper limbs. Usage of tools Machinery or fine-tool use may impact the arms and carpal regions tremendously. Vibrational tools, such as a massage vibrational device, will cause a consistent shock to bone and can weaken structures over prolonged periods of time. Tools that require dexterity, such as sewing needles and computer keypads, can also cause carpal bones to misalign due to repetitive stress on the joint structures. If one often uses these tools for his/her occupation, a healthy recommendation is to take breaks every 15 to 20 minutes. Tools are not limited to occupation: Recreational sports and hobbies may also include tool use. A golf club, for example, can have a similar impact on the body as a gardening tool—if it is used repetitively. The average golfer may take over 300 swings a day, which places tremendous torque factors on the wrist region. Golf gloves are designed to ease the burden; however, their impact is limited. Any golfer can eventually swing a club one too many times, causing injury—no matter how effective the gloves are in easing stress. and published in the May 2007 edition. It indicated frequency rates caused by numerous factors such as age, gender, pregnancy, and body mass index (BMI). This research piece was selected to fill this section because of the vast array of variables presented within this study. This broad perspective allows the learner to consider multiple factors of CTS epidemiology. a common causative mechanism of CTS is sleeping in a lateral position. Study findings include the following: ● Age: The development of CTS is related to age. Phalen reported the number of cases increased for each decade of age to 59 years, after which, the number of cases in each decade decreased. Atroshi et. al observed a similar age distribution with the highest prevalence of CTS in men of 45 to 54 years and in women of the age 55 to 64. Bland and Rudolfer found cases of CTS had a bimodal distribution for age with a peak of age 50 to 54 and a second peak of 75 to 84 years. Similarly, Mondelli et al reported “The age specific incidence for women increased gradually with age, reaching a peak between 50 and 59 years, after which it declined. In men, there was a bimodal distribution with peaks between 50 and 59 years and between 70 and 79 years.” ● Gender: Phalen noted in 1966 that the gender distribution was CTS was two-thirds to one-third female to male. The increased presentation of women with CTS was also noted
EPIDEMIOLOGY
Research published in the medical journal Hand , a publication of the American Association for Hand Surgery, provides great insight into the frequency of carpal tunnel syndrome. The study, entitled “Epidemiologic Associations of Carpal Tunnel Syndrome and Sleep Position: Is there a case for Causation” was conducted by McCabe, S., Uebele, A., Pihur, V., Rosales, R., and Atroshi, I., Abstract Carpal tunnel syndrome (CTS) is thought to be due to compression of the median nerve in the carpal tunnel. It is known that carpal tunnel pressures are elevated in wrist postures of flexion and extension in those patients with CTS. Classic symptoms of CTS include night waking with pain, tingling and numbness. These classic symptoms stimulated our interest in the relationship of sleep to the development of CTS. We reviewed the literature surrounding the epidemiology of CTS and the literature regarding sleep disturbances. Through careful distillation of these studies and a process of reasoning, we have developed a hypothesis for a casual mechanism of CTS. Epidemiologically, it has been shown that CTS is associated with age, gender, general body mass index (BMI), diabetes, pregnancy and is more common in some populations. The same associations noted above for CTS are strongly associated with sleep disturbances. Sleep disturbances due to age, gender, BMI, pregnancy and population variations are all associated with sleeping in the lateral position supporting the hypothesis that
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by Mondelli et al. with 79.7% of cases in women. Atroshi et al. found the male to female ratio to be 1: 1.4. Within women, using a nested case control design, Ferry et al. found associations with previous history of another musculoskeletal complain, past use of oral contraception, obesity and diabetes and myxedema. ● Age, gender and insomnia: There is extensive literature that links age and gender with sleep disturbances. Insomnia is more common in women and increases with age, increasing more in women than in men. Recently, Shepertycky has shown that women with obstructive sleep apnea often presented with complaints of insomnia. This suggests some of these women with insomnia may have also had obstructive sleep apnea. ● BMI: The associations of CTS with obesity or increased BMI have been noted and found repeatedly. Nordstrom et al. found the risk of CTS increased 8% for each unit increase of BMI (about 6 pounds). Nathan and Keniston summarized that being overweight, older and physically inactive are major risk factors for slowing of the median nerve and clinical CTS. Bland found some complexity in the relationship between age and obesity, and CTS. Bland found that “increased BMI is a significant independent risk factor for CTS in patients under the age of 63 but is less important in older patient” and further suggested that “CTS in the elderly population may have different underlying pathogenetic mechanisms.” BMI can be influenced by exercise and Nathan reported that people with CTS who embarked on an exercise program decreased body fat, BMI, sensory latency at the carpal tunnel and carpal tunnel symptoms. ● Age, gender, BMI and sleep disorders: Snoring and sleep apnea are known to be associated with age and BMI. Gislason et al. reported that 15.5% of Swedish men and 11.2% of Icelandic women reported habitual snoring. They reported an increase with age for men and women until the age of 60 years after which there was some decline in men. These authors found sleep apnea to be more common in older postmenopausal women than in men, but this specific finding is not typical. Most studies of snoring and sleep apnea find these problems to be related to age and in contrast to insomnia, more common in men. Snoring and obstructive sleep apnea increase with age in adulthood and decrease in the elderly. Men are affected more than women. Redline looked at age strata found that BMI > 28 kg/m2 (OR 11.7) and male gender (OR 12.2) are significant risk factors for sleep apnea in subjects aged 22 to 55 years but not younger or older. Through its influence on sleep position, sleep apnea may offer insight to the potential causal relationship of sleep disturbances and sleep positions related to CTS. ● Pregnancy: There is a general belief that CTS is associated with pregnancy. Padua reported that 59% of women in their eighth or ninth month of pregnancy complained of paresthesia in at least one hand (56% R, 45% L, 41% bilateral). Electrodiagnostic studies were consistent with CTS with 43%. The duration of symptoms was a mean of 3.4 months. Stolp-Smith noted 50% of CTS cases in pregnant women occurred in the third trimester. It is widely recognized that CTS will usually resolve after pregnancy. ● Pregnancy and sleep positions: The relationship of pregnancy and sleep position offers further evidence of the association of sleep positions to CTS. As noted above, CTS is common in the third trimester of pregnancy. Because of the enlarging uterus, clinicians recommend that pregnant women adopt a sleeping position on the left side. ● Populations: Nathan found the prevalence of probably and definite CTS much lower in Japanese compared to American populations but the prevalence of slowing of the median nerve to be similar. ● Sleep position related to a specific population: In our review, we were intrigued by a sleep disorder called “Sleep
Paralysis (SP) and Associated Hallucinations” because “it is widely believed that lying in the supine position is a proximate cause of SP.” We do not believe CTS is related to SP; however, research into SP has created some interesting information about sleep position. In one study of sleep positions of Japan and Canada, Fukuda found that 58.8% of Canadian university students and 32.4% of Japanese university students sleep on their side, whereas 40.5% of Japanese and 3.5% of Canadian students sleep on their back. ● Diabetes: Singh et al. wrote CTS occurs in 6-30% of individuals with Diabetes and in 2-3% of the general population. The prevalence increases with the duration of Diabetes. Those who had developed CTS had Diabetes longer than those who had not developed CTS. The calculated lifetime risk of CTS was 50% after 44 years and 85% after 54 years of having type 1 Diabetes. Becker et al showed that while Diabetes may be a significant risk factor for CTS in women, Diabetes only appears to be a risk factor for CTS when combined with BMI. ● Diabetes, obesity and sleep disturbance: According to the National Sleep Foundation’s survey, 11% of those who claim that sleep problems also have been diagnosed with Diabetes. Khuram et at concluded that Diabetes Mellitus (65%) and sleep disorders (35%) were obesity-related complications in subjects of age range 50 to 59 years. Sleep disturbances and insomnia are more common in Diabetics than in control groups. Skomro et al concluded that adult type 2 Diabetics had higher incidences of insomnia than control groups. Compounding the problem of reduced sleep in DM patients, Gottlieb et al. showed that a study of sleep restriction suggested a casual association between shortened sleep and impaired glucose tolerance. Sixty-four percent of the respondents to the 2005 Sleep in America Poll conducted by the National Sleep Foundation had a BMI < 25.0. These individuals were more likely to get less than 6 hours of sleep a night, experience insomnia and are at a higher risk for sleep apnea. BMI/obesity have been found to be predictors of heavy snoring. As elevated BMI/obesity is an elevated risk of sleep problems, in kind, it puts an individual at a higher risk of acquiring Diabetes. Obstructive sleep apnea is more common among Diabetic populations as heavy snoring can lead to “oxygen desaturation which increases catecholamine and cortisol levels, thereby increasing insulin resistance.” Snoring caused by obstructive sleep apnea, or sleep-disordered breathing has been found to elevate the risk of acquiring type II Diabetes. There is a high prevalence of insomnia in Diabetic hemodialysis patients. ● Shift work: Shift work and night work are probably the most severe precipitating factors of insomnia. Shift work is one of the leading circadian rhythm disorders causing insomnia. Roth and Roehrs suggest that shift work is one of the leading risk factors for developing insomnia. ● Arthritis: A number of studies have noted that sleep disturbances are a common problem in children with juvenile rheumatoid arthritis. In a study by Power et al., pain was determined to be a key mediator in the correlation between arthritis and sleep disturbances. Similarly, Ohayon found that arthritis as a chronic painful condition was a cause of major sleep disturbance. Nicassio and Wallston observed that RA appears to be a strong cause of sleep disturbance and that RA patients attributed their sleep problems to their arthritic pain more often than other stresses in their life. ● Hypothesis: We believe, after reviewing of the literature, that the associations of CTS have a common causative pathway through sleep position and can be best explained as resulting from a sleep position on the side causing the wrist position to be deviated into flexion or extension, compressing the median nerve in the carpal tunnel, and initiating the sequence of events resulting in CTS.
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NERVE ANATOMY
To better understand how carpal tunnel signs and symptoms manifest, a basic understanding of the anatomy and physiology of nerve tissue will aid our efforts. All nerves are composed of cells called neurons . Remember that a neuron is a single nerve cell; a nerve is a bundle of neurons wrapped together. All neurons have three components that regulate nerve signal conductivity and protect anatomical structure from damage. These three parts are depicted in Figure 3: 1. Cell body : The main portion of the cell that integrates electrical messages. Integration refers to the processing of the chemical pieces of the messages received. This portion contains the nucleus and the supporting cellular elements, which include Nissl bodies which are a site of protein synthesis within the cell body. A neuron damaged at the cell body will not regenerate. 2. Dendrite: An appendage-like portion that conveys an electrical message into the cell body. The terminal branches of an adjacent axon will communicate with neighboring dendrites. Dendrite receptors receive chemical messages; a polarity switch creates a conductive electrical signal to take these messages into the cell body. A neuron damaged at the dendrite will not regenerate. 3. Axon: The tail-like portion that conducts an electrical message away from the cell body. Polarity switches guide the chemical message, down the axonal branch and toward the terminal portion. Gateways on the synaptic terminals send out the chemical messages toward the adjacent tissues. Axons vary in length from a few millimeters in the brain to several inches in the upper and lower limbs. Figure 3: Three Parts of the Neuron The axons of myelinated neuronal tissue are covered by a lipid-based structure called the myelin sheath . This sheath is a protective wrapping that conducts electrical signals properly and prevents damage due to compression or tension forces. A neuron damaged at the axon with preservation of the cell body may slowly regenerate, approximately a millimeter per month. Nervous tissue may be either gray or white. Gray nervous tissue is unmyelinated, which means it is lacking a myelin protective sheath. White nervous tissue is myelinated, and possesses a myelin protective sheath. Nervous tissues are gray or white, depending on the presence of Schwann cells, or neurolemmocytes. Notches within the white myelinated tissue – called the Nodes of Ranvier (also called nerve fiber nodes ) – will expedite nerve signals by facilitating a “trap door” mechanism by which signals may skip entire axonal segments. The opening of one “trap door” notch allows for a signal to temporarily leave the axon. It is still retained by the endoneurium tissue, however, until it enters a distal “trap door” notch of the axon before its terminal portion. Nerves are composed of connective tissue as well: These tissues both bind neurons into bundles and surround individual neurons. Epineurium, a dense connective tissue, wraps an entire nerve. Perineurium, also a dense connective tissue, segments neuron cells into bundles (called fasciculi ) within the nerve. Endoneurium is a loose connective tissue that surrounds individual neurons.
Figure 4: Nerve Tissue
This connective tissue arrangement mirrors the same connective tissue orientation of muscle: Epimysium a dense connective tissue wrapping that surrounds an entire individual muscle. Perimysium is a dense connective tissue that segments muscle cells into bundles, called fasciculi , within the muscle. Endomysium is a loose connective tissue that surrounds individual muscle fibers. Highlighting this similarity allows one to more easily learn the common language of anatomy. The prefix “epi” implies the top of an entire structure; “peri” means surrounding a portion bundle. Further, “endo” implies units within a structure. Nerves are classified by functionality: 1. Sensory: Sensory nerves conduct electrochemical neural signals from the peripheral nerves into the central nervous system (brain and spinal cord). 2. Motor: Motor nerves conduct electrochemical neural signals from the central nervous system toward the peripheral nerves. 3. Mixed: Mixed nerves carry both sensory and motor neurons. Compartment units may send messages both toward and away from the central nervous system. Nerve conductivity occurs by two processes: The slower process occurs in gray nervous tissue and allows nerve conduction at a rate of 5 to 10 miles per hour. The faster process, called saltatory conduction, occurs only in white nervous tissue. Saltatory conduction is a highly efficient function and conducts messages quickly throughout the body. Messages may travel up to 250 miles per hour within myelinated tissue. Neuronal speeds attributed to Structure and Function of Human Anatomy, Steiner Education Group. Spinal nerves that emanate from spinal column bones C4 through T1 will innervate the superior limbs. These nerves stem from the inferior portion of the brachial plexus – a bundle of nerves innervating musculature of the superior limb and upper torso. As illustrated in Figure 5, the median nerve is a convergence of the lateral and medial cords of the brachial plexus unit. Nerve signal interference along either the lateral and/or medial cord pathways can cause intermittent disruptions of signals along the median nerve. This interference can be witnessed along the spinal column or along the tracks of nerve traveling through the axilla, as well as along the anterior superior limb. Here are a few mnemonics students may use to learn the subdivisions associated with the brachial plexus:* ● “Read that Dastardly Cadaver Book.” ● “Rugby Teams Drink Cold Beer.” ● “Reach to Drink Cold Beer.” *(R = Roots; T = Trunks; D = Divisions; C = Cords; B = Branches.) Branching from the brachial plexus, the median nerve descends distally within the superior limb bilaterally. The median nerve initially travels lateral to the brachial artery that crosses medially just proximal to the elbow (cubital fossa) region. This nerve innervates the following muscles: ● Pronator teres. ● Flexor carpi radialis.
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Book Code: MLA1224
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● Palmaris longus. ● Flexor digitorum superficialis. ● Flexor digitorum profundus. ● Flexor pollicis longus. ● Pronator quadratus. ● Thenar musculature. ● First and second lumbrical muscles.
When the median nerve travels through the carpal tunnel arch, the nerve splits into two other branches: The recurrent branch, which innervates the four thenar muscles, and the palmar digital branch , which innervates the palmar surface and fingertips of the lateral three and half digits, as well as the lateral two lumbrical muscle units. Figure 5: Spinal Nerves
The mnemonic “LOAF” helps one remember innervation of the hand supplied by the median nerve: L = lumbricals 1 and 2; O = opponens pollicis; A = abductor pollicis brevis; F = flexor pollicis brevis. Further dissecting the median nerve, we observe as this nerve travels between the flexor digitorum profundus and the flexor digitorum superficialis muscles. This branches into two main segments: The anterior interosseous nerve , which supplies the deeper anterior antebrachial muscles, and the palmar cutaneous nerve , which supplies the skin of the middle and lateral palm. Anomalies of the median nerve On occasion, rare anomalies may be witnessed in cadavers. Some of these occurrences that affect the median nerve structure include: ● Riche-Cannieu anastomoses : Which result in a connection between the recurrent branch of the median nerve and the deep branch of the ulnar nerve within the hand. ● Martin-Gruber anastomoses : Which result when median nerve branches cross each other in the antebrachium merging with the ulnar nerve, causing sensory and motor abnormalities in the anterior antebrachium. ● An extra artery, called the median artery : May remain present upon birth. This creates an extra artery in the antebrachium and the hand. ● The median nerve : May bifurcate proximal to the carpal tunnel and/or carpal bones, rather than after exiting the carpal tunnel itself.
Hilton’s Law states that a nerve that innervates a muscle will also supply the skin, adjacent joints, and the surrounding tissues with nervous signals. This law is important to understand for several reasons: First, knowing that the adjacent joint to a muscle is affected indicates that the musculotendon load at the neighboring joint region will likely carry additional stress with the injured nerve and muscle tissues, thus leading to strain injuries. Second, CTS may not initially be experienced with obvious pain, tingling, or weakness typical of CTS; rather, vague skin sensations may initially be experienced. These sensations can clue a practitioner toward a CTS diagnosis. Third, if one presents with CTS symptoms (not merely the wrist), all joints within a region may need to be examined. This significant anatomical law, defined by John Hilton in 1860, demonstrates a key understanding about how one may interact with the nervous system in the care of neurological conditions such as CTS.
SIGNS AND SYMPTOMS
Major signs and symptoms of carpal tunnel syndrome include these prominently witnessed phenomena: 1. Atrophy of the thenar muscles. There are four thenar muscles, located at the radial (thumb) side of the hand. When one presses his/her thumb next to the index finger, the thenar muscles create a bulge in this region. 2. The four thenar muscles are the abductor pollicis brevis, the flexor pollicis brevis, the opponens pollicis, and the adductor pollicis muscles. The term “pollicis” refers to the thumb: ○ Abductor pollicis brevis pulls the thumb away from the palm in a lateral manner. ○ Flexor pollicis brevis pulls the thumb away from the palm in an anterior manner. ○ Opponens pollicis pulls the thumb toward the other digits. ○ Adductor pollicis pulls the thumb back toward the palm. 3. If the hypothenar muscles are located at the ulnar (pinky) side of the hand atrophy, this indicates Guyon’s canal syndrome – an impingement of the ulnar nerve. Diagnostic features 1. Compression of the anterior wrist, recreating the symptoms: ○ Compression does not need to be deep; as little as one pound of pressure is enough to illicit a neurological or a pain response. 2. Examination of the wrist circumference itself. If wrist circumference is less than six inches, one is more at risk of acquiring CTS.
4. Tingling, numbness of first 3½ digits (thumb, index, middle and radial half of ring fingers): This is often referred to as paresthesia , a “pins and needles” sensation, and may often accompany the tingling and numbness experience by CTS patients. 5. Pain in the wrist and hand: This pain usually worsens when the wrist is brought into a flexed (bent) position. It is experienced by a sharp, shooting pain radiating through the antebrachium. Chronic pain becomes nuanced as treatments and self-care become less effective or if the condition worsens over time. 6. Loss of gripping and/or pinching strength: Lifting, carrying, and moving objects becomes more challenging as hand strength weakens over time. Supportive wrist guards become a useful tool for the patient to supplement his/her lost strength. 7. Interference with sleep: The paresthesia and similar sensations experienced often wake up patients several times per night. The lack of sleep creates a secondary list of health challenges and occupational concerns. 3. X-rays that determine inflammation or structural damage to carpal bones can be a powerful diagnostic tool. 4. Electromyogram tests will determine muscular activity within a region. Improper nerve supply causes the muscles to atrophy and the activity to diminish. 5. A nerve conduction study to determine electrical impulse flow through the wrist: This exam, combined with prior mentioned diagnostic tools, can become a powerful measure for CTS potential, as well as current diagnosis.
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Book Code: MLA1224
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Economic impact The economic impact of carpal tunnel syndrome has been measured and researched by numerous organizations in recent decades. Impacts differ based on demographic and psychogenic factors, yet carpal tunnel syndrome has conclusively been found to negatively affect economies. Washington State’s Department of Labor & Industries tracked the loss of earnings of CTS sufferers using time-loss claims, from 1993 to 1994, and for six years following their claims. These individuals were compared to two other groups from the same time frame: workers with medical-only claim for dermatitis and workers with time-loss claims for fractures of the antebrachium and manus bones. Results of this study indicated that a typical CTS claimant is expected to lose an alarming $52,326 or more over the six-year period than the group with fractures, and $82,776 more than the
group with dermatitis. This study demonstrates the long-term negative ramifications of acquiring carpal tunnel syndrome. Hindawi’s online resource on sleep disorders (published in 2014) studied a correlation of sleep disorders amongst carpal tunnel patients. Measuring results via the Levine-Katz Carpal Tunnel and Pittsburgh Sleep Quality Index (PSQI) questionnaires, 66 CTS patients were tracked in three adult age ranges for at least 11 months. Results indicated that CTS patients slept 2.5 hours less than recommended for their respective age ranges and were more at risk for comorbid conditions. CTS patients consistently reported awakening on multiple occasions due to paresthesia and similar phenomena. Malalignment of the wrist joint (caused by various sleeping positions) is said to create these sensations. Patients with other sleep-related disorders, including sleep apnea, were excluded from the study to aid in data clarity.
CURRENT RESEARCH FINDINGS
There are numerous research studies that indicate the efficiency of massage therapy techniques to aid carpal tunnel patients. We will explore the many studies involving massage therapy’s effectiveness with this condition. These research items are adapted from searches using the government’s primary health resource database: pubmed.gov There are many reasons to emphasize research findings with massage therapy efforts: First, showcasing research that indicates the effectiveness of treatment validates anecdotal claims of massage therapy’s benefits. Second, highlighting research also aids therapists in persuading insurance companies to include massage therapy as a covered treatment. Third, the medical community will respect legitimate research when considering massage therapy as a viable treatment endorsement option. Finally, the public will view massage therapy as a legitimate allopathic means of health care when research confirms proposed benefits. “Massage Therapy as an Effective Treatment for Carpal Tunnel”; Elliot, R., Burkett, B.; Journal of Bodywork and Movement Therapies, July 2013. Abstract Carpal tunnel syndrome is a common peripheral entrapment that causes neuralgia in the median nerve distribution of the hand. The primary aid of this study was to evaluate the efficacy of massage therapy as a treatment for carpal tunnel syndrome. Within this process, the locations of trigger points that refer neuropathy to the hand were identified. The creation of massage pressure tables provides a means of treatment reproducibility. Twenty-one participants received 30 minutes of massage twice a week for six weeks. Carpal tunnel questionnaires, the Phalen, Tinel and two-point discrimination tests provided outcome assessment. The results demonstration significant (p<0.001) change in symptom severity and functional status from two weeks. Based on this study, the combination of massage and trigger point therapy is a viable treatment option for carpal tunnel syndrome and offers a new treatment approach. “Reliability and Efficacy of the new Massage Technique on the Treatment in the Patients with Carpal Tunnel Syndrome”; Madenci, E., Altindaq O., Yilmaz M., Gur A.; Rheumatology International, October 2012. Abstract We aimed to bring a more understandable and application technique to the literature instead of “massage therapy” in Carpal Tunnel Syndrome (CTS). We compared our technique with the splint wear, of which the efficacy in CTS has been proven in many studies. Eighty-four patients between 31 and 65 years of age were included in the study. The patients were divided into two equal groups. In the first group, split and “Madenci” hand massage technique were applied, and in the second group only split was applied. The splint was provided for all patients with tendon and nerve gliding exercises, and
also when needed analgesic drugs were given. When the pretreatment and posttreatment parameters were compared via repetitive measurement analysis, it was found that PGA and MDPGA were significantly decreased in both groups (P = 0.001), whereas grip strength was significantly increased (P = 0.001). While no statistically significant different was found between the groups regarding pretreatment values (P > 0.05), the post treatment PGS, MDPGA and grip strength scores significantly improved in Group 1 compared to Group II (P < 0.05). To the best of our knowledge, the present study is the first and largest study in the literature conducted on the massage technique that will contribute to the treatment of CTS. As this new massage technique is easy for self-application, cheap and practical, every patient with CTS can apply the massage to him/herself easily. “Response of Pain Intensity to Soft Tissue Mobilization and Neurodynamic Technique: A series of 18 patients with chronic Carpal Tunnel Syndrome”; De La Llave-Rincon, A., Ortega-Santiago, R., Ambite-Quesada, S., Gil-Crujera, A., Puentedura, EJ., Valenza, MC., Fernandez De Las Penas, C.; Journal of Manipulative Physiology Therapy, July 2012. Abstract The purpose of this prospective case series was to examine the combined effects of soft tissue mobilization and nerve slider neurodynamic technique on pain and pressure sensitivity in women with Carpal Tunnel Syndrome (CTS). Eighteen women with a clinical and electromyographic diagnosis of CTS participated. Patients completed the numerical pain rating scale (NPRS) for current, worst and lowest pain intensity and underwent pain pressure threshold (PPT) testing over the median, radial and ulnar nerves; the c5-c6 zygapophyseal joint; the carpal tunnel; and the Tibialis Anterior muscle. Pain was assessed at baseline and 1 week follow up, whereas PPT were assessed at baseline and immediately after and 1 week after intervention. Each received soft tissue mobilization and nerve slider neurodynamic technique directed at different anatomical sites of potential entrapment of the median nerve. A decrease in the mean current intensity and worst level of hand pain (P < 0.01) was found 1 week after treatment. A treatment effects for PPT levels over the c5-c6 zygapophyseal joint (P < 0.01) was found: PPT increased bilaterally 1 week after intervention. No other significant changes in PPT levels were found (P > 0.195). The application of soft tissue mobilization and neurodynamic technique decreased the intensity of pain but did not change pressure pain sensitivity in this group of women with chronic CTS. “Massage Therapy Plus Topical Analgesic is more Effective than Massage alone for Hand Arthritis Pain”; Field, T., Diego M., Solien-Wolfe, L.; Journal of Bodywork and Movement Therapy, July 2014.
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Book Code: MLA1224
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