Field, T., Diego, Miguel, Cullen, Christy, Hartshorn, Kristin, Gruskin, Alan, Hernandez-Reif, Maria, Sunshine, William. (2004).

Carpal tunnel syndrome symptoms are lessened following massage therapy. Journal of Bodywork and Movement Therapies, 8, 9-14.
BACKGROUND
median nerve innervation is dark gray

The Touch Research Institute in Miami, FL has done a tremendous amount of work to investigate the physiological effects of massage therapy. Yet, only a few of the studies from the TRI have focused on the effects of massage in addressing orthopedic disorders. This study should help pave the way for further investigations into the effectiveness of massage in treating a number of nerve compression pathologies. Carpal tunnel syndrome (CTS) is a nerve compression problem that has expanded to epidemic proportions. Due to repetitive occupational activities, and especially the advent of the computer, the incidence of this condition is dramatically increasing. It is characterized by pain, numbness, and/or tingling in the median nerve distribution of the hand (see Figure 5). In more severe cases weakness in grip strength may be noticed as motor fibers are affected. The carpal tunnel is the space in the wrist (actually at the base of the hand) that is bounded by the carpal bones and the transverse carpal ligament. The transverse carpal ligament (TCL) is sometimes referred to as the flexor retinaculum. The TCL attaches to the pisiform and hamate on the medial side of the wrist and then spans the tunnel to connect with the trapezium and scaphoid on the lateral side (see Figure 6). There are nine tendons, including synovial sheaths, and the median nerve that travel through the carpal tunnel. The median nerve is the most superficial structure traveling through the tunnel and is therefore likely to get compressed against the TCL in this condition. Compression of the median nerve in the tunnel will produce the characteristic symptoms of CTS. If the compression is not severe, the person can recover full, pain-free function once the damaged nerve tissue has healed. However, if the compressive forces on the median nerve are not relieved, severe and irreversible damage can occur. A number of medical interventions are currently used to treat CTS. Wrist splints are one of the most common with the idea being that holding the wrist in a neutral position will allow less compressive force on the median nerve and allow for healing of the nerve to take place. Other commonly used treatment procedures include stretching, non-steroidal anti-inflammatory drugs (NSAIDS), and corticosteroid injections. If these conservative measures are not effective, surgical treatment is performed. Surgical treatment usually consists of a procedure aimed at cutting the transverse carpal ligament in order to decrease its compression of the median nerve. While a number of these treatment approaches have been studied in the literature, none have proven to be highly effective in treating the problem. Very few alternative treatments have been studied and this is the first clinical study I am aware of that has looked specifically at massage therapy being used for treatment of carpal tunnel syndrome.

Figure 5 Median nerve distribution in the hand

Mediclip image copyright (1998) Williams & Wilkins. All Rights Reserved.

transverse carpal ligament Figure 6 The span of the transverse carpal ligament (exor retinaculum)
Image Courtesy of Primal Pictures, Inc. (London)

In this study 16 participants with a confirmed diagnosis of CTS were identified. All of them engaged in work that involved significant time at the computer as well. The diagnosis of CTS was based on symptom complaints, as well as a positive Phalens test and Tinel sign at the wrist. Electrodiagnostic testing was not used in the diagnosis because it is not considered a reliable means of determining the presence of a nerve compression syndrome in this region. The participants were divided into two groups. One group received the massage treatment while the other group did not. Several criteria were set up to identify the differences in improvement of the CTS between the two groups. The massage treatment consisted of moderate stroking techniques from the fingertip to elbow region. The technique was described as stroking the wrist up to the elbow and back down on both sides of the forearm. No further elaboration of the technique was given. After that another technique was described as a wringing motion applied to the same area. This was most likely describing petrissage-type techniques. Two more techniques were described as part of the massage process. The first was stroking using the thumb and forefinger in a circular back-and-forth motion covering the entire forearm and hand. The final technique described was rolling the skin between the thumb and forefinger across the hand and up both sides of the forearm. The massage treatment was done once a week for a 4-week period and the participants in the massage group were also taught self-massage techniques that were to be done at home just before they went to bed. In order to identify if there were any significant changes resulting from the massage intervention, all participants, both the control and treatment group, were assessed by a physician prior to receiving any treatment as well as after the 4 treatment sessions had concluded. Each subject was assessed based on four criteria: A) carpal tunnel symptoms; B) the Tinels sign; C) the Phalens test; and D) a nerve conduction test. Following the treatments each participant was asked to assess their condition according to four different criteria: grip strength, pain, anxiety, and depression. Anxiety and pain are often correlated with various pain and injury conditions and that is why they were evaluated in this study. Each of these criteria was evaluated using a self-reporting survey tool filled out by the subjects at the end of the study. There were greater improvements in the massage group as compared to the control group in a number of different categories. The massage group showed fewer carpal tunnel symptoms as well as improvement on the nerve conduction test. Improvement was also noted when the Phalens test was performed post treatment. In addition, improvement was also noted in functional activities, as there was a decrease in pain and an increase in grip strength. The findings from this study indicate that massage therapy is effective in reducing pain and improving various symptoms of carpal tunnel syndrome. Now it will be important to isolate which aspects of the treatment were most important in achieving these effects. For example, was the treatment effective because of the specific techniques that

FINDINGS AND DISCUSSION

were used or was it primarily that one group got some type of structured touch while the other group got none. The authors mention that future studies should investigate alternative control groups to look at these questions. Several possible explanations were presented as to why massage may be effective in managing the pain sensations associated with this condition. It has been suggested that the gate theory of pain may explain some of these effects. According to this theory, the larger, more myelinated nerve fibers associated with the pressure receptors, close the gate on signals from the smaller fibers associated with the pain receptors. In addition, there is some suggestion that massage may increase the secretion of various pain-relieving neurotransmitters such as serotonin and oxytocin. While it wasnt mentioned in the study, I think it is important to consider the role of massage in reduction of hypertonicity of the forearm flexor muscles. A decrease in hypertonicity in these muscles may reduce tensile loads on the tendons and subsequent irritation of structures traveling through the carpal tunnel. It is certainly beneficial that massage therapy has demonstrated effectiveness in treating this problem. Yet, there are other factors that need further investigation. For example, the authors state that the massage was administered by a therapist but there is no other description of who performed the treatment. Was this a trained massage therapist or was it some other therapist that also does massage - i.e. physical therapist or occupational therapist? There is also no mention of whether all the massage treatment was performed by one individual or by multiple therapists doing the same treatment. This is an important question to ask, as it is necessary to determine if the treatment effects resulted from the characteristics of one individual, or from numerous practitioners performing the same treatment techniques. As we see more studies like this it is tempting to immediately jump on the bandwagon and further hail the great results that massage can produce. However, it is also important to temper our excitement and look at the specifics of the study in detail and see what else we might learn from the way the study was constructed or performed. It is exceptionally difficult, if not impossible, to design a study that is completely free from confounding variables and clearly isolates only the treatment intervention without the influence of any other factors. In order to gain our best clinical understanding of these problems and how to address them with massage, we need to replicate studies like this under different circumstances so we can best understand the physiological rationale of our treatment interventions.