Episode 138 – Carpal Tunnel Crash Course (with Whitney Lowe & Til Luchau)

Summary

Episode Transcript

 

Whitney Lowe:  Welcome to the Thinking Practitioner podcast. 

Til Luchau: A podcast where we dig into the fascinating issues, conditions, and quandaries in the massage and manual therapy world today. 

Whitney Lowe: I’m Whitney Lowe, 

Til Luchau: and I’m Til Luchau.

Whitney Lowe:  Welcome to the Thinking Practitioner. And welcome to the Thinking Practitioner, where Books of Discovery has been a part of the massage therapy and bodywork world for over 25 years.

Nearly 3, 000 schools around the globe teach with their textbooks. e-textbooks and digital learning resources. Books of Discovery likes to say that learning adventures start here and they find that same spirit here on the Thinking Practitioner Podcast and are proud to support our work, knowing that we share the mission to bring the massage and bodywork community thought-provoking and enlivening content that advances our profession.

Til Luchau: Instructors of manual therapy education programs can request complimentary copies of books of Discovery’s textbooks for review for use in their programs. Please reach out to them at booksofdiscovery.com.  Listeners like you can explore their collection of learning resources for anatomy, physiology, pathology, kinesiology, ethics, and business mastery at booksofdiscovery.com, where Thinking Practitioner listeners save 15% by entering “thinking” Hello, Whitney. 

Whitney Lowe: Good afternoon, sir. How are you doing today? 

Til Luchau: I’m good thanks. We’re going to talk about an interesting topic today. And it’s common. And I gotta say, in some ways, it’s low-hanging fruit because, it’s so common and because there is a lot we can do. 

Whitney Lowe: Yeah. I was looking at this and thinking like, how are we five seasons into this podcast and we’ve never talked about this topic before on our podcast? I don’t think that was odd.

Til Luchau: That is odd. It was, yeah, it’s it’s like I said, it’s pretty common, there’s things we can do and it’s a good one to explore, so I look forward to jumping into the topic, which is carpal tunnel symptoms or carpal tunnel syndrome. 

Whitney Lowe: Yeah. What do you want to 

Til Luchau: tell us about it to start us off?

Whitney Lowe: Let’s just go over the basics first. Just so that we’re all on the same page on what are we talking about here. Of course, there is an anatomical space in the wrist we refer to as the carpal tunnel. Created by the carpal bones, carving out a convex, concave kind of shape and then over the top of them, a connective tissue band we refer to as the flexor retinaculum.

And then that creates a tunnel through which we have about nine flexor tendons. I think it’s nine, is that correct? Nine flexor tendons that are traveling through that carpal tunnel along with the median nerve. And that’s the primary problem, is compression of that nerve as it travels through that tunnel in the wrist.

Til Luchau: And what are risk factors? How can we as practitioners identify when this might be going on for our clients? 

Whitney Lowe: Yeah, so most people are aware of carpal tunnel syndrome occurs as a repetitive overuse injury, or something that’s caused by [00:03:00] some repetitive compression of the nerve mechanically, and that can happen by constantly using the finger flexors that we’re using. Again, carpal tunnel syndrome got so much popularity in the last several decades because of the automation that’s happened in the workplace with an extensive amount of computer work, typing automation in industrial sectors where people are doing small precision work with their fingers and hands repeatedly over and over for hours and hours on end.

Those things can cause inflammatory reactions in the tendons and tendon sheaths of those tendons that travel through the tunnel and then of course that puts compression on the median nerve. And also, I think there’s too chemical irritation of that nerve from the inflammatory chemicals that are around there as well.

That doesn’t get talked about as much, but I think that’s a factor. 

Til Luchau: There’s a debate about back pain being, is it all, or sciatic pain, let’s say. Is sciatic pain always due to compression [00:04:00] forces, or could it just be it’s proximity to inflamed structures without a mechanical compression? And I would be surprised if that’s not the case for carpal tunnel as well, because a lot of people will see their carpal tunnel symptoms rise and fall maybe, along with their other inflammatory load or inflammatory activity. 

Whitney Lowe: And there are genetic anatomical factors that make people somewhat more susceptible to this than others. And this doesn’t get I see this in the literature a lot, but I ran across this decades ago, a study about the shape of the wrist in relation to the frequency that people develop carpal tunnel syndrome.

Apparently when you have a square-shaped wrist, meaning the depth, which makes sense, the depth of that tunnel gets a little deeper if your wrist is more like it, when I say the shape of the wrist, I’m talking about if you took a cross- section of the wrist right at the base of the carpal tunnel there at the base of the hand, took a cross-section of it and looked at it, the more oval and flattened out it is, the more likely you are to develop carpal tunnel.[00:05:00] 

The more square shaped and larger that oval is, then the less you are likely to develop those symptoms. And again, that just makes sense because there’s a bit more space in there. 

Til Luchau: And then my personal legacy or heritage as a structurally based practitioner, that’s how we originally would approach it, treat carpal tunnel symptoms to look to increase rather the depth of that tunnel to look at opening up the backside of the wrist and there seemed to be, at least in my experience, a good success rate for that approach of just letting the backside or the volar side, not the palm side, opening up that backside of theirs and making sure it’s mobile and that those bones have a place to go.

Whitney Lowe:  What do you think about that? ‘Cause I know it’s been debated a bit in terms of treatment processes. Can we move or shape or change the structural positioning of those bones basically in the wrist and 

Til Luchau: hand? I think in [00:06:00] some cases, yes, just anecdotally, I’ll, I think it would be hard to research and prove that.

I think more often we can change their adaptability, their willingness to move, either that’s the nervous system’s control of those bones, so it doesn’t keep them as stiff, or maybe it’s a tissue effect, but I think we can increase mobility quite a bit. For sure we can increase and shift and change body awareness and the sensation part of that.

Yeah. So just giving somebody a greater awareness, for example, of the back of their wrist might open things up and movement possibilities. I’m just speculating here. 

Yeah. 

Til Luchau: Maybe we’re altering someone’s ideomotor body map more than we’re altering the ligaments between their bones. But in any case, there seems to be that model of getting space in one example. Getting space in the back of the wrist does seem to help a lot of people with their symptoms. And there are some fun exercises with balls and movement and things like that I detail in, I think it’s [00:07:00] volume one of my Advanced Myofascial Techniques that give some ideas for that. Yeah. Did we cover the risk factors you wanted to cover?

Whitney Lowe: We yeah, we talked about repetitive motion disorders, and there’s a few other things too. There’s something referred to as gestational carpal tunnel syndrome, which is gestational? Yeah, there’s carpal tunnel syndrome as a condition, increases frequently during pregnancy just because increased fluid content, fluid retention in the wrist.

Again, anything taking up more space in there is likely to be contributing to that. And so I think those are definitely potential risk factors as are, other kinds of things that might be systemic nerve irritants. There are metabolic factors, like that as well. 

Til Luchau: But yeah, back to gestational for a second, there’s also hormonal differences that change inflammatory reactions and change ligamentous laxity.

Yeah. 

Til Luchau: And so maybe there’s more physical compression and more reactivity, but there’s a lot more sciatic pain in pregnancy, so it only makes sense that there’s more median [00:08:00] nerve or carpal tunnel pain. 

Whitney Lowe: Yeah. Yeah. These are certainly are major kind of risk factors of things that we would want to be trying to uncover in our client history as much as possible.

Til Luchau: Do you think it’s important that we, or how important do you think it is that we get really specific around, say, differential diagnosis? Do you pay attention to what parts of the hand, or how do you tease that apart? I think 

Whitney Lowe: that’s absolutely crucial because I have clinically seen lots of people come in and say they’ve been told they have carpal tunnel syndrome and start asking some questions and find out the distribution of their nerve sensations in their hand is actually in the ulnar nerve distribution, not the median nerve, and so which 

Til Luchau: should be more the little finger side 

Whitney Lowe: of the little finger side of the hand. Yeah, the ulnar aspect of the hand. And then, of course, for me, my treatment is going to be different for those two different types of things in terms of how I’m going to try to encourage freedom of mobility of those nerve structures that might be impaired, etc.

Or where else, might there be [00:09:00] potential problems? Because a lot of times something like carpal tunnel syndrome occurs because there are other nerve compressions along the pathway of that nerve somewhere between its starting point at the nerve roots and then where the carpal tunnel is. And there’s multiple locations where the median nerve may potentially get compressed along that route.

And if it’s compressed at some of those other locations, it might, it makes it more sensitive to compression at the carpal tunnel. 

Til Luchau: And do you have specific questions? You mentioned that. 

Whitney Lowe: Yeah. A lot of this is going to be both questions and then provocative positioning and provocative tests that we’ll try to see does this make it worse?

Does this make it worse? Does that make it worse? What does it, do you have problems? Does it come on at night? Does it make, or is it worse when you’re sleeping? All those kinds of things that we try to narrow down. Where that might be involved. 

Til Luchau: Could you give us one or two of those specifics?  I bet there’s a lot of them, but yeah 

Whitney Lowe: examples. Yeah, so sleeping’s a big one I just mentioned that when you know night pain is common for people who have carpal [00:10:00] tunnel problems this is a good example Because people tend to sleep with their wrists curled into flexion without realizing it a lot That’s one of the things that increases the carpal tunnel compression and one of the very common Conditions that this is mistaken for is compression of the median nerve in the forearm by the pronator teres muscle and the symptoms can be almost identical, but pronator teres compression is generally not aggravated during night sleep because you’re not doing anything to further compress that nerve in that location there.

But again, you may have compression in both locations simultaneously and then that will potentially contribute to it. So in terms of 

Til Luchau: specific questions, you might ask, is it worse at night or when you wake up in the morning? Yeah. And if it was, you’d think, okay, maybe carpal tunnel. If it wasn’t, you’d think, okay, pronator syndrome could be.

And then 

Whitney Lowe: there’s always. Tell me or show me something that makes it worse. What are the things that really aggravate it, and so looking at that in [00:11:00] positions that might be Potentially involved and then you know, you can simply do a lot of your physical examination with palpation of compressing locations where the median nerve is vulnerable to compression seeing if any of those are particularly tender sensitive or Reproducing those kind of sensations.

Til Luchau: That’s my I like that a lot because that’s a lot of my approach I spent This is one of the first courses I developed many years ago for my audience, and I got very specific. In fact, hey, I think this is how you and I met. Maybe it was carpal tunnel, maybe it was thrusting outlet. But I wrote you, you had an article out about one of these topics.

This is, 

Whitney Lowe: you’re ringing a bell, yeah. 

Til Luchau: Yeah, and this was probably the 90s or something, and I said, hey, you guys, great article, Whitney, could I use it in my trainings? And you said, yeah, absolutely. But anyway. That’s putting piecing this together. I was very specific about the tests people could use and spent a bunch of time with that.

And then as I ran it a few times and saw how people [00:12:00] were using it, I steered more and more toward an empirical approach of the treatment as the assessment. Let’s see if we can, start with the same questions. What makes it worse? What makes it better? Let’s see if we can do something with our hands that also either provoke it or relieve it.

And going through the pathways that way. 

Whitney Lowe: Yeah. 

Til Luchau: Yeah. 

Whitney Lowe: And there’s some other important kinds of questions that I like to ask in terms of clarifying the nature of this problem. For example, there’s a unique aspect of anatomical physiology with the median nerve. And this is true of all of our nerves basically the nerve fibers within the large bundle of the nerve itself are wavy and a little bit slackened to allow them to be able to get pulled when that nerve gets fully stretched and then they get pulled taut. But that also 

Til Luchau: they’re crimped a little bit to allow for our arm movement and the length changes.

Yeah, exactly. 

Whitney Lowe: And so What that means is that they’re going to be at low, different locations throughout the [00:13:00] nerve, but when they get near the carpal tunnel, this is in the median nerve in particular, the distribution of the fibers inside the nerve have a particular pattern that plays out in symptom recognition.

For example, remember the median nerve is a mixed  motor and sensory nerves. So it’s got motor fibers and sensory fibers in there, but the sensory fibers tend to be distributed closer to the periphery of the nerve than the motor fibers are. Motor fibers tend to be closer to the center of the nerve. This is at least in the location near the carpal tunnel.

Consequently, Most people with carpal tunnel syndrome will get sensory symptoms first. The pins and needles, the numbness, the tingling sensations in the hand. And then, later on, as that condition progresses or it gets much worse, then you start to see symptoms like loss of grip strength, difficulty with coordination, things like that.

When you’re asking muscle wasting. Muscle wasting, exactly. When you’re asking questions about this, try to establish do they have any of those motor symptoms yet? And if [00:14:00] not, this might just be indicating the earlier stages where compression is mostly impacting sensory fibers and not the motor fibers.

Til Luchau: Fascinating. I’m learning. I knew I’d learned a bunch, but I’m learning something right here. Yeah. I, I’d heard about the sensory effects first in severity, and then in an argument for being fairly active and aggressive at that point about trying to relieve things or change habits or something 

to 

Til Luchau: prevent the motor symptoms, which I learned as a symptom of demyelization of the nerve damage.

Yeah. From the reduced perfusion or nutrition they get in the compressed state. 

Whitney Lowe: Yeah. Yeah. So those are things that are indicating severity, important questions I think to ask. 

Til Luchau: Interestingly, in sciatic pain, it’s not a mixed motor and sensory nerve, and so the people don’t typically, there’s not as much motor, at least, so people don’t typically have as many motor symptoms, but they do come more in crippled tone than some others as well.

[00:15:00] Yeah, for sure. Is it how does soft tissue work address? Carpal tunnel and how, what are the primary things we can think about or goals for our work? 

Whitney Lowe: Yeah, this is what I wanted to talk with you about and see like where we are on our sort of approaches about this. Because there’s a lot of different kinds of thoughts about this.

Yes. For me, I always start with what’s the real nature of this problem? And with a nerve problem, there really isn’t much I think that we can do for the nerve disorder itself. It’s not like we’re going to massage the median nerve and make it better. 

Til Luchau: Huh. 

Whitney Lowe: Because the problem is nerve compression. So anything that puts more pressure on the nerve is going to be potentially problematic over the long haul.

So just on 

Til Luchau: the most facile interpretation then, we’re not going to Get their thumbs and just start scrubbing and pressing on someone’s wrist because it hurts. I’m not going to have to work on pressure. That’s a fact 

Whitney Lowe: of pain provocation test to make sure that you have carpal tunnel [00:16:00] syndrome.

So let’s don’t do that. But I will say I’ve found this really fascinating. I ran across an article, this was many years ago, probably late mid to mid-90s to late-90s or something like that, about a technique that was described as a myofascial release technique for carpal tunnel syndrome, basically grasping the hand and pulling the two sides of the hand apart, as much as possible to with the idea of stretching the flexor retinaculum.

Yes. And saying they were getting beneficial results with this and. I’m curious about that because I’m really curious, first of all, how much that flexor retinaculum was really stretching, and in the process, you’re probably putting some adverse pressure on that median nerve, 

Til Luchau: it’s, yeah, there’s a lot of exceptions to these rules we come up with, and the rule that I was giving people for a long time was don’t try to stretch that flexor retinaculum.

First of all, I don’t know if we can, like you said. Yeah. But, too, if you think of it like a bow and a bowstring, you don’t make the bow deeper. have less compression in that bow by making the bowstring longer. 

Yeah, 

Til Luchau: You want the back of the [00:17:00] bow to be opened up if anything, so there’s more room in there.

Whitney Lowe: Yeah, that makes sense. 

Til Luchau: But I can, it makes kind of structural sense, but I can imagine, just to find mechanisms possibly for what you just described, that There’s, that the stimulating a little bit of sensation or perfusion could change symptoms. Sometimes things feel better because we made them stronger in a non- threatening context.

And later they feel better. Yeah. For example. I don’t know how therapeutic that is in the long run, but that can explain some of the improvement people feel. 

Whitney Lowe: Yeah. 

Til Luchau: From the direct techniques. Yeah. 

Whitney Lowe: I think that is most applicable in a lot of different types of tissues. And I tend to. Okay. At least with nerve problems, I tend to really shy away from anything that increases irritability.

Because the nervous system is so sensitive to that and to the repeated interventions of anything that increases its irritability. So when I might do something [00:18:00] like, for somebody with a, really tight trigger points and tight muscles or something like that, feel okay about getting in and working moderately intensively in there with something that they say Oh man, that really is.

That hurts and they’re sore, and if we’re doing something that is still achieving a beneficial result in reducing muscular hypertonicity and making them feel better when it’s over, that’s one thing when you do it to a muscle, but this is not the kind of thing that I think is to be done for a nerve compression problem like carpal tunnel syndrome.

Til Luchau: We don’t rub irritation better. 

Whitney Lowe: Yeah. 

Til Luchau: And it’s, there’s lots we can do, but it’s not a direct rubbing of that irritated thing. 

Whitney Lowe: Yeah. So for me, the goal is really to get pressure off the nerve, and that might mean working extensively on the flexor tendons in the forearm, and really getting the reduced hypertonicity through the muscles that whose tendons are possibly inflamed, but over-irritating that nerve and try to get as many tissues throughout the forearm to be [00:19:00] flexible, pliable.

And I love your thing frequently talking about the slide and glide, making that happen extensively with all of those tissues throughout the entire upper extremity, actually, we don’t want to limit this just to the forearm, but certainly throughout the entire upper extremity so that nerve and its adjacent pathway and all those other tissues can move the way they really need to.

Til Luchau: That’s really key to my thinking too, Whitney, and I was, I gotta give credit to Richard Rossiter, a Rolfer, who developed his own therapy technique involving the feet, and he got established by working at chicken factories in the south, where he’d train the workers to basically step on each other’s forearms as they opened and closed their fists, and then he sold his program to the factories and they saw a huge reduction in their workers, workman’s comps.

Whitney Lowe: Wow. 

Til Luchau: Just from a little bit of, peer care there. He trained certain people to, how to lay the people down and just step on their forearm and have them open and close [00:20:00] their fist and the chart how many times they did it. Wow. That’s interesting. They give a rating about how much they were cheating.

He said if they weren’t, if they weren’t opening and closing very much, they were cheating. You got some pretty dramatic results. 

Whitney Lowe: Huh? That’s interesting. I’ve never heard that story from him. That’s fascinating. 

Til Luchau: You mentioned like small mechanical or small repetitive motions, also being a risk factor for finger gripping.

That 

Til Luchau: made me think of Sienna Goodwin, another author who did a carpal tunnel study, like I think it was a case study of her work at a hearing aid factory. in Minnesota And I learned a lot from her too about carpal tunnel and some of her techniques of opening and helping the hand be adaptable in all different directions and after spending so much time in that opposed grip of a small tool.

Whitney Lowe: Yeah. Yeah. And a lot of times we see We’ve seen a lot of studies being done, for example, in the food processing factories, especially chicken plants and things like that, when they’re using sharp knives, which they’re gripping firmly to cut into, chickens and cut meat and things like [00:21:00] that.

Those types of gripping activities with significant Hand holding on tools and the other thing is cold. It’s 

Til Luchau: cold there. It’s cold, right? Yeah, 

Whitney Lowe: that’s and the other thing we haven’t talked about a lot here with tools and some of these things is vibration That’s a big thing too. That is a risk factor a vibratory tool any type of Motorized hand tools that you’re using jackhammers or construction tools and things like that.

They also have a high Correlation with onset so getting away from anything that irritates the nerve is always an important part of that Treatment process if we can do it, you know now a lot of times for the occupationally driven carpal tunnel syndromes That’s really hard because people say I can’t quit my job.

I got to keep doing this. Yeah 

Til Luchau: You’re making me think of a client who came with pretty severe wrist pain classic carpal tunnel symptoms and worked with her and She was excited. She came back again, right back to where she started asking more questions. She [00:22:00] was a software engineer by day, spent a lot of time on her keyboard.

And then played keyboards in a jazz band at night. Oh, wow. So she was always at some keyboard. Doing it, yeah. Yeah. Plus, she talked about a lot of cocaine use. This was, this was part of her gig too, is that. So I can’t say that maybe. Cocaine would make things feel better temporarily, but my guess is long term not helpful.

And so it was it, after a few sessions and there really wasn’t a lasting improvement that she saw, I suggested somehow finding my way to suggest that maybe a change in her activities was going to be needed to change the symptoms. And at that point I didn’t see her again. I didn’t find a way to have that conversation that continued our relationship.

I don’t know what she did with that information. But there’s a limit to what we can do just with our hands in a session. 

Whitney Lowe: There is, and this is a good example. I’m glad you brought that up because I think this is such an important thing that people need to remember. We can do some [00:23:00] really remarkable things in the treatment room with people, but They can both mess it up in 30 minutes once they leave by going and immediately doing something that is going to be detrimental, or they can really enhance the longevity of those effects by things that they’re doing.

And this is where it comes into the education piece of what we do. We are both a clinician working with them doing things, but we’re also educators with our clients. And this is where the education piece is so crucial. 

Til Luchau: I think I’ve gotten a lot better at that conversation and it’s a delicate one and it’s easing into and it’s posing it as questions and it’s waiting for the right time to ask the question, for example, if, what if, let’s say, the way to get symptom improvement was to change how much you’re doing, how often you do it, or how intense you do it.

What would you think about that? I might ask the client. 

Yeah. 

Til Luchau: So that’s giving them the variables, it’s posing it as an inquiry. Because it’s, we get really attached to the way we [00:24:00] live and what we do. That’s what gives our lives at least structure, if not meaning and purpose. 

Yeah. 

Til Luchau: And it’s a big one when they’re, when those things are actually causing us physical problems too.

Whitney Lowe: And important to remember that a lot of people may have some real significant fear and apprehension around what’s going to happen in their lives If they’re not able to do the things that they want to do or if they’re not able to do, you know the other particularly challenging things that they have to do and I remember having a client one time that had carpal tunnel syndrome so bad that she couldn’t hold silverware to eat, and just was really having a very difficult time just with the motor control of holding, holding onto silverware.

I was just, super, super distraught about what does this mean for the rest of my life kind of thing. Yeah. Absolutely. And the other really good lesson that I remember coming out of that time of working with her is that this has been going on for quite a while, that this has been, creepy.

This was not a sudden onset thing. This had been coming on for a long time and it was occupationally related. [00:25:00] Clearly overwork of physical activity that she was doing with data entry things on the computer. But what was clear is that the work that we were able to do with her had to start with just super light touch.

Because that’s all we could do before the nervous system was just freaking out. Yeah. And we have to really adjust the nature of how we approach things based on where it is for each person individually. 

Til Luchau: Calming down the nervous system would come first before any kind of tissue or decompression kind of approach probably.

Yeah. 

Til Luchau: And it’s, I’m also thinking of a client of mine who. He was a carpenter by day and for his creative side, for his soul, he was a potter, a ceramicist at a wheel. 

Whitney Lowe: Huh. 

Til Luchau: And both of those things would worsen his symptoms. He felt a lot of pain with both of those. And it was really a quandary for him to have to weigh out his creative side to his pay the bills day job side.

Yeah. [00:26:00] And it was, it’s a tough one to untangle. It’s often, again, it’s back to There are ways that you can change how long you have to do it, how often you have to do it, or how intense you have to do it. And then there’s braces and supports and things like that. Did you, did we talk about night splinting yet?

Whitney Lowe: We mentioned, the night symptoms. I don’t know that we mentioned night splinting, so let’s touch on that. Tell us something about 

Til Luchau: that if you would. 

Whitney Lowe: Yeah, that is one of the most important ways to start working on decreasing the compressive loads over time. Because an important factor to remember with nerve compression problems is there’s two key determinants of what’s going to determine how much that nerve is getting irritated.

It’s pressure and time. How much pressure is applied? Because you can take a moderately high level of pressure over a very short period of time without much damage. You think about the times that you’ve banged your funny bone, and then, for the next 30 seconds, your hand’s completely zinging and gone [00:27:00] to sleep or whatever.

30 minutes later, you don’t even remember that you did that. 

Til Luchau: How about sitting on your leg and making it go to sleep? You just put some major pressure on that nerve. 

Whitney Lowe: Yeah, and pressure and time. You can have a low level of pressure. which is what happens in carpal tunnel syndrome all the time, a moderately low level of pressure, but left on for a long period of time.

And that’s causing a lot of nerve symptoms and nerve impairment. So like with sleep, wearing a night splint, which keeps your wrist in neutral versus allowing you to flex the wrist, which people so frequently do.

And remember that nerve tissue heals so much slower than many other tissues in our body. So when you’re working with your clients who have these kind of things, try to encourage them to be patient with the progress because it’s. It’s quite likely it’s not going to be fast in terms of lips. We’re used 

Til Luchau: to these things we can do where we press on something in a special way and it [00:28:00] feels instantly better.

Yeah. And it’s good. There are a lot of things like that. Yeah. Like you said, nerves aren’t often in that category. Yeah. We can’t see a lot of improvement, but it’s a longer term process often. 

Whitney Lowe: Exactly, yeah. And again, I just want to also at this moment put in a plug for the Great approach that I think manual therapy, like what we do, offers for treating these kinds of things, because certainly from my time spent working in orthopedic environments, seeing a lot of carpal tunnel treatment approaches, which just focused on the wrists only.

And I think that’s a mistake because when you have a nerve compression problem like that, you really need to address the health and functionality of that nerve throughout its entire path. And so that means neck work, shoulder work, upper arm work work on other parts of the body that are going to be part of the entire connected kinetic chain there to really get the nerve functioning.

Til Luchau: We’re going to make this a three [00:29:00] hour podcast? 

Whitney Lowe: Why not? We have to talk about the connection of the carpal tunnel, the median nerve eventually has all the rest of the nerve fibers throughout the body there, it doesn’t mean that. And it doesn’t 

Til Luchau: mean that your sessions have to be three hours either. It just means you need to, you can’t just keep wailing on the.

One thing that seemed to help last time. Yeah. Or didn’t help last time. It’s great. You need to broaden your lens and think about, like you said, the whole nerve pathway or the whole system in a way. Yeah. 

Whitney Lowe: And again, so just putting in a plug for why this is important for us to learn some things about nerve anatomy, because this is not unique to us in the.

sort of massage and manual therapy worlds. I’ve talked to a lot of folks in physical therapy, occupational therapy, athletic training, etc. who said we didn’t really learn much about the nervous system and its structure and function when we were in school. We learned some basic things but we really didn’t get into learning a lot of these other nerves, where they are, where they go, what they do, what kind of actions are affecting them and that sort of thing.

So this is a [00:30:00] thing where a lot of people have to do some of their own study. to get out there and start exploring it. 

Til Luchau: You just, if you didn’t know about the median nerve proof for today, you heard about it here, and you heard about some ways to improve it. We gotta talk about gliding of nerves.

Yeah. 

Til Luchau: What do you want to tell us about that? I know you know a thing or two about that. 

Whitney Lowe: So this is both a treatment and evaluation approach that got popularized. I’m gonna go back and look for, see, I think about that mid 80s or so was when David Butler’s book first came out.

Does that sound right? Mobilization of the nervous system. 

Til Luchau: 80s, early 90s, somewhere in there, yeah. Yeah, I think it was 

Whitney Lowe: mid to late 80s possibly. That was At least in my mind, the thing that lit the fire under a lot of people to start thinking about the nervous system and how it moves and how it needs to stay as mobile as possible.

I remember the very first time that I encountered Butler’s book, I think it was in a Medical book, maybe even been a medical bookstore, I think it was. That was back in the days when there were medical bookstores you could go to and find books, now everything’s online. But anyway, I came across this [00:31:00] book and I was thinking like, mobilization movement of the nervous system.

I’m like, what is this guy talking about? It was just really a very foreign concept to me. I thought oh man, somebody’s just finding some little thing to, to try to sell another book or something. And then I started opening up this book and reading it like, Holy crap, this is fascinating. Anyway what we’re looking at here and wanting to make sure we include is some discussion about the need for those nerves to be able to slide and glide thoroughly through the upper extremity.

against adjacent structures, and so treatment techniques, in addition to trying to get pressure off the nerve, are often aimed at trying to make sure that nerve can move and glide appropriately against adjacent structures, and that’s frequently done with what are called neurodynamic techniques, or nerve flossing, or neural mobilization, goes by lots of different names, but the main concept is you’re trying to Slide that nerve, all the way to, from one end to the other, as far as it can out into its fully stretched position and [00:32:00] trying to, just slide it back and forth, pull it from one end, which would be your hand, the distal end of that nerve, and then pull it from the other end, which would be your head and cervical region when you’re pulling on the nerve roots that are associated with it, and just slide it back and forth.

A little bit difficult to say in an audio podcast here exactly what that looks like because there are specific positions for it, but take a look on YouTube for median nerve mobilizations. You’ll see lots of examples of that being done. 

Til Luchau: Yeah, if you just, listeners, if you just raise your arm right now above your head and then pull your fingers down.

back. So extend your wrist. You’ve considerably lengthened the pathway the intermediate nerve needs to take. 

Yeah. 

Til Luchau: And you can, we can leverage that principle, not just, not specifically to stretch the nerve, but to vary the tension on it in two directions. So if you raise your arm again, extend your wrist again and drop your head away from it, now you’re stretching the nerve.

But if you alternate the head and hand together, then you’re going to be pulling on one of the [00:33:00] nerves. at a time and sliding it back and forth in its pathway. 

Yeah. 

Til Luchau: Very oversimplified version of a neurodynamic move. 

Yeah. 

Til Luchau: Where the goal isn’t always, rarely, to stretch the nerve per se, but it’s more to help it glide within its structures and to soothe it or ease its function by that gentle massage it gets through its gliding motion.

Whitney Lowe: Yeah. And this understanding of neurodynamics is particularly valuable because I think it really helps you both get and recognize some other ways in which you might apply that. For example one of the most common Orthopedic test that’s used to evaluate carpal tunnel syndrome is something called the Phelan’s test, which a lot of people are familiar with where you Place the backsides of your hands together at least for those on the video.

I’ll hold my hands up here like Backsides of your hands together pushing like this and seeing if this reproduces the symptoms there are questions about the specificity and sensitivity of the Phalen’s test. It’s not quite as accurate as some other methods of doing that. After I was reading about [00:34:00] neurodynamics, I got thinking about this and thinking there’s ways that you could make that Phalen’s test more sensitive and more accurate because your elbow is bent in flexion, and that means the median nerve is slackened at the elbow, and your shoulder is up in that position, that might slacken it a little bit. So instead of, Holding your hands in front of you touching the back sides of your wrist together if you did what you were talking about, which is hold your hand all the way out to the side and flexed your wrist in that position.

Now the median nerve is much more tensioned and then if you tilt your head to the opposite side You said flex the wrist? The wrist is flexed. Did you like, extend the wrist? No, the wrist is flexed like it would be in the Phelan’s test position. Ah, okay. Yeah, and then you pull your head to the opposite side you’re tugging on that median nerve more effectively and that might make that test potentially more sensitive.

So sometimes it would show up, wouldn’t be painful if you did the true Phelan’s test, but you did some of these other variations on it that might make it show up for somebody who’s, again, telling you a little bit [00:35:00] more about the severity of that condition. 

Til Luchau: There’s been a lot of work done on the ways to use this principle therapeutically.

There’s been research. 2017 systematic review showed a definite improvement in meeting neurofunction, just as a result of neurodynamics. This, the idiot’s version, I’m going to insult a lot of skilled neurodynamic practitioners by just saying this. If you can find motions and positions that trigger a little bit of that sensation, and then back out of them, back off a little bit, and then play with going in and out of that, looking at variations of head position, wrist position, arm position.

You can freeform your own neurodynamic assessment. Again, think, if you think the goal, think about the goal being to gently glide and soothe the nerve, rather than just find the symptom and stretch into it. That’s not the goal. 

Whitney Lowe: Yeah, that’s an important clarification when we talk about neurodynamic movements and stretching because we often get in this idea of stretching muscles where we take them into a position of feeling like they’re really stretched and there’s a little bit [00:36:00] of, discomfort with that stretch position.

You just say, all right, just hold that stretch position, take in some deep breaths and really just hold it till you get it to let go and relax. And you do feel a change in sensation from doing that. But you don’t want to do that with nerves. You don’t want to hold them in that irritating position because you’re just increasing the nociceptive input from that irritated nerves.

Like you said, go right out to that position, then back off, out, and back off, out, and back off if you’re going to do that kind of thing with it. 

Til Luchau: One end with the other end. And we, we suspect nerve and we have tingling, or numbness, or prickly sensation of those kind of nerves and nerve signs. Yeah.

That’s going to let us know we’re not about finding the tight thing and stretching it, but helping things glide and calm down instead. Yeah, 

Whitney Lowe: And when we, I don’t think we talked about this earlier, but again, just to keep in mind you, because you mentioned this early on when we’re trying to make some distinctions between carpal tunnel syndrome and other things you might have nerve pain in your hand in the median nerve distribution, but you also have nerve pain throughout the entire upper [00:37:00] extremity.

And that would be more likely indicative of a cervical nerve root. issue than carpal tunnel syndrome, because the symptoms from carpal tunnel syndrome, most of the time are going to be felt distal to the side of compression, which is in the hand and not so much up the arm. But if you’ve got symptoms throughout the entire upper extremity, you’re now more likely to be looking at something that’s caused by a more proximal compression, which is probably a nerve root or.

Maybe even a thoracic outlet involvement or something like that. Yeah, I 

Til Luchau: was going to ask you about the overlap with thoracic outlet as well. 

Whitney Lowe: Yeah, so there is some overlap in those symptoms. A key distinction is that thoracic outlet symptoms, not all the time, but as a tendency, do tend to have their symptoms appear first and more prominently in the ulnar nerve distribution than they do in the median nerve.

And that’s mainly because of the anatomy of the brachial plexus. The branch that feeds into the ulnar nerve is the most [00:38:00] inferior of those branches of the brachial plexus. And that’s the one that gets compressed first in our thoracic atlas and symptoms or thoracic atlas conditions. 

Til Luchau: Yep, so symptoms typically starting along the little finger side of the hand.

Yeah, and not that changeable with risk position compared to carpal tunnel typically. Yeah. Yeah. I got, I got a quick literature review in front of me. Oh great. Look, looking at the ways that massage and manual therapy has been seen to help with carpal tunnel. Basically, let’s say one, two, three, four, five different mechanisms, clear evidence of reduction in pain and symptoms in general.

I’ll put these references in the show notes from a 2013 meta study and a 2021 one, a study as well showed just a clear overall reduction of pain and symptoms, improvement in median nerve function decreased swelling has been shown to Happened as a result of massage and manual therapy. Improved grip strength and function.

And the [00:39:00] fifth was enhanced overall quality of life of people suffering from carpal tunnel has been measured pretty, to be pretty clearly improved as a result of getting massage and manual therapy. 

Whitney Lowe: Nice. Now, you know what It is a bit frustrating, at least for me, with a lot of these studies, is I always want to know what they were doing.

Sure. With the manual thing, because they often just clump this in saying massage and or manual therapy. They may describe it in some of these studies. They may describe it in detail, because that’s the next question is like, How important is what we do, and the way in which we do it, in making those changes?

That’s another big question for people. Yes, and that’s, 

Til Luchau: and you and me probably have horses in that race. Yeah. Where I, I do think that the better therapist I am, the better results I see. And I’m dedicated to helping people be the best therapist they can be. Yeah. So yeah, like I’m with you to lump all massage and manual therapy and say it helps or it doesn’t.

Yeah. It’ll be a lot of that question out.   

Whitney Lowe: Good. We I think touched on a lot of the the key things here. Like you said some nice good low hanging [00:40:00] fruit, but some also interesting little diversions on things that might be helpful to know and be paying attention to with clients potentially having carpal tunnel syndrome or other median nerve compression.

If 

Til Luchau: you got questions about this, let us know. I’m going to put those research notes in the show notes. Come check those out. Anything else you want to say before we thank our sponsors? 

Whitney Lowe: No, I think that that kind of wraps that up again. Let us know if you have any other questions, happy to dive into some of those things.

And maybe we’ll explore some of those other subtopics in future episodes there. So great. So do remember the Thinking Practitioner podcast is supported by ABMP, the Associated Bodywork and Massage Professionals. And ABMP membership gives professional practitioners like you a package including individual liability insurance, free continuing education, quick reference apps, online scheduling, and payments with PocketSuite, and much more.

Til Luchau: ABMP CE courses, podcasts, and Massage and Bodywork magazine always feature expert voices and new perspectives in the profession, including [00:41:00] articles by Whitney Lowe and myself, Til Luchau. Thinking practitioner listeners can save on joining ABMP at abmp.com/thinking. 

Whitney Lowe: And thanks again to all our listeners and to our sponsors.

You can stop by our sites for the video, show notes, transcripts, and any extras. You can find that from me over on my site at academyofclinicalmassage.com. And Til, where can people find you there? 

Til Luchau: Advanced-trainings.com Just go there and click on the podcast link and you’ll see it. We want to hear from you, listeners, with your ideas, your input, your thoughts, your questions.

Send us a message or a short voice memo at an email to us at info@ thethinkingpractitioner. com or look for us on social media. Under our names, I am Till Luchau. Whitney Lowe, what is your name? 

Whitney Lowe: Today, my name is Whitney Lowe. You can find me over there on social media under my name as well. You can also we encourage you to check out the wealth of resources we have for rehabilitative massage on our YouTube channel as well, [00:42:00] also under my name.

And if you would, please make sure that you Rate us, if you could, on Apple Podcasts, Spotify, Stitcher, wherever you happen to be listening to our podcasts, as it does help people find the show. It really does make a difference, so take a moment to do that if you would. Let us know about it as well, what your thoughts are.

And wherever you happen to listen to your podcasts, please share the word, tell a friend, and we’ll look forward to seeing you in the next episode. 

Til Luchau: I would probably do this anyway, even if no one listened. I would just sit here and talk to you about this, Whitney. But listeners, if you do rate us or if you do telephone, that lets us know that we’re actually reaching you and that’s actually happening.

That’s how we hear back that there’s somebody out there. So thanks for taking the time to do that. 

Whitney Lowe: Nice 

Til Luchau: to be with you, Whitney. 

Whitney Lowe: You too. We’ll see you again soon.