Pain Assessment. Dana Calhoun, LMT Updated 2/2/2018

Transcription

1 Pain Assessment Dana Calhoun, LMT Updated 2/2/2018

2 What is Pain? The International Association for the Study of Pain (IASP) defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is whatever the experiencing person says it is, existing whenever he says it does

3 PAIN FACTORS Pain is 100 % Subjective Pain relies on self-reporting Pain is person specific Age Gender Culture

4 Pain Theories Nociception Specificity Theory of Pain Gate Control Theory of Pain Neuromatrix Theory of Pain

5 Types of Pain Mental Emotional Psychological Physical

6 Acute vs. Chronic Pain Acute Pain- Sudden pain that is associated with injury and/or trauma. Chronic Pain-Pain that persists longer than 3 months

7 Empathy and Pain Seeing others experience pain can make us uncomfortable. Exercise #1 Name some of the feelings that we experience while witnessing others in pain Helplessness, Frustration, Fear, Anger, Anxiety

8 PERSONAL PAIN EXPERIENCE Exercise 2- Personal Pain Experience

9 The role of a Myomassologist and Let go of preconceived notions about how much pain the client is in Honor the client s pain Pain Sympathy, empathy vs. pity Understand that we can t fix the client, the client has to be willing to fix themselves We can guide our clients to less pain, but ultimately they are doing the work

10 Physical Pain Descriptions Local, Referred or Radiating Pain Intermittent vs Constant pain Throbbing Dull & Aching vs. Sharp & Burning Electrical, Tingling Weakness, Fullness

11 Pain Scale

12 Pain Treatments Medications ex. Ibuprofen, Acetaminaphen, Opioids, Steroids, Non-Steroidal Anti-Inflammatories Physical Therapy Chiropractic Care Allopathic Medical Treatment Massage and other Complementary Alternative Medical (CAM) Modalities

13 X-RAY Typical Diagnostic Tests & Procedures BONE SCAN CAT SCAN MRI Best for tissues. EMG Neuromuscular problems. MYELOGRAM Spinal cord and disc problems. ISOKINETIC EVALUATION For joint movement and muscular strength. ARTHROGRAM For Tendon, ligament, or meniscal tears.

14 Assessment vs Diagnosis WHAT IS ASSESSMENT? Assessment is a possible indication or evaluation of a condition. It is an unconfirmed finding limited to one s scope of practice. In a word, assessment is only an appraisal (Stedman s Concise Medical Dictionary). WHAT IS DIAGNOSIS? A diagnosis is a confirmed finding by a doctor using all the diagnostic tools at his disposal. The determination of the nature of a disease (Stedman s Concise Medical Dictionary).

15 The HOPS Method of Soft Tissue Assessment History Observation Palpation Special Tests

16 History WHAT IS THE NATURE OF YOUR PROBLEM? It is very important to get information in the client s own words about what is the primary complaint. You may be the first professional to actually listen to them. WHERE DO YOU FEEL THE PAIN EXACTLY? It is important to find the exact location of the client s pain. For instance, a small localized pain would be more likely to indicate a condition with mechanical disruption of the soft-tissue, where a larger area of diffuse pain would be more likely to indicate neurological involvement. HOW DID THE PAIN ARISE? Is it acute or chronic pain because you will be treating sudden onset (acute) and gradual onset (chronic) quite differently.

17 History WHAT IS THE CLIENT S OCCUPATION OR DAILY ACTIVITY? This information will give you clues as to the activities of your client that may be adding more aggravation to their situation. Overuse syndrome is common among factory workers in assembly plants who do repetitive motions for eight hours a day or more. HAVE YOU EVER HAD THIS CONDITION BEFORE? IF SO, HOW WAS IT RESOLVED? Predisposing factors are those elements that make this particular injury more likely to occur or more likely to reoccur in the future. WHAT KIND OF MEDICATIONS IS THE CLIENT TAKING FOR THE PAIN? Pain medications can mute sensations in the client, so you must be aware of too much pressure or taking clients beyond their normal ROM.

18 History WHAT IS THE NATURE OF THIS PAIN? HOW WOULD YOU DESCRIBE IT? IS IT SHARP, DULL, BURNING, ACHING, DIFFUSE, ELECTRICAL, ETC.? The nature of the pain will very often tell you a great deal about the primary tissues that are injured. For example, pain from a nerve injury is often sharp and shooting. ARE THERE ANY SPECIFIC ACTIVITIES WHICH AGGRAVATE THE PAIN OR DISCOMFORT? HAVE YOU FOUND ANYTHING THAT MAKES THE PAIN BETTER? If there is a problem with the musculoskeletal structures, it is likely that there will be more aggravation with activity and relief of pain with rest. A possible exception to this is pain from an intervertebral disk problem which often will be aggravated by sitting and relieved with movement. The movement patterns that cause discomfort are important for gaining more information.

19 LOOK FOR POSTURAL DISTORTION By simple observation a massage therapist may see patterns of distortion in body symmetry which will give indications about muscle tension and tissue dysfunction. Observation ALSO IMPORTANT IS: To recognize whether a deviation from an established norm is significantly dysfunctional as to be a cause of some type of softtissue pathology. A compensation pattern may be functional.

20 Observation USING GRIDS By using a grid or plumb line the therapists can easily see and record the distortion patterns. Apps are also available for your smart phone s camera that can photograph the standard grid pattern on top of the clients profile.

21 Goniometers for ROM Measuring

22 Palpation PALPATION IS THE MASSAGE THERAPIST MAIN ASSESSMENT TOOL You will be performing palpation not only in assessment before the treatment, but during the entire treatment as well. WHY YOU USE PALPATION? You will use information gained during palpation to verify the location of injured tissues or pain referral patterns.

23 Summary of Four Special Tests ACTIVE TESTS - Give us information about the Muscle- Tendon Unit. SPECIAL ORTHOPEDIC TEST PASSIVE TESTS Give us information about inert tissues like Joint Tissues and Ligaments. MANUAL RESITIVE TESTS Give us more information about the Muscle-Tendon Unit since the joints are not moving. SPECIAL ORTHOPEDIC TESTS Give specific information about a Condition or Syndrome like Carpal Tunnel Syndrome.

24 Active Range of Motion Tests Active Movements focus on the contractile tissues, the muscle-tendon unit. Several different types of information can be gained from active movement: 1. The Willingness to Move. 2. Range of Motion. 3. Muscular Strength. 4. Coordination/Balance. It is important to remember that both contractile and inert tissues will be moving with active movements. Also the clients willingness to move must be noted. Is their limited AROM psychological or physical or both?

25 Passive Range of Motion Tests Passive motions focus on the inert tissues. In passive movements the contractile tissues are also moved, but not engaged. This is an important distinction. Remember that certain contractile tissues or portions of them can be stressed (tensile stress) by Stretching. One of the more valuable types of information that will be gained through the use of passive range of motion tests is the quality of movement at the joint. The quality of the end of accessory motion is an important indicator of joint or soft-tissue pathology. The information can be categorized by what is called the end-feel.

26 Manual Resistive Tests Manual resistive tests are frequently called resisted isometric movement since they use isometric muscle contractions. This test is designed to confirm and elaborate on findings from the active and passive range of motion tests. The emphasis is on determining problems associated with the muscle-tendon unit. If there is weakness against the resistance, this could indicate a problem with the nerve.

27 Special Regional Orthopedic Tests This is a group of tests that are designed to discover a particular problem in an isolated area such as the likelihood of carpal tunnel syndrome at the wrist or an injured medial collateral ligament at the knee. These tests will take into account specific factors of functional anatomy of the region. Some sort of specific stress or change in the state will be administered to a certain area with the likelihood of a positive test, indicating the likelihood of a certain condition. A negative test would indicate the likelihood that a particular condition is not there. Remember that these are not definitive tests, only possible indications of a particular condition.

28 Foot Conditions

29 Overview of Common Single Plane Movements of the Foot, Ankle and Leg DORSIFLEXION Tibialis Anterior Extensor Digitorum Longus Extensor Hallucis Longus INVERSION 50 Tibialis Posterior Flexor Digitorum Longus PLANTAR FLEXION Gastrocnemius Soleus Plantaris Flexor Digitorum Longus Peroneus Longus Peroneus Brevis Flexor Hallucis Longus Tibialis Posterior Flexor Hallucis Longus Tibialis Anterior Extensor Hallucis Longus EVERSION 25 Peroneus Longus Peroneus Brevis Peroneus Tertius Extensor Digitorum Longus

30 CONDITION: PLANTAR FACIITIS Plantar Fascia Ball of the Foot pain Heel Pain The plantar fascia is a thick sheet of connective tissue found on the plantar surface (sole) of the foot extending from the Calcaneus to the toes. Inflammation of this fascia produces the characteristic symptoms.

31 CHARACTERISTICS: PLANTAR FASCIITIS Signs and Symptoms: The person complains of pain in the heel or bottom of foot first thing in the morning. The pain is relieved by rest. There is tenderness near the attachment of the fascia to the Calcaneus, medial aspect of the foot. Risk Factors: It is common in individuals with high arched feet and those over the age of 40. In the younger group it can occur in those who are active in sports. People who are in occupations that involve prolonged standing or walking are also prone. Can lead to Bone Spurs.

32 ASSESSMENT: PLANTAR FASCIITIS Upon palpation to the attachment of the plantar fascia at the calcaneus or the distal metatarsals just below the ball of the foot is a positive test for Plantar Fasciitis.

33 TREATMENT: PLANTAR FASCIITIS Recommendations to Therapist: Ice massage may be used during the acute phase. In the sub acute or chronic stage, friction massage at the origin of the Calcaneus is given to reduce adhesions. Mobilize the joints of the foot, to reduce stiffness. Lymphatic drainage techniques can be used in the leg and ankle. Remedial exercises to stretch the Gastrocnemius, Soleus and the plantar fascia should also be done. Longitudinal stripping techniques while actively engaging the Tibialis Posterior and flexor muscles may enhance fiber elongation and decrease accumulated tension in them.

34 CONDITION: TARSAL TUNNEL SYNDROME Posterior Tibial Tendon Tarsal Tunnel Posterior Tibial Nerve This is a medial view of the right foot. The posterior Tibial Nerve travels through the tunnel with the posterior Tibial tendon. (CHRONIC)

35 CHARACTERISTICS: TARSAL TUNNEL SYNDROME This is a nerve entrapment condition that happens in the region just posterior and inferior to the medial malleolus of the ankle. The Tibial Nerve passes through the tunnel created by the flexor retinaculum (the roof), and the calcaneus and talus (the floor). In this tunnel the Tibial Nerve sits between the tendons of the flexor hallucis and the flexor digitorum longus muscles. If it is irritated by these structures from overuse it will be painful.

36 ASSESSMENT: TARSAL TUNNEL SYNDROME The client may report a sharp, shooting pain on the medial side of the ankle while walking. It may also radiate onto the plantar side of the foot. Over pronation will also cause pain. Passive/Active dorsiflexion and eversion of the foot will test positive for pain. This would be an indication of Tarsal Tunnel Syndrome. DORSIFLEXION-EVERSION TEST

37 TREATMENT: TARSAL TUNNEL SYNDROME This condition usually involves biomechanical problems of the foot and ankle complex. Reeducation of the gait pattern may be helpful, especially if over pronation is a contributing factor. Longitudinal stripping techniques while actively engaging the Tibialis Posterior and flexor muscles may enhance fiber elongation and decrease accumulated tension in them. Deep transverse friction applications to the tendons may be called for if tendinitis or tenosynovitis are present. Do not perform this technique on the Tarsal Tunnel itself.

38 Knee & Thigh Conditions

39 Overview of Common Single Plane Movements of the Knee KNEE FLEXION 160 KNEE EXTENSION 180 Biceps Femoris Rectus Femoris Semimembranosus Vastus Medialis Semitendinosus Vastus Lateralis Gastrocnemius Vastus Intermedius Plantaris Popliteus

40 CONDITION: PREPATELLAR BURSITIS Prepatellar Bursitis is commonly called housemaid's knee. This type of bursitis is a common cause of swelling and pain above the kneecap. It s due to inflammation of the prepatellar bursa. Housemaids knee is different from preacher s knee, as preacher s knee is bursitis of the infrapatellar bursa just under the kneecap. (ACUTE or CHRONIC)

41 CHARACTERISTICS: PREPATELLA BURSITIS The prepatellar bursa is located just under the skin directly on top of the patella. This bursa can become inflamed or irritated from a single direct trauma such as a blow to the anterior knee, or it may become irritated from repetitive compression stress such as kneeling on the knees. The pain will most often be felt above the patella and there may be local redness and swelling accompanying this condition. The client will complain of pain in the region as the knee is flexed.

42 ASSESSMENT: PREPATELLA BURSITIS Prepatellar bursitis is most easily assessed by a few simple signs and symptoms. There will be swelling and redness superficial to the patella. This area may be tender to a moderately light touch. Resisted motions of the knee will not cause additional discomfort and the pain will be limited to the area just above (anterior) to the patella. PALPATION TEST

43 TREATMENT: PREPATELLAR BURSITIS Prepatellar Bursitis responds best to rest and behavior modification. Ice applications may be helpful to avoid painful swelling. If swelling is severe, the region may be aspirated (the withdrawing of fluid by a syringe). Massage Applications will not be of much help with this condition and in fact, if applied to the area would likely be detrimental.

44 Hip and Pelvis Conditions

45 Overview of Common Single Plane Movements of the Hip and Pelvis HIP FLEXION 90 HIP EXTENSION 20 Psoas Biceps Femoris Iliacus Semimembranosus Rectus Femoris Semitendinosus Sartorius Gluteus Maximus MEDIAL/INTERNAL ROTATION 30 Adductor Longus Adductor Brevis Adductor Magnus Gluteus Medius Gluteus Minimus LATERAL/EXTERNAL ROTATION 60 Piriformis Obturator Internus Obturator Externus Quadratus Femoris Gemellus Superior Gemellus Inferior

46 Overview of Common Single Plane Movements of the Hip and Pelvis ABDUCTION 45 ADDUCTION 30 Tensor Fasciae Latae Adductor Longus Gluteus Minimus Adductor Brevis Gluteus Medius Adductor Magnus Gluteus Maximus Pectineus Sartorius Gracilis

47 CONDITION: PIRIFORMIS SYNDROME PIRIFORMIS SYNDROME is a nerve compression syndrome that will mimic the symptoms of a lumbar disk protrusion on a spinal nerve. The piriformis muscle is a primary lateral rotator of the hip. The sciatic nerve goes over the other five deep hip rotators and under the piriformis as it is leaving the sacral plexus and descending limb as shown above. (CHRONIC)

48 CHARACTERISTICS: PIRIFORMIS SYNDROME In some instances the sciatic nerve will come over the top of the piriformis muscle or actually perforate the muscle. This is much more likely to lead to problems with the sciatic nerve being compressed. Depending on its severity, pain may be felt in the immediate gluteal region, down the posterior thigh, or all the way down the leg if compression on the nerve is severe.

49 ASSESSMENT: PIRIFORMIS SYNDROME The position of the client in the Piriformis test is in side-lying with the asymptomatic leg against the table and the symptomatic leg in a position of 60 to 90 degrees of flexion in the hip and 90 degrees flexion in the knee joint. The patient should lay with the face directed to the examiner, the examiner s hand is placed on the pelvis to stabilize this point, the other hand is placed on the lateral side of the knee. The examiner is going to give resistance on the lateral side of the knee and tries to get as far as possible in this movement, until there is pain or numbness starting. This test is also named as the FAIR test, Flexion/ Adduction and Internal Rotation. The examiner performs adduction while putting pressure on the knee in the direction of the table until the point when the client feels pain or discomfort. PIRIFORMIS FAIR TEST

50 TREATMENT: PIRIFORMIS SYNDROME If the primary problem is resulting from piriformis tightness, massage applications and stretching aimed at the gluteal muscles and deep rotators of the hip will be helpful. The therapist should be careful when applying pressure in the gluteal region to make sure that the pressure does not contact the irritated sciatic nerve and make the discomfort worse.

51 LUMBAR & THORACIC SPINE CONDITIONS

52 Overview of Common Single Plane Movements of the Lumbar and Thoracic Spines SPINAL FLEXION SPINAL EXTENSION Psoas (Major and Minor) Erector Spinae Rectus Abdominis Semispinalis External Oblique Multifidus Internal Oblique Quadratus Lumborum Transverse Abdominis LATERAL FLEXION Latissimus Dorsi Erector Spinae Quadratus Lumborum Transversospinalis External Oblique Intertrasversarii ROTATION LUMBAR ROTATION THORACIC 45 Semispinalis Multifidus Rotatores

53 CONDITION: HYPER LUMBAR LORDOSIS ANTERIOR PELVIC TILT HYPER LORDOSIS NORMAL LORDOSIS Hyper Lordosis is associated with the anterior pelvic tilt. When the normal Lordosis becomes exaggerated it is considered pathological. (CHRONIC or ACUTE)

54 CHARACTERISTICS: HYPER LUMBAR LORDOSIS An increased Lumbar Lordosis is often seen in conjunction with an anterior pelvic tilt, a tight psoas muscle, tight lumbar spinal extensors, and a variety of other soft tissue compensations. There are a number of factors which may lead to exaggerated lumbar Lordosis, such as sitting in poor posture all day or wearing high heel shoes for long periods.

55 ASSESSMENT: HYPER LUMBAR LORDOSIS As with the anterior pelvic tilt, this condition is best assessed from a lateral position. Look for an exaggerated curve in the lumbar spine, prominence of the gluteal region, and a backward leaning of the torso. It is helpful to examine the client in supine position with legs extended. If the Lordosis is exaggerated there will be more room to slide the hand under the lumbar region then normal. NEUTRAL PELVIS ANTERIOR PELVIC TILT

56 TREATMENT: HYPER LUMBAR LORDOSIS Treatment will vary depending on the cause of the Lumbar Lordosis. The THOMAS TEST will determine if the Psoas is the main cause of the Hyper Lordosis of the Lumbar. If the client while in supine position, with the uninvolved side hip flexion of 135 degrees, shows the involved side femur horizontal or higher, the Psoas and Rectus Femoris needs to be released (Usually both sides). THOMAS TEST

57 CERVICAL SPINE CONDITIONS

58 Overview of Common Single Plane Movements of the CERVICAL SPINE SPINAL FLEXION 80 SPINAL EXTENSION Rectus Capitis Anterior Splenius Capitis Rectus Capitis Lateralis Semispinalis Capitis Longus Capitis Longissimus Capitis Sternocleidomastoid Spinalis Capitis Longus Coli Trapezius Scalenes (All) Splenius Cervicis Longissimus Cervicis Semispinalis Cervicis

59 Overview of Common Single Plane Movements of the Cervical Spine LATERAL FLEXION ROTATION 80 Levator Scapulae Levator Scapulae (IL)* Splenius Cervicis Splenius Cervicis (IL) Iliocostalis Cervicis Iliocostalis Cervicis (IL) Longissimus Cervicis Longissimus Cervicis (IL) Semispinalis Cervicis Multifidus (CL)* Multifidus Scalenes (CL) Scalenes Sternocleidomastoid (CL) Sternocleidomastoid *(IL) ipsilateral *(CL) contralateral

60 CONDITION: THORACIC OUTLET SYNDROME SCALENES SUBCLAVIAN PECTORALIS MINOR Thoracic outlet syndrome is one of several common nerve impingement syndromes. (1) Between the anterior and medial scalenes, (2) the area of the subclavian arteries, (3) the Pectoralis minor and the upper ribs. (CHRONIC)

61 CHARACTERISTICS: THORACIC OUTLET SYNDROME The region between the anterior and medial scalene muscles where the nerves of the brachial plexus exit the neck is know as the thoracic outlet. If the anterior and medial scalene muscles are tight, they may press on nerve structures in the thoracic outlet. In addition, they may also press on the vascular structures such as the subclavian artery. Symptoms will usually be pain, numbness, or paresthesia down the arm.

62 ASSESSMENT: THORACIC OUTLET SYNDROME The client with TOS will usually have tight scalene muscles. There is also poor posterior compensations involving the shoulders as well. The primary problem is the impingement of the brachial plexus that is causing pain down the arm. ADISON TEST ADISON TEST: the client is in a seated position. The therapist will located the radial pulse on the affected side. Next the therapist will bring the client's shoulder into extension and lateral rotation. The client then takes a deep breath. If the pulse disappears or diminishes it is a positive test for TOS.

63 TREATMENT: THORACIC OUTLET SYNDROME Stretching of the scalene muscles and decreasing muscular imbalance in the cervical muscles will be of prime importance. Also the release of the Pectoralis Major and Minor if shoulders are medially rotated and slumping inferiorly. A good knowledge of anatomy is important in the area in order to avoid damaging the vascular and nerve tissues.

64 SHOULDER CONDITIONS

65 Overview of Common Single Plane Movements of the Shoulder SHOULDER FLEXION 180 Anterior Deltoid Pectoralis Major Coracobrachialis Biceps Brachii SHOULDER ABDUCTION 180 Deltoid Supraspinatus Infraspinatus (Upper Fibers) SHOULDER EXTENSION Posterior Deltoid Teres Major Teres Minor Latissimus Dorsi Pectoralis Major Triceps (Long Head) SHOULDER ADDUCTION Pectoralis Major Latissimus Dorsi Teres Major Subscapularis

66 Overview of Common Single Plane Movements of the Shoulder MEDIAL ROTATION 100 * Pectoralis Major Anterior Deltoid Latissimus Dorsi Teres Major Subscapularis HORIZONTAL ABDUCTION 30 Posterior Deltoid Teres Major Teres Minor Infraspinatus LATERAL ROTATION 90 Infraspinatus Posterior Deltoid Teres Minor HORIZONTAL ADDUCTION 140 Pectoralis Major Anterior Deltoid

67 CONDITION: SHOULDER IMPINGEMENT SYNDROME Shoulder Impingement Syndrome (SIS) can have number of different tissues that can be at fault. What is shown above is in impingement of the shoulder by an inflamed tendon of the Supraspinatus Muscle. (CHRONIC)

68 CHARACTERISTICS: SHOULDER IMPINGEMENT SYNDROME There is a region in the shoulder joint called the coracoacromial arch. The supraspinatus tendon and the sub-acromial bursa are underneath this arch. repeated abduction and forward flexion of the shoulder will impinge the supraspinatus tendon or sub-acromial bursa underneath the coracoacromial arch. This is a common repetitive motion injury brought on by over use of the same shoulder movements. Example would be a house painter, assembly worker, or a swimmer.

69 TREATMENT: SHOULDER IMPINGEMENT SYNDROME SIS can be well treated by massage approaches. It is important to establish, if possible, the tissues that are being impinged in order to determine the most effective treatment. If primary impingement is caused by an inflamed supraspinatus tendon then cross fiber friction would be a possible treatment. This will promote the proper development of scar tissue. Stretching and range of motion exercises would help here. If primary impingement is due to an inflamed sub-acromion bursa sac then treatment could focus on the balancing of the muscles surrounding the shoulder.

70 ELBOW CONDITIONS

71 Overview of Common Single Plane Movements of the Elbow ELBOW FLEXION 140 ELBOW EXTENSION 0 Brachialis Triceps Biceps Brachii Anconeus Brachioradialis

72 CONDITION: LATERAL HUMERAL EPICONDYLITIS LATERAL HUMERAL EPICONDYLITIS involves trauma and micro tearing of the tendon fibers of the common extensor tendons of the wrist where they attach to the lateral epicondyle of the humerus. (CHRONIC)

73 CHARACTERISTICS: LATERAL HUMERAL EPICONDYLITIS This condition was first reported because of the frequency which it affected tennis players. The irritation and micro tearing of the tendon fibers of the extensor group is mostly the result of excessive eccentric loading on the extensors of the wrist. The client will have pain, possibly some swelling, and limitation of movements that involve the wrist extensors. This condition frequently develops in occupational situations where people have to do repetitive flexion and extension motion of the wrist.

74 ASSESSMENT: LATERAL HUMERAL EPICONDYLITIS The client will usually present with pain at the lateral region of the elbow that is associated with movement. They may feel pain on stretching the wrist extensor group (in full flexion of the wrist) and the region to be tender to palpation. TENNIS ELBOW TEST: The client is in a standing or sitting position. The therapist has one hand with thumb just distal to the lateral epicondyle. Client puts wrist into hyper extension (45*) while therapist resists by pulling the wrist into flexion. If pain or discomfort results, the patient has some level of epicondylitis present. TENNIS ELBOW TEST

75 TREATMENT: LATERAL HUMERAL EPICONDYLITIS Anti-inflammatory measures may be taken such as ice massage applications or other techniques. Deep transverse friction will help coupled with deep stripping of the forearm extensors and flexors while using both passive and active movements of the wrist. Also bracing and rest to the effected area will be helpful.

76 WRIST CONDITIONS

77 Overview of Common Single Plane Movements of the Wrist and Forearm FLEXION 85 EXTENSION 85 Flexor Carpi Radialis Extensor Carpi Ulnaris Flexor Carpi Ulnaris Extensor Carpi Radialis Brevis Palmaris Longus Extensor Carpi Radialis Longus PRONATION 85 Pronator Quadratus Pronator Teres RADIAL DEVIATION/ABD 15 Flexor Carpi Radialis Palmaris Longus Extensor Carpi Radialis Longus Extensor Carpi Radialis Brevis SUPINATION 90 Supinator Biceps Brachii ULNAR DEVATION/ADD 45 Flexor Carpi Ulnaris Extensor Carpi Ulnaris

78 CONDITION: CARPAL TUNNEL SYNDROME Carpal Tunnel Syndrome (CTS) is becoming more and more prevalent. This is due to the occupations that require repetitive motions of the hands, especially the flexion of the fingers.

79 CHARACTERISTICS: CARPAL TUNNEL SYNDROME CTS is a nerve compression syndrome which is created by the compression of the median nerve in the anterior region of the wrist. A tunnel is formed in the wrist by the carpal bones which make up the roof or the tunnel and a soft-tissue band called the flexor retinaculum which makes up the floor of the tunnel. The tunnel is shared by the median nerve and the tendons of hand and wrist flexors. Due to overuse the tendons of the flexor muscles will swell within this tunnel. When they swell, they press on the median nerve causing pain, numbness, and lack of motor function.

80 ASSESSMENT: CARPAL TUNNEL SYNDROME PHALEN S TEST: The client places both wrists together with the dorsal surface of the hands resting against each other. The wrist should be held in a position of maximum flexion for about 60 seconds. If this produces pain, numbness in the 2 nd, 3 rd, or 4 th fingers, this may indicate CTS. PHALEN S TEST TINEL S SIGN: The therapist will supinate the client s hand and lightly tap on the anterior surface of the wrist. If this produces pain, numbness, or paresthesia along the distribution of the median nerve, it is indicative of CTS. TINEL S SIGN

81 TREATMENT: CARPAL TUNNEL SYNDROME CTS is treated in a number of ways. Rest is usually the best solution coupled with a method to decrease the inflammation of the flexor tendons. Ice and antiinflammatory medicines can accomplish this. Massage should focus on decreasing any accumulated tension in the flexor muscles of the wrist. Deep stripping techniques will accomplish this. Massage should include the whole kinetic chain, arms, shoulder, and neck. Surgery is the last resort.

82 Suggested Reading