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Healthy Hands


Course Objectives

This course specifically discusses how massage therapists can deal with forearm, hand and wrist pain. When you finish this course you will be able to:

  • List four areas where treatment of attachments for the forearm, wrist and hand is commonly missed when relying on a treatment routine.
  • Explain how resolving the origin of pain benefits massage therapists and their clients.
  • Describe how to begin a treatment by working with fascia.
  • Detail the three massage techniques and the preferred direction of the strokes used that are described in this course for forearm, hand and wrist work.
  • List four areas of common nerve entrapment.
  • List three muscles that can compress nerves in the spine.
  • List the six potential causes for chronic pain described in this course and a possible solution for each.
  • Describe two ways to investigate sources of pain for your client that go beyond the area of acute injury.

Course Description

This course describes how to use massage therapy to treat the cause of pain in the forearm, wrist and hand. The concepts addressed in this course can be used to keep massage therapist professionals healthy, strengthen the massage therapy profession, and provide additional insights and tools to serve your client base.

Contact Hours: 2

For many massage therapists, helping people deal with—or get rid of—pain is part of their work. You see clients who are suffering feel better after they’ve received a massage. And for some, the massage therapy you provide may be where they find the most relief.

But what happens when you are who is in pain?

Unfortunately, many massage therapists are unable to continue working in the profession they love because of pain, especially in their forearms, hands and wrists. Some find longterm relief at the hands of a fellow massage therapist who can help them work through the problem.

Others, however, aren’t so lucky. Chronic pain that isn’t completely relieved by massage therapy alone doesn’t need to end a career. Massage therapists experiencing chronic problems can develop a more complete plan to help resolve the origin of the pain instead of simply abating the symptoms. Often, these comprehensive plans are tailored to the needs of the individual to ensure maximum effectiveness.

This CE course will specifically discuss how massage therapists can deal with forearm, hand and wrist pain. The concepts addressed in this course, however, can be used in a broader sense to keep massage therapist professionals healthy, strengthen the massage therapy profession and provide additional insights and tools to serve your client base.

Where to Begin

Although massage therapy might not be able to completely relieve chronic pain, massage is still a valuable part of the process. Before starting, you may want to briefly review fascia anatomy and theory.

Depending on the area of the body being worked on, the superficial fascia has hundreds of tiny nerve endings per square inch. Without any actin and myosin, the fascia has no cross bridges to shorten, so gliding strokes with lubrication do not have the same effect seen with muscle tissue.

Remember, too, that part of the structure of fascia tissue is what John Barnes calls a “plastic” component. I liken this property to candle wax when teaching. When cool, candle wax is solid and difficult to manipulate. When warmed, however, the wax becomes soft and pliable, and, when reshaped, can maintain the new form upon cooling.

For pain in the forearm, wrist and hand, therapists should begin by warming up the fascia. Start with the superficial tissues, rolling around the forearm, wrist and hand to heat up the collagenous matrix of fascia. If the area is too tender for this exercise, consider warming up the tissues with brisk, broad friction such as full hand across the full surface of the forearm or hot packs.

From here, you can begin stretching the fascia with your hands crossed and your fingertips pushing away from each other along the length of the forearm, holding the superficial skin and fascia stretched until a release is felt. This release may take anywhere from 10 to 15 seconds up to a full minute. Since the key here is holding the stretch instead of gliding, no lubrication should be used.

You can start at the proximal end of the forearm and work your way systematically on a line to the distal end and across the wrist. Move your hands around the forearm to the next line and follow proximal to distal again. Follow this procedure to release the fascia of the entire forearm. Next, stretch the superficial tissues by torquing across or around the circumference of the forearm, gripping the forearm with both your hands and turning in opposite directions.

Once the superficial tissues are released, you can begin warming up the muscle tissues by applying light to moderate effleurage, using lubrication. Make your gliding movements from distal to proximal, keeping in mind the blood vessels and superficial circulation.

Start at the wrist on the thumb side of the flexor side of the forearm and glide up to the elbow until the tissue is warmed up and more supple. Repeat the gliding movement up the forearm, beginning at the following points around the wrist: center, ulnar side of the flexors, medial side of the forearm, ulnar side of the extensors, middle of the extensors and radial side of the extensors.

You can now use cross-fiber strumming to create a vibrational relaxation of the muscles. The pressure used and the number of strokes needed should be decided by the massage therapist. For example, a client just rolling out of bed before coming to an appointment may take a little longer to warm up than a person who comes to see you after a day of activity.

When the muscles have been warmed up, massage therapists can use deeper effleurage to thoroughly treat each muscle in the forearm, wrist and hand. Be sure to pay attention to your client, and be ready to amend the therapy as needed.

If you notice specific spots in the tissue that might benefit from less general stimulus, try effleurage and holding digital pressure to remove the cause of contraction. Or, hold digital pressure and use friction to stop trigger points from referring to a remote spot. You could also release entrapped nerves by using deepspreading effleurage or cross-fiber friction. Deep-spreading effleurage will improve circulation in deeper tissues.

Secondary Routine

When working with a specific location, it is imperative for massage therapists to remember the tissues that are proximal to the area they’re working on, as these tissues can be the cause of the pain. For example, when treating pain in the forearm, wrist and hand, be sure you consider the upper arm, shoulder and neck as the possible origin.

Referring to a trigger point chart can help you determine if there might be trigger point referrals from areas not included in the primary treatment protocol. You should also use your knowledge of anatomy to find any muscles that could be causing pressure on nerves. Common nerve entrapments or compression should also be considered, including where the nerves exit the cervical spine and past the scalenes. Additionally, you should check where the brachial plexus travels under the clavicle, where the brachial plexus travels under the pectoralis minor, and where the brachial plexus splits and passes between layers of the triceps.

Nerve root compressions can also be problematic, so look for paraspinal muscle tension around C-6, C-7, C-8 and T-1, as these muscles may compress or rotate the vertebrae, causing abnormal pressure on the spinal nerves. Larger, more superficial muscle forces can also compress vertebrae. For example, the sternocleidomastoid may be pulling the head down and forward, compressing the vertebrae. Anterior cervical muscles that straighten normal lordotic curve might cause discs to move posterior into the spinal nerves.

Remember, you should be specifically trained in local anatomy and techniques that safely avoid the nerves and blood vessels of the anterior cervical region.

The Extra Mile

When massage therapy isn’t helping resolve chronic pain—either for a massage therapist or a client— thinking about what causes the muscle tension in the first place can sometimes produce even better results. Potential causes include: Insufficient muscle strength or endurance; muscle imbalances; injuries from overuse, improper use or improper body mechanics; injuries from traumas and accidents; inflexible muscles.

Let’s take a look at these problems and potential resolutions individually, first discussing the issue followed by methods that may prove effective in helping.

Problem: Insufficient muscle strength and endurance.
Sometimes, injury is caused by not being properly physically prepared for the work. Massage therapy is physically demanding, so you need to know how to prepare you body for the hours of physical labor you’ll be performing.

Think of preparing your body this way: If a client came to you saying they’d been successfully lifting a 50-pound weight as part of their exercise regimen, but began experiencing pain after increasing the weight to 90 pounds, your immediate reaction would probably be that the increase in workload is inappropriate. As a massage therapist, you would expect the body to be injured when a person continues to do more than they are conditioned or prepared to do.

In exercise physiology, when a person’s body has become accustomed to an exercise being performed, the typical progression is to add 10 percent to the workload. Massage therapists need to be very aware of the strength and endurance needed to work the number of hours that will be required of them to make a living in this profession. Remember, massage therapy involves exercising our own muscles, especially the hands, arms, shoulders and chest.

Possible solution:
Injury of hands, wrists and other body parts is more likely to happen when a therapist is not strong enough for their desired workload. Daily exercises of squeezing a ball or putty can make the hands stronger in general.

Finger strength is imperative in a pushing movement, such as massage strokes where the hand does not close but fingers are flexing into the tissue. Fingertip push-ups can be very helpful in strengthening your fingers. Most people tell me they can’t do a regular push-up much less a fingertip push-up, but you don’t need to make the exercise complicated. Start by standing and leaning slightly forward to push off a wall, for example, then move your feet farther from the wall when you feel you are able. Soon enough, you’ll be doing fingertip push-ups on your knees and then, before you know it, a fully extended push-up.

You only need to progress any exercise you do to the level of conditioning required by your practice goals. If you plan to do four treatments per day, five days per week in a busy office, you need a different level of conditioning than someone who plans to supplement their income by doing one massage per evening.

The same can be said for endurance. Some of the problem for students coming out of school is that they are entering the work force and performing six hours of massage therapy where they used to perform one or two massages a day in a school clinic.

As with exercise, consider taking your time and building up the number of hours you work per day— whether new to the profession or recovering from an injury—until you reach your desired level of practice.

Problem: Muscle imbalances.
Often, an imbalance in antagonists allows one set of muscles to remain chronically shortened and contracted. An obvious example is the client with posture exhibiting a forward tilting pelvis and an increase lumbar curve.

The lumbar erector spinea, quadratus lumborum and multifidus may be massaged to release the contraction, pulling up the back of the pelvis. But, if the person continually comes back with the same posture, you need to figure out why. If the abdominal muscles that pull up on the front of the pelvis are too weak to counter the low back muscles that pull up on the back of the pelvis, this strength imbalance will cause the posterior muscles to keep shortening and the tilt will keep returning regardless of how many times we massage the posterior muscle.

In the same way, many massage therapists strengthen the forearm, hand and wrist flexors by squeezing various balls, grippers or putty, and, in doing this activity, create an imbalance between the flexors and the extensors. Without extensors to counter the flexors, a chronic excess tension on the flexor side of the forearm might create a perpetual ischemic condition where fatigue sets in more easily and pain is increased.

Possible solution:
As you might assume, the solution to this specific muscle imbalance is to do strength exercises that create a relatively balanced flexor/extensor strength relationship before strengthening both concurrently. You could put rubber bands around your fingertips or place your fingertips in firm putty to resist opening or spreading the fingers, thus strengthening the extensors. You might also be able to create resistance with the opposite hand while extending the fingers of the other.

Problem: Overuse &Improper use.
Even with good strength and endurance conditioning, there are limits to the amount of workload that can be placed on your forearms, wrist and hands. A properly designed training program must contain adequate stress, encouraging the body to adapt. When a body is overstressed to the point that it can’t adapt, training must be altered to the point where the person can adapt. Similarly, a massage therapist may need to maintain a moderate workload to allow for recovery before adding work.

Along with overuse, improper body mechanics is another big reason for pain in the forearm, wrist and hand. For example, many therapists wear out their thumb because of the way they use it. Imagine using your thumb while bracing the rest of your hand on the client’s body. The thumb starts from an extended position away from the little fingers, moving toward the palm while pressing into the muscle being massaged. The muscle action in this example would be predominately thumb adductors.

In contrast, if you hold your arm out straight in front of you and point the thumb so it’s in line with the radius bone, moving the arm forward and backward, the thumb is utilized for palpation while the bulk of the massage movement is still created from larger muscle groups. The thumb adductors would still be in an isometric contraction, but other muscles can provide stability and minimize the overall demand put on just a single body part.

Possible solution:
You can use several strategies to reduce the build up of tension in your daily work:

  • Look at the total current workload in light of the multitude of other possible stressors, including relationships, finances, and emotions, to name only a few. Ask how overstimulated the system is already before adding repetitive movements.
  • Review your own body mechanics and make adjustments so you are certain you’re not setting yourself up for future problems. Periodically look at your notes from school, or visit the AMTA’s online continuing education material and search for courses that deal with this topic.
  • Warm up your forearm, wrist and hand anytime they’ve been relatively inactive for an hour or two. Simply move the joints of the fingers, wrists and elbows for 10 to 15 repetitions. The exercise provides a basic warm-up of the muscles across these joints without fatiguing them, heats up the connective tissues in and around the joints, and moves fluid into the joints to act as a protective lubricant.

Problem: Injuries from trauma or accidents.
Traumatic injuries usually involve sudden excessive force to body tissues. This force can compress osseous and soft tissues, like falling on your own hand or arm, compression of only soft tissue, as happens when the tissue is struck by an object or stretched beyond its range of motion.

Although these injuries are going to first be treated to relieve inflammation, after dealing with the acute phase, ask yourself (or the client) these questions to determine how to proceed: What joints were compressed or impacted in the incident? What soft tissues were involved in the area of the primary impact? What are the primary symptoms? What soft tissues in other areas were affected by the injury?

Possible solutions:
For optimal results, a treatment plan should be tailored to a client’s own experience and their answers to the above questions. For example, consider if the wrist joints were compressed. We may apply traction as part of our treatment plan, as traction decompresses the joints, and, according to Hilton’s law, joint decompression results in the nerve segment being less stimulated. When the spinal segment is less stimulated, fewer reflex stimuli are sent out the motor pathway to the muscle.

Suppose, too, that the thumb and flexor side of the hand had compression trauma from the momentum of the body hitting the sidewalk. In this example, compression to the tissue seems to be the source of the problem, and so the massage therapist would want to choose techniques that avoided compression strokes and digital pressure. Instead, you would want to use massage techniques that spread fibers and lift the tissues, such as petrissage or effleurage in opposing directions starting from the compressed point in the thumb or wrist.

Massage therapists should also consider soft tissues in other areas that might be affected, in this case perhaps the elbow and shoulder, as they’d be the joints that stabilized the body and the point of contact. Two possible effects include soft tissue trauma and/or fiber tearing from the momentum of the body weight across the elbow and shoulder catching the fall, as well as joint compression or ligament stretching from the force of impact.

Taking an in-depth history from the client is necessary, as well as doing some active, passive and resistive testing for muscle, ligament and joint injuries that include a thorough palpation of the elbow and shoulder muscles to see which are ischemic, tender or in spasm. Having all this information gives the massage therapists a way of deducing if these proximal tissues may also be causing trigger point referrals to the hand and wrist, pressure directly on nerves from osseous or soft tissue origin, or excess stimulation of the reflex arcs at the spinal nerves that keep perpetuating the cycle of overstimulation.

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