Tricks of the Trade
Clients always seem to come to us with their aches and pains. Sometimes the area that hurts is not the area that causes the pain. As a trainer, I am not qualified to make a diagnosis, so I would tell my client to see a doctor for a diagnosis and then offer to show the client some stretches to alleviate the pain and reduce the symptoms.
Pain from carpal tunnel issues can show up in several places. A client may feel it in his neck, shoulder, upper back, chest, armpit, upper arm, elbow, forearm, wrist, palm, thumb and/or fingers. Based on where the pain is, I would show him stretches for the affected area(s). The stretches should be slow, soft and gentle. He should hold the stretches at the correct stretch point (a feeling of tiny stretching or aching sensation in his muscles) until he feels the release. The release is when the stretch point disappears, and the muscle softens and lengthens.
Another thing the client can do to help reduce the symptoms is to make sure he has a good chair with an adjustable seat. The seat can be raised so his knees are level with or slightly lower than his hips, and his feet are flat on the floor. Adjustable arm rests are great, and the client can adjust them to be a half-inch lower than his forearms. He should try not to use the arm rests for constant support because doing so can cause shrugging in the shoulders and result in stress in the neck, shoulders and upper back. The seat back should be locked into position. Leaning back in the chair can cause the client’s head to be positioned forward of his torso. This leads to strain in the chest, neck, shoulders and upper back.
Last, a client can wear wrist braces during the day to help keep the wrist supported. Sometimes, just wearing a brace for a few weeks can make all the difference. Some clients bend their wrists back at night when they sleep, which could be causing the pain during the day. FUTURO™ (www.Futuro.com) has a wrist support that clients can wear when they sleep. It not only supports the wrist, but it keeps fingers in a neutral position all night, which reduces stress on the carpal tunnel area.
All of these things can help reduce the pain from carpal tunnel problems, but these clients do need to see a doctor to determine the actual cause of the pain.
Holly Kouvo Fitting Fitness In™ Boxborough, Massachusetts
First, I want to be sure the client understands her symptoms and her diagnosis, if she has received one. If she has not had a diagnosis, it does not mean that she should not be exercising. However, I always recommend that the client obtain an evaluation by a licensed medical provider.
Carpal tunnel is often an “umbrella” label given to many upper-extremity repetitive-strain-type injuries. This is important since so many repetitive-stress injuries to the wrist and hand regions are directly related to body mechanics and soft-tissue fibrotic changes at the elbow, shoulder and cervical and thoracic spines.
Carpal tunnel symptoms include tingling, numbness, weakness or pain in the fingers or palm. Depending on the severity of the symptoms, I always consider the possibility of loss of grip strength due to weakness or reflexive inhibition. This loss of strength means avoiding any situations where a client needs to stabilize free weights overhead or over the face, as in a supine chest press. I always omit any movements or positions that provoked the symptoms.
Proactively, I provide corrective exercises to address postural issues throughout the kinetic chain. Along with the appropriate corrective exercise intervention, I instruct the client on self-myofascial release techniques that begin with the entire shoulder girdle region of the affected extremity. This should be progressed along the oblique fascial lines to the opposite hip of the affected extremity.
Locally on the affected extremity, I provide gentle stretches for the wrist and finger flexors and forearm pronators. The wrist- and finger-flexor stretching exercises are always done with the elbow both flexed and extended.
I also discuss the client’s work environment or hobbies that may have predisposed her body to the bio-mechanical breakdown. Very often, some simple changes to environment and technique can have a big impact. Taking periodic breaks during the activity also allows normal circulation to return to the overworked tissue.
Anthony Carey MA, CSCS, CES CEO, Function First San Diego, California
The first thing I do is ask the client when he was first diagnosed and by whom. It is important to ascertain that a qualified medical professional has diagnosed him and that he did not self-diagnose. I then inquire as to what treatments have been tried and what the success rate was. In addition, I transmit a Physician Approval for Activity form to his physician and/or physical therapist. This form allows medical professionals to communicate relevant information such as contraindications and side effects of medication(s).
The next step is to observe the client’s posture (static and dynamic). As is often said, “If you are not assessing, then you are guessing.” Poor posture and muscle imbalances will influence the cervical spine and shoulder. If the shoulder and neck are compromised (e.g., an elevated and internally rotated shoulder), this can irritate the brachial plexus and specifically the median nerve. The brachial plexus and the resulting median nerve arise from the cervical spine and pass through the shoulder; therefore, dysfunction of these two regions can immediately wreak havoc on the associated neuromyofascial tissues. In the case of carpal tunnel syndrome (CTS), the symptoms manifest themselves in the wrist, but the root problem is higher up the chain.
When addressing observed muscle imbalances and postural dysfunctions, I suggest using the following evidenced-based approach:
Step 1. Do myofascial release of observed hypertonic (short/tight/overactive) tissues such as the scalene, sternocleidomastoid, latissimus dorsi, pectorals, supraspinatus and infraspinatus.
Step 2. Use various forms of flexibility (static, PNF, dynamic) to further restore optimal length tension relationships in the tissues that myofascial release was performed on. Make sure to stretch not just individual muscles but myofascial lines.
Step 3. Strengthen the hypotonic (weak/lengthened/underactive) tissues. These tissues are the functional antagonists to the above-mentioned hypertonic tissues. When strengthening these tissues, focus on improving both intramuscular and intermuscular coordination.
Why aren’t the traditional approaches to carpal tunnel issues working? In my experience, the traditional approaches of stretching, immobilization braces, corticosteroid injections and surgical release are not working because they seek to address the symptoms instead of addressing the underlying root cause of the problem. For example, if you search online for stretches related to CTS, you will find pictures and videos that demonstrate extension of the wrist. This is accurate, yet it fails to stretch the tissues above the elbow. The majority of people I’ve encountered with CTS have poor upper-extremity posture and multiple muscle imbalances. By addressing these imbalances and deficits, I’ve always seen a reduction in the symptoms (pain) and often seen the syndrome disappear.
Bill Sonnemaker, MS, PES, CES, CSCS
CEO, Catalyst Fitness
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