By David Weinstock
Originally published in Massage & Bodywork magazine, October/November 2000.
With the widespread use of computers, carpal tunnel syndrome and repetitive stress injuries (CTS/RSI) are quickly becoming the leading cause of workplace absenteeism in the United States. But computer operators are not the only ones affected with these maladies. Cashiers, hairdressers, massage therapists and countless other professionals can be seen wearing wrist braces in the line of duty. Allopathic medicine treats these conditions with anti-inflammatories, cortisone injections and ultimately surgery. However, almost all the physical therapists I’ve talked to who specialize in wrist and hand therapy agree that this surgery is mostly unsuccessful. Why? Because the underlying weaknesses and disorganization of the neuromuscular system have never been addressed. Post-treatment patients return to work and continue harming themselves, because they are still using the same maladaptive biomechanics as before. What can be done?
I divide CTS/RSI into two distinct stages. In the first or more acute stage, the client cannot tolerate any pressure applied to the muscles of the forearm or hand without a severe rebound effect. With this scenario, very gentle myofascial release techniques are applied (over several sessions if necessary) until the pain diminishes and medium to deeper pressure can be used. Once this is accomplished, the client moves into the second stage where neuromuscular reprogramming™ (NMR) can be used to remedy those underlying weaknesses and disorganization. Some clients enter therapy at stage two and can benefit from NMR immediately.
How does NMR work? With the use of very specific muscle tests, NMR can detect muscle weaknesses. These tests can also define complex compensation patterns which can be the origin of stubborn, recurring problems. More importantly, the tests cue the motor control center in the cerebellum. When the movement patterns are reorganized in a healthy fashion in the motor control center, then true and lasting changes can be realized. Other neuromuscular techniques may affect the loop from the spinal cord to the muscles; NMR, with its use of a specific muscle testing protocol, actually affects the motor control center.
In NMR we recognize three basic patterns of muscle relationship. The first is “functional opposites,” where the antagonist inhibits the agonist. For instance, someone who uses a computer will overuse his finger flexors (flexor digitorum superficialis and profundus). This might create weakness in the finger extensors. Is it enough to just recommend exercises to strengthen the extensors? No. This could exacerbate the imbalance because the flexors are inhibiting the extensors. The motor control center would actually instruct the flexors to work harder, thus creating a vicious cycle.
The appropriate protocol is to first test the extensors for strength. There could be weakness, for instance, at a distal interphalangeal (DIP) or proximal interphalangeal (PIP) joint and it could be anywhere in the joint’s range of motion. It is also necessary to test the wrist extensors. The second step is to release the flexors. In NMR, passive or active spindle cell releases are used, but many kinds of release work can be employed. Therapy localization technique is used to ascertain the exact spot in the flexors that is inhibiting the extensors. When a point in the flexor is touched while testing the extensor and the extensor is strengthened, we know that is the exact point we want to release. The third step is to retest the extensors. If they don’t test strong, we find another point on the flexor to release. If they do test strong, we then activate the flexor and challenge the extensor again to make sure it can withstand the rigors of repetitive motion in a new coordination pattern. This process is repeated four or five times to ensure the muscle’s new capability doesn’t disintegrate under duress.
The above example shows how overuse creates inhibition and that creates a new use pattern in the motor control center. The messages to the extensors are now going to the flexors. The NMR protocol allows for a reprogramming of the motor control center and lays down a new and healthy pattern. Your results with bodywork will be temporary unless you address the coordination patterns in the motor control center.
The second pattern is “core to extremity.” We find in this case that the muscles along the spine compensate for weaknesses in the extremities. For example, a weakness may be discovered in wrist extension that can’t be resolved in relation to the flexors. Instead, points along the upper thoracic and lower cervicals might be found which are compensating for wrist extension. The pattern is then released using the NMR protocol of test, release and retest.
The third pattern is “lines of force.” Muscle weaknesses are compensated for by other muscles that have fibers running in the same direction. For example, overuse of the thumb often leads to weakness in the thumb extensors (extensor pollicis brevis and longus). Muscles which can compensate include the extensor carpi radialis and ulnaris, brachioradialis, triceps, middle deltoid, supraspinatus, upper trapezius and scalenes. Specific tests determine the compensations and restructure the pattern. This is one of the most common situations I find in repetitive stress injuries, thereby making NMR an invaluable piece in resolving a puzzling pattern.
Another common RSI complaint is elbow tendinitis (especially medial epicondylitis). Tennis players, golfers, dentists and mechanics are some of the people who suffer. What creates this pattern? It is an imbalance in pronation and supination. Sometimes the pronator teres and the supinator can inhibit each other, especially in a precise, repetitive motion pattern like overusing a screwdriver. More often than not, the compensations occur along lines of force. If the thumb extensors weaken, then the supinator could take over. If the pronator teres weakens, the internal rotators of the shoulder (subscapularis, anterior deltoid, pectoralis major) can substitute. Clearly, overuse or underuse of the pronators or supinators can cause difficulties from hand to shoulder. This is where the NMR protocol is so successful in unraveling complex compensation patterns.
Grip strength is compromised in carpal tunnel syndrome. If the median nerve is compressed by swelling in the tendons of the flexor digitorum superficialis and profundus, the hand becomes weak and numb. If there is substantial tenderness, first use gentle myofascial release. Later, NMR is used to rebalance the finger flexors. One contributing factor can be a reciprocal inhibition imbalance between the opponens pollicis and opponens digiti minimi. Another is a line of force extending from the thumb through the flexor carpi radialis, palmaris longus and pronator teres to the internal rotators of the shoulder. Another is a line of force from the little finger through the flexor carpi ulnaris, the supinator and the external rotators of the shoulder. This is a crucial piece in carpal tunnel syndrome rehabilitation where NMR really shines because it addresses all of the relevant elements with its elegant detail and specificity.
Of course there are other factors that contribute to CTS/RSI. The brachial plexus must be freed up, with attention paid to the scalenes and the pectoralis minor. Cervical and thoracic subluxations, as well as subluxations of the shoulder, elbow and wrist, must also be addressed. Proper rest, splinting, posture, ergonomics and exercise are crucial elements in rehabilitation. Again, proper exercise is best implemented after unwinding the compensation patterns. I have seen too many disastrous results from clients improperly exercising, especially during weight-bearing activities for which their bodies are not properly organized. I have found the NMR approach, in combination with client cooperation, to be an excellent treatment for CTS/RSI.