upper extremity nerve special thanks … extremity nerve entrapment syndromes facilitated by bob...
TRANSCRIPT
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UpperExtremityNerveEntrapmentSyndromes
FacilitatedByBobMcAtee,LMT,CSCS
Pro-ActiveMassageTherapyColoradoSprings,COwww.stretchman.com
#AMTAconv
SPECIALTHANKS
• Wemoveourprofessionforwardbysharingandbuildingontheworkofothers.Thankstothesecolleagueswhoallowedmetostandontheirshoulderstoday:
• DavidLauterstein andTheDeepMassageBook
• JoeMuscolino D.C.,prolificauthor,forhisbeautifulanatomyexamples.
• GroveHigginsD.C.forconsultingandstrategizingonthecoursecontent.
• WhitneyLoweforpermissiontousehisvideoassessments.
LearningObjectives
• Uponcompletionofthiscourse,participantswillbeableto:
• 1.Discussthecommonmechanismsofnerveinjuries.• 2.Delineatethepathwaysofthemedian,ulnar,andradialnervesthroughthearm.
• 3.Listthemajorentrapmentsitesforthemedian,ulnarandradialnervesoftheupperextremity.
• 4.Demonstratetypicalnerveassessmenttests.• 5.Discusspracticaltreatmentinterventionsformassagetherapists.
NerveInjuryMechanisms
• Stretch• Tear• Entrapment/Compression• CumulativeInjury(repetitivestress)• Crush(Double-Crushphenomena)
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NerveEntrapment/Compression• AKA:Nervecompressionsyndrome,compressionneuropathy,orentrapmentneuropathy.
• Usuallydefinedasdirectpressureonasinglenerve.
• Symptomsvarywidelyandmayincludepain,tingling,numbness,andmuscleweakness.
CompressionInjurySchematic
DoubleCrushSyndrome• Aperipheralnervecompressionsyndromeinwhichthereisa'central'compressiononanervebundle(e.g.atthenerverootorthethoracicoutlet)anda2ndmoreperipheralcompression(e.g.atthecarpaltunnel).
UENerveEntrapmentSites• 1. spine• 2. scalenes• 3. 1st rib/clavicle• 4. pec minor• 5.coracobrachialis
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NerveDistributionRegions ThoracicOutletSyndrome
• Thoracicoutletsyndrome(TOS)describesagroupofdisordersthatresultfromcompression,injury,orirritationofneurovascularstructuresattherootoftheneck,theupperthoracicregion,orbeneaththepectoralisminormuscle.
TOSLocations• AnteriorScaleneSyndrome:entrapmentbetweenanteriorandmiddlescalenemuscles.
• CostoclavicularSyndrome:impingementbetweenclavicleandfirstrib.
• PectoralisMinorSyndrome:entrapmentbetweenpectoralisminorandunderlyingribs. PhotoCourtesyofJoeMuscolino
Brachialplexus(C5–T1)
• Thelastfourcervicalspinalnerves,C5throughC8,andthefirstthoracicspinalnerve,T1,combinetoformthebrachialplexus
• Atangledarrayofnerves,splitting,combiningandrecombining,toformthenervesthatservetheupperextremityandupperback.
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NeuralTOS• NeurogenicTOS=95%ofcases,morecommoninwomen
• Bonyand/orsofttissuesinthelowerneck/upperchestcompressandirritatethenervesofthebrachialplexus.
• Symptoms:• Weaknessornumbnessofthehand(esp.4th-5thfingers).
• Atrophyofhandmusclesontheaffectedside.• Pain,tingling,prickling,numbnessandweaknessintheneck,chest,andarms.
ArterialTOS
• Impingementofthesubclavianarterybybonyorsofttissues.
• Symptoms:• Coldsensitivityinthehandsandfingers• Numbness,painorsoresofthefingers• Poorbloodcirculationtothearms,handsandfingers.
• Skinmaybepale.
VenousTOS• Venous:causedbyimpingementtothesubclavianvein.Thisveindoesnotpassthroughthescalenes,soisnotaffectedbyanteriorscalenesyndrome.
• Theconditiondevelopssuddenly,oftenafterunusualandtiringexerciseofthearms.
• Symptoms:• Swellingofthehands,fingersandarms.• Heavinessandweaknessoftheneckandarms.• Theveinsintheanteriorchestwallmayappearswollen.Skinmaybebluish/purple.
Assessment• AccurateassessmentofTOSsymptomsinourclientsisimportantbecauseTOSrespondswelltomassageandbodyworktreatments.
• Duetotheoverlappingofnatureofsymptoms,it’softendifficulttomakeadefinitiveassessment.It’scommontohaveneuralandvascularentrapmentsimultaneously.
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Tests• Thesethreeproceduresstartwithlocatingtheradialpulse.Adiminishedpulseduringthetestindicatesarterialimpingementatthestructurebeingassessed.Neuralsymptomsmayalsoincreaseduringtesting.
• Adson’sTest:AnteriorScaleneSyndrome
• Eden’sTest:CostoclavicularSyndrome
• Wright’sTest:Pec.MinorSyndrome
PalpateRadialPulse• Assessmentofthestrengthoftheclientsradialpulsewhentheclientisrelaxedandinaneutralposition.
• ThisisdoneatthebeginningoftheassessmentforeachofthethreeTOSlocations.
Adson’sTestforAnteriorScaleneSyndrome
• Theclientrotatestheheadtoward(oraway)fromtheaffectedside,thenlaterallyflexesawayfromtheaffectedside,thenextendstheneck,whilethepractitionerpalpatestheradialpulse.
• Accentuatethetestbyhavingtheclienttakeandholdadeepbreath(scalenesarerespiratorymuscles).
• Decreaseinstrengthoftheradialpulseispositiveforanteriorscalenesyndrome.
EdensTestforCostoclavicularSyndrome
• Clientpullstheshouldergirdlebackanddownandpushesthechestforward(militaryposture),whiletheradialpulseispalpated.
• Accentuatethetestbyhavingtheclienttakeandholdadeepbreath(liftsribstighteragainstclavicle).
• Decreaseinstrengthoftheradialpulseispositiveforcostoclavicularsyndrome.
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WrightsTestforPec.MinorSyndrome
• Passivelymovetheclient’sarmupandback,whiletheradialpulseispalpated.
• Accentuatethetestbyhavingtheclienttakeandholdadeepbreath(liftsribstighteragainsttautpec.minor).
• Decreaseinstrengthoftheradialpulseispositiveforpectoralisminorsyndrome.
TreatmentGoals
• Short-term:relievetheimpingementsontheaffectedstructurestoallowthemtoheal.
• Long-term:correctupperquadrantposturalasymmetries(slumpedshoulders,forwardheads,hyperkyphosis,etc.)tokeepthethoracicoutletopen.
AddressingScalenes
• Reducinghypertonicityinthescalenes,especiallytheanteriorandmiddlebellieswillhelprelievepressureonthebrachialplexusasitexitsthecervicalspine.
• Caution:deepmassagetothescalenes whenthey’realreadytootightiscounterproductiveandmaycausemoreirritationtothenervoussystem.
• Considerusinglightpressureasthiscanbemoreeffectiveinhelpingrestorepropertone.
ScalenesandElevatedShoulders
• Reducingscalenehypertonicityallowsthewholeribcagetodrop,releasingthechronicallyelevatedshouldergirdleandcreatingspacebetweentheclaviclesandthefirstribs.
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ScaleneHypertrophy• FromMikeReinold.com:• Oneofthemajorreasonsthat
thoracicoutletsyndromeoccursinbaseballpitchersisfromhypertrophyofthescalenemuscles(andSCM).Throwingabaseballcausesmanyadaptationstothebody,includingthisincreaseinscalenesize.
• Herearephotosoftheathleteinhalingwithhisheadturnedtoeachside.NoticethesignificantlylargerscaleneandSCMonhisrightside.
TreatmentInterventions:Scalenes
• Scalenes Sweep
• Scalenes FacilitatedStretch
ScaleneSweep• Themostcomfortablewayto
workscalenes,whichalsohelpspulltheforwardheadbackandupontopoftheshoulders,istosweepacrossthemfromtheanteriorneckallthewayaroundtothespinousprocesses,thusassistingtheotherneckmusclestomigrateback.
• Inallcases,erronthesideofconservativenesswithyourpressure.Thepointistodrawthemusclesback,nottopressintotheneck- especiallynotpressinghardintotheanteriorandlateralaspect.
CourtesyofDavidLauterstein’s“TheDeepMassageBook”
ScalenesStretchontheTable
1. Active lateral flexion of the neck to stretch the scalenes.
2. Easy isometric contraction of the stretched scalenes.
3. Active stretch to new range motion Askmetodemonstratetheshrug
stretchoption.
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AddressingPectoralis Minor
SincethePectoralis MinorisacommonentrapmentareainThoracicOutletSyndrome,reducingthehypertonicity inthethisareaiscritical.
PalpatingPectoralisMinor
• Withtheclientsupine,layyourthumbalongtheclavicle,thenslideinferiorlyintothesofttissue.
• Slidelaterallyuntilyoucometothefirstbonyprominence(thecoracoid),whichisusuallyquitetender.
• Pecminorattachmentisat7o’clock(leftside).
• Coracobrachialisat6o’clock,• Bicepsbrachiiat5o’clock.
TreatmentInterventions:Pectoralis Minor
• PinandStretch
• FacilitatedStretch
PinandStretchTechniquePectoralisMinor:
•Withclientsupine,usethepadsofyourfingerstopalpatethepectoralisminoratthecoracoidattachment.
•Gentlystretchthemuscleinferiorly,awayfromthecoracoidprocess,whiletheclientpullstheshoulderstowardthetableandbringstheshoulderbladestogetheranddown,asifputtingtheminthebackpockets.
•Thenasktheclienttoexternallyrotatethearmsandslidethemupthetabletowardtheirheadtoincreasethestretchonthepecminor(andthepecmajor).
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PecMinorStretch• Thisstretchreduceshypertonicityin
thepecminorandmayreducecompressionontheneurovascularstructures.
• Holdtheclient’shandtokeepthearmfrombouncingaround.
• Clientfirststretchesbypullingtheshouldertowardthetableandslidingthescapuladowntheback.
• Duringtheisometricphase,theclientattemptstopushtheshouldertowardtheceiling.
CommonMedianNerveCompressionSyndromes
• PronatorTeresSyndrome
• CarpalTunnelSyndrome
MedianNervePathway MedianNerveEntrapmentSites
• 1. spine• 2. scalenes• 3. 1st rib/clavicle• 4. pec minor• 5. coracobrachialis• 6. ligament of struthers• 7. pronator teres• 8. flexor digitorum arch• 9.carpaltunnel
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IllustrationsofEntrapment1.Entrapmentatthepronatorteres
2.Fibrousarchoftheflexordigitorumsuperficialis.
3.Lacertusfibrosus(bicipitalaponeurosis)
4.supracondylarprocessandligamentofStruthers
AssessingNerveMobility
• GlidersandSliders• Usingassessmentstohelppinpointpossibleentrapments
PronatorTeresSyndrome
• Acompressionneuropathyofthemediannerveatthepronatorteres.
• Oftenaccompaniedbymedialepicondylitis
PronatorTeresSyndrome
• Symptoms:• Paresthesiainthumb,index,middlefingerandradialhalfofringfinger(similartocarpaltunnelsyndrome).
• Paresthesiaoftenmadeworsewithrepetitivepronation-supination.
• Differentiate fromcarpaltunnelsyndrome(CTS):• exacerbatedbyrepetitiveelbowflexion• achingpainoverproximalforearm• lackofnightsymptoms
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PronatorTeres Syndrome Assessment• The client stands with the elbow in 90 degrees of flexion.
• Place one hand on the client's elbow for stabilization and hold the client's hand in a handshake position.
• The client holds this position as you attempt to supinate the client's forearm (forcing the client to contract the pronator muscles).
• While holding this isometric effort, straighten the client's elbow (stresses flexor digitorum superficialis).
CarpalTunnelSyndrome(CTS)• Compressionneuropathyofthemediannerveasitpassesundertransversecarpalligament.
• Oftenresultsfromtenosynovitisoftheflexortendonsinthecarpaltunnel.
• Consideredarepetitivestresscondition.
• DoublecrushconditionmakesthenervemoresusceptibletoCTS.
CarpalTunnelAnatomy• The carpal tunnel,
formed by the carpal bones and the flexor retinaculum, contains 9 sheathed tendons:
• 1 flexor pollicislongus
• 4flexordigitorum superficialis• 4flexordigitorum profundus• Andthemediannerve.
CarpalTunnelSyndrome(CTS)• Symptoms:• Paresthesia,numbness,paininthemediannervedistributionofthehandandfingers.Atthewrist,thenerveiscomposedofover90%sensoryfibers.
• “Nightsymptoms”causedbysleepingwiththewristsflexed.
• PrimaryAssessment:• Phalen’s Test
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NoteAboutCarpalTunnel• Truecarpaltunnelsyndrome
doesnothavesensorylossoverthethenar eminence.
• Thisisbecausethepalmarcutaneousbranchofthenerve(sensory),whichinnervatesthatarea,branchesoffthemediannerveandpassesoverthecarpaltunnel.
• Thisfeatureofthemediannervecanhelpseparatecarpaltunnelsyndromefromthoracicoutletsyndrome,orpronatorteressyndrome.
CarpalTunnelSyndromePhalen’sTest
• Theclientpressesthebackofthehandstogethertoflexthewriststoapprox.900.
• Ifpain,paresthesiaornumbnessinthemediannervedistributionarereproducedwithinabout60seconds,thetestisconsideredpositive.
CarpalTunnelTetheredMedianNerveTest
• Usefulindetectingchronic,low-grademediannervecompression.
• Producesthegreatestamountofdistalnerveexcursioninthecarpaltunnel.
• Performbyhyperextendingthesupinatedwristandtheindexfingerforoneminute.
CarpalTunnelTinel’s Test
• Lightpercussionoverthemediannerveasitpassesunderthetransversecarpalligament.
• Theleastsensitiveofthemediannervetestsbutisthemostspecifictestformedianneuropathyatthecarpaltunnel.
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MedianNerveTreatmentGoals
• Short-term:relievetheimpingementsontheaffectedstructurestoallowthemtoheal.Accomplishthisthroughsoft-tissueworkandstretching.
• Long-term:identifyandcorrectperpetuatingfactors.
EffectiveTreatment Interventions
• PinandStretchTechniques
• TransverseFriction
• FacilitatedStretching
PinandStretch:ForearmFlexors• Clientsupine.• Supinatedforearmfullysupportedonthe
treatmenttable,withthewristfreetoflexandextend.
• Beginningatthefully-flexedwrist,useyourloosefisttoapplyafirmglidingstroketowardtheelbow,alongthelengthoftheforearmwhiletheclientslowlyextendsthewrist&fingers.
• Formorespecificwork,useasmallercontact,suchasaflatthumbpointingalongthelengthoftheforearm.
PinandStretch:PronatorTeres• Clientsupine.Upperarmfullysupported
onthetreatmenttable,withtheelbowbent.
• Withtheforearminneutralorsomewhatpronated,useabroadthumborloosefisttoapplyafirmglidingstrokediagonallyfromtheradialattachmenttothemedialepicondylewhileslowlysupinatingtheforearm.
• OKtokeeptheforearmonthetableandusealoosefistforthestroke.
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TransverseFriction:Forearm• Usetransversefrictionworkto
addressadhesionsinmuscles,tendonsandligamentsandtoreleasethemediannerveentrappedinthesetissues.
• Startwithgeneralfrictiontoanentirestructureandthengetmorespecificasnecessary.
• Toperformtransversefrictionwell,palpatethedesiredstructureandthenworkacrossthegrainofthetissue.Applythestrokeusingathumborfinger,asifgluedtotheskin.
TransverseFriction:Wrist• Usefingersorthumbtoapply
transversefrictiontothetendonsandtheretinaculumatthewrist.
• Startwithgeneralfrictionandthengetmorespecificasnecessary.
• Toperformtransversefrictionwell,palpatethedesiredstructureandthenworkacrossthegrainofthetissue.Applythestrokeusingathumborfinger,asifgluedtotheskin.
FacilitatedStretching:WristFlexors• Clientsupine,forearmfullysupported
onthetable,wrist&fingersfullyextended.
• Matchyourfingersandthumbtoclient,useyourotherhandtostabilizetheforearm.
• Directtheclienttoslowlytrytoflexthewristandfingers,whileyoupreventthemovement.Holdthisisometriccontractionfor6seconds.
• Aftertheisometric,theclientactivelystretchesbyextendingthewristandfingerstoanewROM.
FacilitatedStretching:Pronators• Clientsupine,elbowbent,forearmsupinated.• Supporttheforearmwithonehandandplacetheotheracrossthewristandhand.
• Directtheclienttoslowlytrytopronate,whileyoupreventthemovement.Holdthisisometriccontractionfor6seconds.
• Aftertheisometric,theclientactivelystretchesbysupinatingtoanewROM.
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CommonUlnarNerveCompressionSyndromes
• CubitalTunnelSyndrome
• Guyon’sCanalSyndrome(cyclistspalsy)
UlnarNervePathway
UlnarNerveEntrapmentSites
• The6sitesofpotentialulnarnerveentrapmentaroundtheelbow:arcadeofStruthers,medialintermuscularseptum,medialepicondyle,cubitaltunnel,deepflexorpronatoraponeurosis(betweentheheadsoftheflexorcarpiulnaris)andGuyon’scanal.
ArcadeofStruthers• Thinaponeurosisextendingfrommedialheadoftricepstothemedialintermuscular septum.
• NottobeconfusedwiththeLigamentofStruthers(whichmaycompressthemediannerve).
• Located8-10cm(3-4in.)proximaltothemedialepicondyle.Notalwayspresent.
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CubitalTunnelSyndrome• Ulnarnervecompressionattheelbowisthe2nd mostcommonnerve
entrapmentoftheupperextremity,aftercarpaltunnelsyndrome.• Thecubitaltunnelisformedbythetwoheadsofflexorcarpiulnaris.
Oneheadblendswiththeflexortendonattachmentsatmedialepicondyle(humerus),theotherattachestotheolecranonprocess(ulna).They’reconnectedbyanaponeurosis.
CubitalTunnelSyndrome• Symptoms mayinclude:• pain,paresthesia,burning,andweaknessinthefifthfingerandulnarsideofthefourthfingerandnumbnessinthedorsalulnaraspectofthehandandfingers.
CubitalTunnelSyndromeElbowFlexionTest
• Clientstandswithelbowsflexedandwristsextendedfor30-60seconds.
• Thispositioncompressestheulnarnerveatthecubitaltunnelandaddssomestretchatthelevelofthewrist.
• Symptomsmayappearinlessthan30seconds.
Cyclist’spalsy
• Duetocompressionoftheulnarnerveatthewrist(Guyon’scanal).
• Symptomsincludepinsandneedlesinthelittleandringfinger.
• Mayalsoincludeimpairedmotorfunction.
• Oftenpresentalongwithcubitaltunnelsyndrome(double-crush).
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UlnarNerveTreatmentGoals
• Short-term:relievetheimpingementsontheaffectedstructurestoallowthemtoheal.Accomplishthisthroughsoft-tissueworkandstretching.
• Long-term:identifyandcorrectperpetuatingfactors.
EffectiveTreatment Interventions• UlnarNervetreatmentfocusesonthesamemusclegroupsasforMedianNerve,withtheadditionofcoracobrachialis.
• PinandStretchTechniques
• TransverseFriction
• FacilitatedStretching
Coracobrachialis
• Noticethecompactrelationshipbetweenbicepsandcoracobrachialis.
• Palpationandfrictionworkontheinsideofthearmwillhelpidentifynerveentrapmentineitherthemedianortheulnarnerve(ArcadeofStruthers).
CommonRadialNerveCompressionSyndromes
• RadialTunnelSyndrome
• PosteriorInterosseousNerve(PIN)Syndrome
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RadialNervePathway RadialNerve&TeresGroup
• Theradialnervedivesposteriorandpassesnexttothelongheadofthetricepsandthroughthespacebetweentheteres minorandtheteresmajor.
RadialNerveEntrapmentSites
• RadialnerveentrapmentistheleastcommonofthethreemainUEnerves.
• Themostfrequentsiteofcompressionisattheradialtunnel(ArcadeofFrohse)attheproximaledgeofthesupinatormuscle.
ArcadeofFrohse• Theedgeofthearcadeisnormallythinandmembranous.
• Athickened,tendinous proximaledgeisdevelopmental,occurringin30–100%ofpeople,likelyduetorepetitivepronation–supination.
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RadialTunnelSyndrome• Compressionofthesensoryfibersoftheradialnerve.
• Symptoms: pain,paresthesia,ornumbnessnearthelateralepicondyle.Achingorburningsensationalongthelateralaspectoftheforearm,mimickinglateralepicondylitis.
RadialNerve(PIN):PosteriorInterosseusBranch
• Posteriorinterosseousnervesyndrome(motorfibers):weaknessoftheextensormusclesoftheforearm.
• Alsocalledsupinatorsyndrome.
RadialTunnelSyndromeAssessmentIsometricMuscletests:1.Clientattemptssupination,withelbowextended(tominimizebicepsbrachii recruitment).2.ResistedLongFingerExtension.PositiveTest=increasedpainorweakness.
RadialNerveTreatmentGoals
• Short-term:relievetheimpingementsontheaffectedstructurestoallowthemtoheal.Accomplishthisthroughsoft-tissueworkandstretching.
• Long-term:identifyandcorrectperpetuatingfactors.
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EffectiveTreatment Interventions
• PinandStretchTechniques
• TransverseFriction
• FacilitatedStretching
PinandStretch:ForearmExtensors
• Clientsupine.
• Thepronatedforearmisrestingonthetreatmenttable,withthewristfreetoflexandextend.
• Beginningatthefully-extendedwrist,useyourloosefisttoapplyafirmglidingstroketowardtheelbow,alongthelengthoftheforearmwhiletheclientslowlyflexesthewrist&fingers.
• Formorespecificwork,useasmallercontact,suchasaflatthumbpointingalongthelengthoftheforearm.
PinandStretch:ForearmSupinator• Clientsupine.Holdthe
forearminneutral,upperarmrestsonthetreatmenttable.
• Beginningatthedistalendofthesupinator,useyourloosefisttoapplyafirmglidingstroketowardthelateralelbow,whilepassivelypronatingtheclientsforearm.
• Formorespecificwork,useasmallercontact,suchasaflatthumb.
TransverseFriction:Forearm• Usetransversefrictionworktoaddress
adhesionsinmuscles,tendonsandligamentsandtoreleasethemedianentrappedinthesetissues.
• Startwithgeneralfrictiontoanentirestructureandthengetmorespecificasnecessary.
• Toperformtransversefrictionwell,palpatethedesiredstructureandthenworkacrossthegrainofthetissue.Applythestrokeusingathumborfinger,asifgluedtotheskin.
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FacilitatedStretching:WristExtensors
• Clientsupine,forearmsupportedonthetable,loosefistwiththumbinside.
• Wrapyourhandoverthefist,useyourotherhandtostabilizetheforearm.
• Directtheclienttoslowlytrytoextend(open)thewristandfingers,whileyoupreventthemovement.Holdthisisometriccontractionfor6seconds.
• Aftertheisometric,theclientactivelystretchesbyflexingthewristandfingerstoanewROM.
FacilitatedStretching:Supinator• Clientsupine,elbowbent,forearmpronated.• Supporttheforearmwithonehandandplacetheotheracrossthe
wristandhand.• Directtheclienttoslowlytrytosupinate,whileyoupreventthe
movement.Holdthisisometriccontractionfor6seconds.• Aftertheisometric,theclientactivelystretchesbypronatingtoanew
ROM.
PalpationPractice
• Locatecoracoidprocess(whatmusclesattachhere?)
• Coracobrachialisinupperarm• Arcadeofstruthers(ulnarnerve)• Ligamentofstruthers(mediannerve)• Pronatorteres(mediannerve)
AssessmentWorkflow• ClientHistoryandSymptomPattern
• WorkingHypothesis:TOSorOther
• AppropriateNeuralTests– TOS:Adson’s,Eden’sWright’s
– AssessforPronatorTeres Syndrome,CarpalTunnel(Phalen’s),CubitalTunnel(ElbowFlexion),RadialTunnelSyndrome.
– NerveGlides
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TreatmentStrategies
• Protect(Don’tOver-Treat,WorkinthePain-FreeZone)
• PinandStretch• TransverseFriction• FacilitatedStretching
• Nerveglides
BruggerReliefPosture
• Sitwithyour“sitbones”attheedgeofthebench/chair.
• Lengthenyourbackandneckandtuckyourchin.
• Dropyourshoulders.• Externallyrotateyourarmssothepalmsfacetotheside.Keepyourfingersaswideaspossible.
• Holdthispositionfor10seconds,relax,repeat5-10times.
Self-Care:ResistanceBandPulldowns
• Thisexerciseengagesthescapularretractorsanddepressorsasyoupullthebandslowlyoutwardanddownwardtothebaseoftheskull.
• Tuckyourchintoyourthroatandkeepyourearsoveryourshoulders.Don’tbendtheneckforward.
• Yougetthemostbenefitfromtheeccentricphaseoftheexercise.
Self-Care:ResistanceBandPulldowns
• Exhaleasyoupullthebanddownandout.
• Complete8-10repetitionsperset.
• Performingthisexercisebetweenclientsessionswillretrainyourshoulderandupperbackmuscles.
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RecommendedReading• OrthopedicAssessmentinMassageTherapy
• byWhitneyLowe
• FreedomfromThoracicOutletSyndrome
• ByJoeMuscolino,D.C.• AMTAJournal,2006• http://www.amtamassage.org/articles/3/MTJ/detail/1666
References• Miller,T.andReinus,W.NerveEntrapmentSyndromesofthe
Elbow,Forearm,andWrist.AmericanJournalofRoentgenology,2010195:3,585-594,http://www.ajronline.org
• Elhassan,BandSteinmann,S.EntrapmentNeuropathyoftheUlnarNerve.JAmAcad Orthop Surg November200715:1,672-681
• Tubbs,RS,etal.ThearcadeofStruthers:Ananatomicalstudywithpotentialneurosurgicalsignificance.Surg Neurol Int.2011;2:184.
• Graham,B.CarpalTunnelSyndrome.TheWorkplaceSafetyandInsuranceAppealsTribunal,Ontario,Canada.May2001.
• http://www.wsiat.on.ca/english/mlo/carpal.htm
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