Summary: The degree of accuracy in choosing and applying massage techniques will be reflected in the longterm client results.
Objective: At the end of this lesson, you should be able to identify the appropriate techniques for effecting change in each tissue layer.
Anterior Scalenes: The Story Continues
In the first lesson, we demonstrated an example of Carpal Tunnel Syndrome symptoms caused purely by the ASM. Identifying the true source of a pathology is the first important step to a permanent resolution for your client. The second is the accuracy of your treatment.
Each layer of tissue responds uniquely to pathology. By using a few simple tests, you will be able quickly discern where to tailor your treatment. As a reminder, take a look at the below diagram of the different layers we can treat.
In the case of our ASM causing Carpal Tunnel symptoms, each of these tests will give a positive or negative result to help pinpoint the origin of the issue. Negative results mean that that layer of tissue or potential origin can be excluded from the treatment. For example, a negative trigger point test with a positive strike test means that it is unnecessary to treat the muscle tissue but crucial to treat the skin layer. A negative Wartenberg’s Test would rule out tension in the middle or lower portions of the Anterior Scalene Muscle.
Common ASM Tests
Wartenberg’s Test
This test was proposed by Dr. P. Wartenberg in the 1930’s. It gives very accurate information if tension developed in the middle and lower thirds of the anterior scalene muscle.
The first part of the video shows the initial placement of the thumb for the execution of the test. Notice that the thumb must be placed flat just above the clavicle. The second part of the video shows the application of the pressure in the right spot. Notice how the thumb rotates and pushes down behind the clavicle. WT is considered positive if the patient feels acute pain while the practitioner applies even moderate pressure in this area or an already existing symptoms get worse. WT give 100% accurate information if the anterior scalene muscle (especially the middle and lower thirds associated with the median and ulnar nerves) irritates the brachial plexus.
Trigger Point Test (TPT)
Wartenberg’s Test is very accurate, but sometimes it does not give all of the information if tension is formed in the upper third of the scalene muscle. Thus, the practitioner should also use the TPT along with Wartenberg’s Test.
TPT is also easy to perform. Find the area of the main trigger point in the anterior scalene muscle, which is located half the distance between the mastoid process and the clavicle. After pushing the posterior edge of the sternocleidomastoid muscle medially, carefully re-direct pressure to the vertebral column. This area is sensitive in general, so use a moderate pressure. If the patient feels acute pain which radiates up to the mastoid process and/or sensory abnormalities down the arm, forearm and hand, the TPT is considered positive.
The TPT allows us to examine the tension in the upper third of the anterior scalene muscle associated with the radial nerve. If Wartenberg’s Test and/or Trigger Point Test are positive, the practitioner should always start the treatment of any abnormality of the upper extremity with the application of the MEDICAL MASSAGE PROTOCOL for the ASMS, which is presented below. Only after the tension in the ASMS is eliminated and the threat brachial plexus irritation is gone, the local part of the treatment should be applied (e.g., MEDICAL MASSAGE PROTOCOL for the Carpal Tunnel or Golfer’s Elbow, etc.)
If Wartenburg’s Test and/or the Trigger Point Test are positive, evaluate the degree of peripheral nerve(s) irritation and inflammation using the Sensory Test and the Motor Test.
Sensory Tests
The Sensory Test allows the practitioner to detect what part of the brachial plexus and subsequently which of five peripheral nerves innervating the upper extremity is irritated.
1. Ask the client to describe any pain, numbness, tingling or other unusual sensations to you. Pay close attention to the location of these. If any symptoms in the hand are caused by ASMS, different parts of the hand will correlate to a particular part of the brachial plexus irritated by the ASM:
Image by Royal Children’s Hospital Melbourne
2. Reinforce this by asking the patient to close eyes and to compare the sensations from both sides while the practitioner simultaneously strokes the same finger on the affected and unaffected side using the fingernails.
With two simple tests, we’ve managed to gain a great deal of accuracy as to the exact nerve source of the problem.
Motor Tests
The Motor Test allows the practitioner to find out if the ASM irritates the brachial plexus to the degree that muscle weakness develops secondarily to the irritation of the peripheral nerve. If the MT is positive it means that the therapist is dealing with a more difficult, sometimes chronic case which requires longer treatment. The client must be informed about that before he or she commits to the therapy.
Stand in front of the patient, cross your forearms and grasp the patient’s right hand with your right hand and his or her left hand with your left hand. Now ask the patient to slowly squeeze your hands with the same force until you tell him or her to stop and maintain the same pressure.
Concentrate on your sensations. You are examining three parameters:
1. General strength:
First, compare the general muscle strength or how the squeeze feels on the unaffected side as compared to the normal side. Remember that the patients primary hand is always stronger.
2. Correct grip:
Normally when an individual squeezes one’s hand, he or she applies more pressure using the thumb-index fingers, while the rest of the fingers support the hands compression. Let us consider that the patient has initial stages of the weakness of the thumb and thenar eminence of the hand. In such cases the practitioner will feel more pressure elicited by the 3rd-5th fingers instead of the thumb-index fingers. In another scenario, the weakness of the hypothenar muscles (5th finger eminence) the practitioner will feel as a soft, weak attempt of compression by the 3rd-5th fingers as compared to the unaffected hand. The white arrows indicate areas of muscle weakness during the hand squeeze.
3. Muscle Resistance to the Isometric Contraction:
The isometric contraction in much more energy demanding compared to the isometric contraction. This is why you will feel that the grip on the affected side may get weaker despite that initial 5 – 10 seconds of hand squeezes that felt the same on both sides.
MT allows the practitioner to evaluate the intensity of the clinical picture because motor abnormalities, muscle weakness, atrophy, trigger points, etc. appear later, after the sensory abnormalities have already formed and exhibited themselves.
Once you have eliminated tension in the ASM as a possible factor, move to the next potential area of nerve compromise until you either find a positive result or determine that the pain is indeed near the source. In our Carpal Tunnel example, the ASM (while likely) may not be the key. A similar clinical picture on the hand will be triggered by the tension in the pectoralis minor muscle or pronator teres muscle. Once that source has been determined, use laser-like accuracy to treat the appropriate tissue layer(s) for maximal clinical results.
Make this small change now in your practice for great effect on your clients.
Check back tomorrow for Lesson #3
