Ep 73 - Pregnant + Hand Pain:"I Have a Client Who ..."Pathology Conversations with Ruth Werner

0:00:00.0 Speaker 1: Ruth Warner's best-selling book, A Massage Therapist's Guide to Pathology, is a highly regarded comprehensive resource that sets the standard for pathology education. Written for massage therapy students and practitioners, this groundbreaking resource serves up a comprehensive review of the pathophysiology, signs, symptoms, and treatment of more than 500 diseases and disorders. Learn more at booksofdiscovery.com.

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0:01:33.7 Ruth Werner: Hi and welcome to: I have a client who... Pathology conversations with Ruth Warner, the podcast where I will discuss your real life stories about clients with conditions that are perplexing or confusing. I'm Ruth Warner, author of A Massage Therapist's Guide to Pathology, and I have spent decades studying, writing about and teaching about where massage therapy intersects with diseases and conditions that might limit our client's health. We almost always have something good to offer, even with our most challenged clients, but we need to figure out a way to do that safely, effectively, and within our scope of practice, and sometimes, as we have all learned, that is harder than it looks.

0:02:20.4 RW: Today's episode comes from a post on a Facebook page that I would love to spotlight, and that is the massage sloth clubhouse. This is a lovely community of massage therapists who gather to ask questions and share experiences and support each other, not all Facebook pages about massage are this positive and gentle, and I love that participants sometimes share some really nice I have a client who stories here. So sometimes I work with the sloths to pick up some great stories to share, and I promise I will never share on I have a client who story without the contributors permission. Of course, the other way you can share stories with me is on my Facebook page, that's Ruth Warner's pathology page, or through my specially dedicated email address at ihaveaclientwho@abmp.com, that's ihaveaclientwho, all one word, all lowercase at abmp.com.

0:03:28.1 RW: So for today, from the massage sloth clubhouse, we have this interesting question, I have a client who is seven months pregnant and she's experiencing severe pain in both of her hands and wrists. She compares the feeling to carpal tunnel, she says it wakes her up at night, has anyone heard of this? And does anyone have suggestions on how to help her with massage? So we have a couple of different directions we can go with this question, we can talk about pregnancy, and we can talk about carpal tunnel syndrome, and what we'll do is talk about a little of both. So let me start with this. I'm not a highly educated specialist in pregnancy massage, if you want technical information, especially about safety for massage therapy for this population, you have to look for appropriate expertise. However, what I can say is that people who are pregnant tend to retain water in their extremities, and symptoms of carpal tunnel syndrome are very, very common among third-trimester pregnant people.

0:04:36.5 RW: One of the resources that I looked at suggested that about two-thirds of all pregnant people report carpal tunnel symptoms at some point. And this is especially true if that person has a job where they're working at a keyboard or with a mouse, or doing some other kind of repetitive movement with their hands for many hours every day. I am better prepared to talk a little bit about carpal tunnel syndrome, so let's do that first, and then we'll go back and look at what the implications are for massage therapy and this client. As I expect you are aware, carpal tunnel syndrome is a situation that happens when the median nerve is entrapped at the carpal tunnel, that's the small passageway on the anterior side of the carpal bones, where the median nerve and flexor tendons all have to pass through this tiny tight little channel, and if that channel or that tunnel gets too tight and too crowded, then the softest thing in there will be smashed, and that's the median nerve. The median nerve supplies the lateral aspect of the hand. What does that mean? Well, we have to go back to the first week of massage school and remember what anatomical position is, it's standing up with the forearms laterally rotated, so the thumbs are pointing outward and the palms are facing forward. So the lateral aspect of the hand then includes the thumb, the four finger, the middle finger, and the lateral half of the ring finger, along with the associated section of the palm of the hand.

0:06:19.8 RW: When someone has really a true carpal tunnel syndrome and no other nerve compression anywhere else, the symptoms will be felt only in that section of their hand. However, if they have symptoms in the little finger or the medial aspect of the ring finger, will this suggest an ulnar nerve issue rather than or in addition to the median nerve problem. The thing is, carpal tunnel syndrome is almost never that simple. I'm hoping that at some point I'll get an I have a client who story that opens the door for me to go down this rabbit hole a little deeper, because nerve compression syndromes that create confusing signs are really fun to talk about. For right now though, let's just leave it at this. If the median nerve is compressed just at the wrist, it will create symptoms in the hand and those symptoms can include things like numbness, tingling, pins and needles, sharp shooting electrical pain, weakness, and if it persists for a really long time, we can also see some muscle degeneration and that thumb hat or the hypothermia immense can shrink and shrivel. I do wanna point out though, that if the median nerve is irritated in one place like at the carpal tunnel, then it's possible for that whole nerve, which is wrapped in connective tissue to subtly swell.

0:07:51.5 RW: And what this means is that it may also be caught or snagged or compressed or torqued or irritated in other areas as well, where it has to pass through, for instance, the heads of the pronator teres or way up at the roots of the brachial plexus. So I'm hoping we'll get to talk more about the situation, which can sometimes have the somewhat alarming name of multiple crush syndrome another time, so be sure to send me your, I have a client who story is about thoracic outlet or carpal tunnel, or ulnar tunnel or tarsal tunnel syndromes, and we'll be able to take a closer look. I didn't get any more information from the contributor about her client, so I don't know for sure if her symptoms were limited to just her hands or if she was having issues in her forearms or other areas as well. What I can say is that the pattern that's been described here with symptoms on both sides that are worse at night, this pattern is textbook, it is very typical. A person who's having swelling in the extremities will have it on both sides, and so we would expect to see symptoms bilaterally.

0:09:02.9 RW: By the way, we see this happen with other sort of overall systemic edema situations, especially things like hypothyroidism. The good news here is that unlike more typical presentations of carpal tunnel syndrome that might be related to overuse syndromes, this is really likely to go away at the end of her pregnancy. As all that pregnancy related edema resolves, the pressure will probably come off the median nerve and this client will probably no longer have big problems. It seems to me that there might be a connection between people who develop carpal tunnel syndrome while they're pregnant and those who might have an increased risk for it later in life, but I've never seen any specific research or data on that question.

0:09:53.9 RW: So this woman is probably not going to have to contemplate various kinds of surgery or wrist injections to correct her hand pain, and that's terrific, but she does have to think about what she can do to function more effectively and to have less pain. Is massage therapy an option here? My short answer is sure, with some caveats. Here they are, Caveat number one, the biggest risk we have to consider in a situation like this, is the possibility that this client who is seven months pregnant is showing signs of a pregnancy-related complication called preeclampsia. This is a situation that can cause massive fluid retention, which could then lead to the symptoms in her hand. How do you rule out preeclampsia? Well, the obvious way is to ask if your client is undergoing regular medical care, which as a pregnant person, I hope she is, she'll be screened for preeclampsia, which also involves really high blood pressure, headaches, vision problems, urinary issues, and sudden weight gain. If you don't know for sure that she is free of this risk, it seems sensible to me to delay the massage until you get this important information.

0:11:16.6 RW: Caveat number two, anything you do that elicits any kind of pain in her hands must stop immediately. Caveat number three, if you have any education in lymphatic drainage techniques or manual lymphatic drainage, this is a good time to break out that skill, the situation is probably being brought about by congestion of interstitial fluids, so lymphatic work done with skill and expertise and sensitivity will probably be really helpful. And Caveat number four, even if you don't have training in lymphatic work, you can still focus on gently and carefully doing draining type of strokes with her upper arms and forearms, always, always, always watching for any signs that anything you've done elicits a pain response in her hands. I hope this client consults with her OB-GYN or her midwife who once preeclampsia is ruled out, will probably recommend hand splints at least to where at night. These devices work to keep the wrist in a neutral position, either flexor extended, which is the physician in which the median nerve has the most space, a lot of times when we sleep, especially if we sleep on our sides like late stage pregnant ladies do, we tend to curl up our hands and our wrists under our chins, and this is the one reason symptoms can wake someone out of a deep sleep.

0:12:44.8 RW: Do I think massage will fix this client's carpal tunnel syndrome symptoms? Well, I think it's likely that massage therapy could help at least for limited periods of time, and since pregnancy is a time when we'd like to avoid using pharmacological interventions, if we can, massage might make it possible to limit the use of anti-inflammatories and that's a win. All that said, this is a highly specialized population and they deserve a massage therapist who has appropriate education. So if you haven't already done it, I really encourage you, contributor, and any other listener who is thinking about working with pregnant clients to pursue advanced education in this field. Pregnancy massage is exciting, it's fulfilling, it's wonderful. It's life affirming, but it is not for doublers. So if we're going to do it, let's do it right.

0:13:40.2 RW: Hey everybody, thanks for listening to I have a client who... Pathology conversations with Ruth Warner. Remember, you can send me your... I have a client who stories to ihaveaclientwho@abmp.com. That's ihaveaclientwho, all one word, all lowercase at abmp.com. I can't wait to see what you send me and I'll see you next time.

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