The practice of clinical massage provides wonderful opportunities to learn new things about the body and help people who are looking for relief from their pain and injury complaints. In this installment, we follow the case of Dustin, a professional piano player whose pain in his arm and hand is impairing his preparation for an important audition.
Dustin began having significant forearm and hand pain about three weeks prior to his first visit. His family doctor diagnosed his condition as medial epicondylitis, with possible early stage carpal tunnel syndrome (CTS). He was prescribed anti-inflammatory medication to address the epicondylitis and given stretching exercises to perform at home.
As a professional musician, Dustin spends a great deal of time at the piano, both in practice and performance. In the last two months, he has greatly increased the amount of time he practices every day in order to prepare for an upcoming audition. Unfortunately, Dustin’s pain is interfering with this preparation. The anti-inflammatory medication and treatment regimen from his doctor has not helped very much, so he is exploring other options.

Background and Key Considerations
After performing a comprehensive intake history, there are several key factors that are important to note:
• The pain is predominantly in his right hand.
• There is discomfort in his forearm, but the primary pain is felt in his hand.
• He reports the pain in his hand as sharp and penetrating.
• He also experiences significant loss of coordination in his right hand while playing.
• There are times when it feels like his fingers freeze up.
• He’s been playing piano professionally for many years.
• He recently increased his daily practice time.

There are key findings in the history that indicate likely involvement of epicondylitis and/or nerve entrapment. Yet, other conditions can produce similar symptoms, so it is always important to perform a thorough assessment to make sure all the existing signs and symptoms are consistent. When evaluating the information derived from any part of the assessment process, it should fit the pattern of the condition(s) of the diagnosis. While most of the elements from Dustin’s history are consistent with the diagnosis he was given, there are some factors that warrant further investigation.

Initial Physical Evaluation
A comprehensive series of range of motion and resistance tests were performed for Dustin’s elbow, forearm, and hand region. None of the active, passive, or resisted tests/motions reproduced the primary pain Dustin was experiencing. These tests evaluate dysfunction in the local tissues that produce the movements being tested. Sometimes, if a condition is not very severe, it won’t be painful with range-of-motion testing because the tissues are not significantly stressed. However, if the root cause of the problem is in fact epicondylitis and/or carpal tunnel syndrome, and given the severity of the pain he described, some of these procedures should be reproducing that pain.
In order to gather more information, three commonly used special orthopedic tests were also employed. The golfer’s elbow test helps identify the likelihood of medial epicondylitis. In this test, the practitioner applied pressure to the common flexor tendons just distal to the medial epicondyle of the humerus while simultaneously resisting the client’s wrist flexion. Dustin reported mild discomfort with this procedure, but said it did not reproduce his primary pain.
Phalen’s test is one of the best-known procedures for evaluating carpal tunnel syndrome. In this procedure, the client placed the back side of the hands together and held them in that position for about 60 seconds. If this position reproduces neurological pain in the hand, there is a good likelihood of median nerve compression in the carpal tunnel. However, this test did not reproduce any of Dustin’s pain.
The tethered median nerve stress test is also considered accurate for identifying median nerve compression in the carpal tunnel. In this procedure, the index or middle finger is pulled in hyperextension while the wrist is also fully extended. Pain reproduced with this procedure is indicative of median nerve pathology. Dustin reported some mild discomfort with this procedure, but nothing that significantly reproduced the primary pain he experiences when playing the piano.
Based on client history and characteristics of the reported pain, Dustin appeared to have a pretty severe form of neurological impairment in his hand. He also reported loss of coordination in many of his movements, pointing to motor nerve dysfunction. If there was a local nerve compression in the carpal tunnel, it would likely reproduce Dustin’s symptoms during some of the assessment tests, but none reproduced his pain.
Passive and active wrist hyperextension, which would stretch the affected nerve, would also likely increase pain if Dustin had carpal tunnel syndrome. Passive or active flexion might also cause discomfort, as the contents of the carpal tunnel are further compressed at the end of wrist flexion movements.
If there are indicators of neurological involvement, but none of the tests that stress local neurological tissues reproduce pain, the condition may not be a local nerve compression at all. There may be a systemic neurological problem that should be considered.
During the evaluation, there were two key pieces of information in Dustin’s history that warranted deeper inquiry. He mentioned a loss of coordination and a feeling that the fingers in his right hand were freezing up as he was playing the piano. These characteristics indicate some type of motor nerve involvement, but are not commonly described symptoms of local nerve compression in the wrist. Because of these ambiguities in the symptom pattern, Dustin was encouraged to see a neurologist to perform more detailed diagnostic studies of these apparent neurological symptoms.
There was no apparent contraindication to massage and it was still possible that his soft-tissue pathology would benefit, so there was mutual agreement to proceed with an initial treatment session. Initial treatment was aimed at addressing chronic overuse in his forearm muscles and corresponding nerve entrapment that might be occurring in the upper extremity. Dustin was pleased with how he felt after the session and agreed to make an appointment to return after he consulted the neurologist.

Dustin’s Return
Dustin returned three weeks later after having had a successful consultation with the neurologist. He was very thankful for the detailed initial evaluation in the first massage appointment and the recommendation to see the neurologist. The neurologist informed him that while many of his symptoms were quite similar to medial epicondylitis and carpal tunnel syndrome, he was actually suffering from a condition that is common in musicians called focal dystonia or musician’s cramp.

Medial epicondylitis and carpal tunnel syndrome are both examples of a local tissue dysfunction where pathology develops in those tissues as a result of chronic overuse. Focal dystonia is quite different. In a 2013 article, researcher H. S. Lee described the condition as “characterized by abnormal involuntary sustained muscle contractions in a single body part,” generally specific to a particular type of task, such as playing the piano.1 The symptoms are experienced in the forearm and hand, similar to a local tissue dysfunction, but the root of the problem is actually in the brain.
In focal dystonia, the brain sends incorrect information to the muscles and abnormal muscle recruitment patterns develop. When various movements are performed repeatedly, as happens in playing a musical instrument, correct neuromuscular programming is disrupted and the motor signals given to the muscles are no longer properly coordinated. The improper motor coordination leads to painful muscular spasms, problems with coordination, and a sensation of muscles seizing. An analogy frequently used to describe focal dystonia is that of a hard drive crash or computer virus, where the instructions from the main processing center, in this case the brain, are seriously disrupted.

Treatment Strategies
Today, we have a better understanding of the role of massage in treating chronic overuse disorders that involve local tissue dysfunction such as local nerve entrapment, muscle strains, tendinosis, or tenosynovitis. But a clinician would be right in questioning whether massage would be beneficial in Dustin’s case, since focal dystonia is a brain and neurological system disorder and not a soft-tissue overuse issue.
There is very little in the research literature about the use of massage in treating focal dystonia. However, there is no physiological reason that massage shouldn’t be used within normal precautionary parameters. In fact, there are some concepts we now understand about myofascial anatomy and physiology that would help create a beneficial massage treatment strategy for this problem.
Robert Schleip, a well-known fascial researcher and bodywork therapist, wrote about sensory mapping in the brain from the myofascial system in his groundbreaking articles on fascial physiology.2 He states, “It commonly comes as a big surprise to many people to learn that our richest and largest sensory organ is not the eyes, ears, skin, or vestibular system, but is in fact our muscles with their related fascia. Our central nervous system receives its greatest amount of sensory nerves from our myofascial tissues.”3
With this in mind, it seems possible to reorganize some of the dysfunctional neurological programming by influencing neurological input to the brain through soft-tissue treatment of the myofascial tissues. Consequently, numerous myofascial massage applications could be helpful in conjunction with other treatments Dustin might employ.
While medial epicondylitis and carpal tunnel syndrome may not have been the primary pathologies in this condition, the dysfunctional muscular coordination of focal dystonia could easily lead to these complications in the local tissues. Thus, it is still helpful to focus significant attention on reducing cumulative tightness in the wrist and finger flexor muscles, as they are responsible for every repetitive keystroke on the piano.
Because problems in the wrist and finger flexor muscles can easily lead to median nerve entrapment in the proximal forearm, as well as in the carpal tunnel, Dustin will benefit from deep, specific stripping applications to the muscles along the pathway of the median nerve. Addressing the muscles along the nerve’s pathway can help reduce the likelihood of overuse in those tissues.
There is no single traditional medical treatment method that has proven to be highly successful in treating focal dystonia. Commonly used strategies include acupuncture, psychotherapy, relaxation therapy, and other body therapy approaches.4 Botox injections are frequently used to address the local muscle spasms, but this has numerous adverse effects on the delicate and precise muscular coordination that is needed for the musician to continue playing.
An interesting treatment strategy that is increasingly used is the wearing of latex gloves by the musician while playing. Because the gloves slightly alter the pattern of sensation associated with touching the piano keys, this can create new neurological pathways and potentially override the dysfunctional neurological patterns that have developed.5
This case points out the critical importance of taking a thorough history and paying close attention to the pattern of signs and symptoms being presented. Dustin came in with an existing diagnosis from a general practice physician, but the results of the clinician’s initial assessment did not seem to match that diagnosis. At a point where unusual signs and symptoms are present, it is always a good idea to consider a referral for a second opinion, or reevaluate the condition.
Dustin greatly benefited from the massage treatment because there was a physiological rationale for how the treatment could be incorporated with his existing treatment approaches. Massage, in Dustin’s case, was used both as a preventive treatment for other conditions and experientially to influence neurological input to the brain by treating the myofascial tissues, perhaps ultimately reducing the focal dystonia symptoms.

Notes
1. H. S. Lee et al., “Musicians’ Medicine: Musculoskeletal Problems in String Players,” Clinics in Orthopedic Surgery 5, no. 3 (2013):155–60.
2. Robert Schleip, “Fascial Plasticity—A New Neurobiological Explanation: Part 1,” Journal of Bodywork and Movement Therapies 7, no. 1 (2003): 11–19; Robert Schleip, “Fascial Plasticity—A New Neurobiological Explanation: Part 2,” Journal of Bodywork and Movement Therapies 7, no. 2 (2003): 104–16.
3. Robert Schleip, “Fascial Plasticity—A New Neurobiological Explanation: Part 1.”
4. Floris T. van Vugt et al., “Musician’s Dystonia in Pianists: Long-Term Evaluation of Retraining and Other Therapies,” Parkinsonism & Related Disorders 20, no. 1 (2014): 8–12.
5. J. Paulig et al., “Sensory Trick Phenomenon Improves Motor Control in Pianists with Dystonia: Prognostic Value of Glove-Effect,” Frontiers in Psychology 5 (2014): 1,012.

Whitney Lowe is the author of Orthopedic Assessment in Massage Therapy (Daviau-Scott, 2006) and Orthopedic Massage: Theory and Technique (Mosby, 2009). He teaches advanced clinical massage in seminars, online courses, books, and DVDs. You can find more ideas in Lowe’s free enewsletter—and his books, course offerings, and DVDs—at www.omeri.com.