Here are areas to work on, and techniques to apply:

Drain the front forearm before you work on your wrist. Start by placing your fingers on your elbow crease with the fingers pointing toward your hand. Then slide the skin toward your elbow. Once the area softens, slide your fingers to the leading edge of the soft area and pull that material back into the soft area that you have just created. Continue stroking until the entire area softens.

Flexors

If you are not sure of the muscle you are working on, ask the client to flex the muscle and consult a muscle chart. 

Note that ganglions found in this area-on either flexor or extensor side-usually are located in the tendons of the secundum or tertiary layer of musculature. 

The middle flexor layer is comprised of the following: the flexor digitorum superficialis, originating from the humeral medial epicondyle; the tubercle of the coracoid process; and the anterior oblique line of the radius. The insertion is in the palmar aspect of a middle phalanges of the medial four digits. 

Clear the superficial muscles using short pushing strokes. Continue to use short pushing strokes toward the muscle ends until the pain pressure is released. To clear any residue, use a combination of friction and push strokes. 

The deep middle flexor layer includes the flexor pollices longus (laterally). Indices for the index finger are the free portion of the flexor digitorum profundus and the medial aspect of this muscle layer. Use short pushing strokes until pressure is relieved on the pronator quadratus, then perform friction, as needed.

Back Forearm

You may need to spend some extra time in this area because the tissue content tends to thicken and be more sluggish than the content at the front of the arm.
Cup your hand around the elbow so that the tip of your middle finger is on the back of the elbow, exactly opposite where you have just been working. Slide the skin toward your elbow. Once the area softens, slide your fingers to the leading edge of the soft area and pull that material back into the soft area you have just created. Work your way down to the wrist. Continue stroking until the entire area softens.

Remember to use light pressure, about the weight of a nickel. Use a stroke that is 0.25-inch to 0.50-inch. Do one stroke per breath.

Extensors

Most of these muscles usually are packed with metabolite materials and dehydrated into a density approximating rock hard. Work here is slow and long. It takes a lot of hard, tedious labor to clear these muscles. Be patient and persistent.

The superficial posterior muscle group consists of, laterally, the brachioradialis, extensor carpi radialis and extensor carpi radialis brevis. Medially, they consist of extensor digitorum, extensor digiti minimi, extensor carpi ulnaris and anconeus. Use short push strokes until the pressure has been reduced. Follow with friction, as needed. 

The deep posterior muscle group consists of the supinator, abductor pollices longus, extensor pollices brevis, extensor pollices longus and extensor indices. Use short push strokes until the pressure has been reduced. Follow with friction, as needed. 

Beginning with short push strokes, and ensuring that the pressure has been reduced, will promote painless treatment.

Wrist

Finish the superficial portion by "milking the forearm." Then go a little deeper to relieve the tissues that wrap around the wrist and the tissues of the carpal tunnel. Imagine that there is a band all the way around the wrist. Stroke the imaginary band longitudinally, following it around your wrist.

Circle your wrist with your thumb and index finger (see Figure 1). Hold the skin with your thumb. Imagine that there is a band all the way around your wrist. Stroke the imaginary band longitudinally, following it around the wrist. Use a pull stroke with your index finger: Gently pull the skin away from the thumb, toward the edge of the hand. Work your way across the front of the wrist, using this technique.

Once the area softens, slide your fingers to the leading edge of the soft area and pull that material back into the soft area you have just created. Continue stroking until the entire area softens.

Cup your hand around the back of the opposite hand with your thumb, in the crease of the palm (see Figure 2, page 46). Use a pull stroke with your thumb, pulling the skin up toward the elbow. Work your way across the front of the wrist, using this technique.
Once the area softens, slide your fingers to the leading edge of the soft area and pull that material back into the soft area you have just created. Continue stroking until the entire area softens.

This is the end of the superficial portion of the carpal tunnel massage program protocol. If the tissues are not draining as easily now as they were during the earlier parts of the protocol, go back to the beginning and repeat the massage. If the condition continues to persist, get help from someone trained in this protocol or redo the protocol.

Once the pressure has been reduced below the pain threshold, lots of cross-fiber friction usually is in order. When that is completed, have the client take a drink of water. Follow up with slow, light work.

The main soft tissue structures of the wrist not previously noted are the flexor retinaculum and the extensor retinaculum. Hold one part of these structures while applying short push strokes longitudinally for the circumference of the wrist. 

The main contents of the carpal tunnel are the nine tendons with synovial sheaths, the flexors digitorum, the superficialis, the profundus with flexor pollicis longus and their synovial sheaths, and the medial nerve. 

The ulnar nerve and artery are in a separate penetration of the flexor retinaculum rejoining the carpal tunnel. 

The carpal tunnel itself is formed by the flexor retinaculum, extending from the pisiform and Hook of Hamate bones to the tubercles of the scaphoid (navicular) and trapezium carpal bones.

Hand

While the most widespread, Carpal tunnel syndrome is not the only painful condition of the hand that can be treated by lymph massage. An array of contractures and ganglions can occur in any tendon and much of the thumb musculature arises in the hand.

The hand is serviced by three nerves: the median, the ulnar and the radial. Injuries or impingements to these nerves almost anywhere along their pathways could result in a variety of pathological conditions. Some of these are: ape hand (median), claw hand (ulnar), wrist-drop (radial) and Dupuytren's contracture (palmar aponeurosis).

The intrinsic muscles of the hand are on the palmar aspect and are innervated by branches of the ulnar or median nerve. They are divided into three groups:

• Thumb (thenar) muscles;
• Little finger (hypothenar) muscles;
• Lumbrical muscles in the central compartment and the interosseous muscles between the metacarpal bones.

Generally, the palmar muscles are stroked from the muscle bellies toward their ends. The thenar muscles (abductor pollicis brevis, abductor pollicis, flexor pollicis brevis and opponens pollicis) are stroked from the palmar aponeurosis toward the middle of the first metacarpal, and from the base of the proximal phalanx, back toward the middle of the first metacarpal. 
These small muscles are stroked from the middle toward their ends. The first strokes start at the ends, stroking toward the ends, then move to the muscle middles and continue stroking toward the ends.

Work the hypothenar muscles (abductor digiti minimi, flexor digiti minimi brevis, opponens digiti minimi) from the base of the little finger toward the middle of the muscle group, and from the pisiform bone toward the middle of the muscle group.

Work the palmaris brevis muscle from the medial side of the hand toward the middle of the muscle, and from the palmar aponeurosis and the flexor retinaculum toward the middle of the muscle.

Work the lumbrical muscles from the tendons of flexor digitorum profundus and from the lateral sides of Digits II to V toward the belly of the muscles.

The interosseous muscles are in two layers: Four are on the palmar surface and four are on the dorsal surface. They are worked from their origins on the metacarpal bones and from the extensor expansions and bases of the proximal phalanges toward the middle of the muscle.
Have the client sip some water before you start working in these areas. Because the muscles and tissues are in a compact space, the content is in need of water.

Stephen E. Chagnon, BS, RN, LMT, practices in Glen Falls, New York, and can be reached at: 518-792-4607, or at: chagchi@capital.net. Also try: [www.carpaltunnelmassage.com].

This article was adapted from portions of Carpal Tunnel Massage Program for Yourself and Others by Stephen E. Chagnon (Chagnon Health Institute, 110 Glen St., Glens Falls, NY 12801). Copyright 1999.

References

1. Merck Manual (15th Edition). Merck Co., Rahway, New Jersey.
2. Berne, R. M. and M. N. Levy. Principles of Physiology. Philadelphia: C.V. Mosby Co., p. 275, 1990.