THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE

Volume 14, Number 3, 2008, pp. 259267

Mary Ann Liebert, Inc.
DOI: 10.1089/acm.2007.0647

Comparison of a Targeted and General Massage Protocol on

Strength, Function, and Symptoms Associated with Carpal
Tunnel Syndrome: A Randomized Pilot Study
ALBERT MORASKA, Ph.D.,1,2 CLINT CHANDLER, B.S., L.M.P., C.N.M.T.,2
AMANDA EDMISTON-SCHAETZEL, Ph.D.,2 GAYE FRANKLIN, B.A., L.M.T.,2
ELAINE L. CALENDA, L.M.T.,2 and BRIAN ENEBO, Ph.D., D.C.3

ABSTRACT
Objective: Carpal tunnel syndrome (CTS) is a major, costly public health issue that could be dramatically
affected by the identification of additional conservative care treatment options. Our study aimed to evaluate the
effectiveness of two distinct massage therapy protocols on strength, function, and symptoms associated with
CTS.
Design: This was a randomized pilot study design with double pre-tests and subjects blinded to treatment
group assignment.
Setting/location: The setting for this study was a wellness clinic at a teaching institution in the United States.
Subjects: Twenty-seven (27) subjects with a clinical diagnosis of CTS were included in the study.
Interventions: Subjects were randomly assigned to receive 6 weeks of twice-weekly massage consisting of
either a general (GM) or CTS-targeted (TM) massage treatment program.
Outcome measures: Dependent variables included hand grip and key pinch dynamometers, Levine Symptom and Function evaluations, and the Grooved Pegboard test. Evaluations were conducted twice during baseline, 2 days after the 7th and 11th massages, and at a follow-up visit 4 weeks after the 12th massage treatment.
Results: A main effect of time was noted on all outcome measures across the study time frame (p  0.001);
improvements persist at least 4 weeks post-treatment. Comparatively, TM resulted in greater gains in grip
strength than GM (p  0.04), with a 17.3% increase over baseline (p  0.001), but only a 4.8% gain for the
GM group (p  0.21). Significant improvement in grip strength was observed following the 7th massage. No
other comparisons between treatment groups attained statistical significance.
Conclusions: Both GM and TM treatments resulted in an improvement of subjective measures associated
with CTS, but improvement in grip strength was only detected with the TM protocol. Massage therapy may be
a practical conservative intervention for compression neuropathies, such as CTS, although additional research
is needed.

1School

of Nursing, University of Colorado at Denver and Health Sciences Center, Denver, CO.
College of Massage Therapy, Boulder, CO.
3University of Colorado Hospital, Aurora, CO.
2Boulder

259

260

MORASKA ET AL.

INTRODUCTION

arpal tunnel syndrome (CTS) is a disabling neuropathy

that affects the median nerve and impairs wrist and hand
function.1,2 It is the most commonly reported nerve-compression syndrome seen in occupational health care3,4 and
is responsible for a significant number of lost work days,5
functional limitations, and worker disability,6 as well as associated economic impact.7
The classic symptoms of CTS include pain and paresthesia along the radial side of the hand and palm2 that directly correspond to the median nerve distribution.810 The
array of symptoms reported by patients include sensory disturbances presenting as pain, numbness, tingling, and burning.8,10,11 Motor dysfunction is witnessed by a loss of coordination, and muscle weakness as noted by decreased grip
and pinch strengths.2,12 Nocturnal pain, which interrupts the
sleep cycle, is often a result of an increase in intracarpal
pressure owing to flexion or extension positioning during
sleep.13 Nocturnal symptoms can often be resolved by splinting, shaking, or rubbing the arm and hand,14 which may suggest an ischemic origin to these problems.
Typically, conservative care is recommended prior to surgical intervention for CTS.15 Although conservative care can
consist of a broad spectrum of modalities, including nonsteroidal anti-inflammatory drugs (NSAIDS) and splinting,
little research has been conducted on complementary therapies, such as massage therapy, chiropractic care, neural mobilization, or yoga, that are direct conservative interventions.1620 Development of tested manual therapy protocols
are important to further the acceptance and broaden the use
of conservative care options for CTS and may reduce the
need for surgical intervention.
The development of CTS is often subsequent to fibrotic
tissue build-up and associated compression within the carpal
tunnel. For example, tendon friction from repetitive motion
can result in the formation of fibrous adhesions among the
soft tissues, causing pain and reducing function of the
hand.21 Functional limitation can also result from mechanical compression on the median nerve as a consequence of
hyperplasia and general thickening of the flexor retinaculum,22 median nerve epineurium,23 synovial lining of the
tendon sheaths,13 and encroachment by the lumbrical muscles.24 Musculoskeletal pain, both localized and referred, is
a major factor in many cases of CTS.25 Massage and related
manual therapies may be effective for the relief of nerve
compression owing to its ability to reduce connective tissue
fibrosis, edema, or musculoskeletal disturbance.
The aim of this study was to evaluate two distinct massage therapy protocols in the treatment of CTS. The general
massage (GM) protocol emulated a relaxing massage that
would reduce muscle tension and facilitate circulation in the
upper body, while the targeted massage (TM) protocol focused on the affected upper extremity and addressed areas
of constriction, ischemia, and nerve entrapment that are

likely in patients with CTS. The hypotheses were that subjects receiving the TM protocol would experience significant improvement on outcomes measures of grip and pinch
strength, fine motor control, and perceived symptom severity relative to subjects receiving the GM protocol, but both
groups would report significant improvement over baseline
values.

METHODS
Design
The effects of two massage therapy treatment protocols
were assessed using a repeated measures experimental design that allowed for both within- and between-group comparisons. Baseline measures for the dependent variables
were determined twice, at a 4-week interval, immediately
prior to massage. Participants then received 12 structured
massage treatments over the following 6 weeks, with dependent variables measured two days after the seventh and
eleventh sessions. A follow-up evaluation was conducted 4
weeks after the final (twelfth) massage.

Sample
Recruitment and retention of participants. A total of 28
persons with CTS were enrolled and 27 completed the 14week study; 1 subject was removed from the study owing to
an illness unrelated to CTS or massage. Participants were recruited through flyers and posters distributed throughout the
community, as well as advertisements in a local newspaper.
Inclusion/exclusion criteria. All participants provided
written documentation of a clinical diagnosis of CTS (ICD
code 354.0) by a medical practitioner (MD, DO, or DC)
prior to inclusion in this study. Additional inclusion criteria
included a positive CTS diagnosis in one or both upper extremities for at least 6 months prior to enrollment into the
study. Persons who had surgery for CTS were not accepted
into the study unless a nonoperative upper extremity also
met enrollment criteria for CTS. To minimize the effect of
potential confounding variables in this study, individuals
who were pregnant, who smoked, or had diabetes mellitus
were excluded. Subjects were not specifically screened for
the presence of other upper extremity compression neuropathies, such as thoracic outlet syndrome. Participants
were asked to refrain from receiving concurrent manual therapies or acupuncture during the study; this was verified at
study completion. Additionally, medication intake for CTS
was limited to the use of nonprescription pain relievers on
an as needed basis.
Assignment to treatment groups. Participants were randomly assigned to either the GM or TM massage treatment
groups. Participants were unaware of alternative massage

TARGETED VERSUS GENERAL MASSAGE FOR CTS

treatment groups; thus, single-blind conditions were maintained.
IRB approval and consent procedures. The Institutional
Review Board at the Boulder College of Massage Therapy
(Boulder, CO) approved the study procedures. Informed
consent was obtained prior to subject enrollment into the
study.

Massage therapy procedures

Massage was administered by degreed massage therapists
(certified massage therapist, licensed massage therapist, or
licensed massage practitioner) with an average of 10.4 years
(range, 515) of experience in professional practice.26 Three
(3) male and 2 female massage therapists participated in this
study. Prior to the treatment phase of the study, each therapist attended four, 2-hour-long training sessions supervised
by the two therapists who designed the massage protocols.
During these sessions, therapists observed a demonstration,
practiced, and also received the treatment protocol. In addition, the therapists were asked to practice the protocol for 3
hours prior to beginning the study.
Massage was administered in a private room at a college
wellness clinic with low lighting and without any audio accompaniment. All therapists were given strict instructions
to limit the session to exactly 30 minutes, refrain from discussion of the participants condition or progress, and avoid
modifying the treatment protocol. Conversation with the
study participants was limited to the current treatment and
could include explanation of the technique, body positioning, depth of pressure, and so forth.
GM protocol. The GM protocol was designed to model
a typical relaxing massage session and focused on reducing
muscular tension and enhancing circulation to the back,
neck, and both upper extremities. Each 30-minute GM treatment was applied bilaterally and consisted of: (1) 15 minutes of effleurage, petrissage, friction, passive motion, and
cross-fiber friction all directed at the back and neck with the
subject in a prone position27 and (2) 15 minutes of effleurage, traction, petrissage, linear friction, jostling, and
stretching performed on both arms, forearms, and hands with
the subject in a supine position.27
TM protocol. The 30-minute TM treatment was aimed at
probable sites of nerve entrapment along the afflicted upper
extremity. Participants remained in a supine position for the
entire treatment with a cylindrical bolster under the knees.
The protocol was designed to (1) address any increased volume of fluid in the carpal tunnel region, (2) reduce connective tissue restriction (i.e., thickening or adhesions), and (3)
decrease contractile tissue hypertonicity at potential points
of nerve entrapment along the course of the brachial plexus
and median nerve pathway.

261

A double crush condition has been proposed for upper

extremity syndromes, such as CTS.28 In this condition, nonsymptomatic impairment of axoplasmic flow at more than
one site along a nerve might summate to cause a symptomatic neuropathy. Therefore, the TM treatment was directed at anatomic sites along the peripheral nerve pathway
of the upper extremity and areas treated included: cervical
intervertebral foramen, the scalene triangle, pectoralis minor, ligament of Struthers, bicipital aponeurosis, pronator
teres, transverse carpal ligament, and the palmar aponeurosis.
The TM protocol was administered in the following sequence during each session: (1) 3 minutes of lymphatic
drainage of the thorax and axillary regions29; (2) 8 minutes
of mobilization, soft-tissue manipulation, myofascial release, traction, and friction directed at the neck and shoulder region30,31; (3) 9 minutes of myofascial release, soft-tissue manipulation, and mobilization directed at the chest and
upper arm31; and (4) 10 minutes of pin and stretch, crossfiber friction, stretching, and flushing techniques were performed on the forearm and hand.27

Outcome assessment instruments

Assessments that were used to determine participant
progress included both objective and subjective measures of
hand strength, function, and symptoms in the CTS affected
limb. To avoid any confounding immediate effect of massage and reduce participant burden, assessments were conducted immediately prior to the 8th and 12th massage sessions. Outcome assessments were conducted 2 days
following the 7th and 11th massage sessions. Evaluators
were not blind to subject group assignment.

Strength measures
Hand and finger strength was determined by using handgrip and pinch dynamometers.32 For both tests, the subject
sat with feet positioned on the floor, shoulder adducted, and
the elbow bent at a 90-degreeo angle with the forearm parallel to the floor. Maximal isometric grip strength was measured in kilograms, using a Baseline hand dynamometer
(Fabrication Enterprises, Inc., White Plains, NY). The subject held the dynamometer between the fingers and palm of
the hand and was instructed to compress the grip maximally
and relax. The process was conducted a total of three times
and the results averaged. To avoid the confounding effect
of pain or fatigue that may occur with this assessment, this
test was performed last.
Maximal isometric pinch strength was used to measure
the force of prehension and was conducted immediately
prior to grip-strength determination. A Baseline pinch gauge
(Fabrication Enterprises, Inc.) was placed between the subjects first finger and thumb in a key grip formation. Subjects were then instructed to apply as much force as possible to the strain gauge bars and relax. Force was recorded

262

MORASKA ET AL.

RESULTS

in kilograms. This procedure was conducted a total of three

times and the results averaged.

Demographics
Symptom measures
The Symptom Severity Scale (SSS) was used to assess
CTS symptoms in the affected hand.11 The questionnaire
consists of 11 questions in which the subject rates how severely CTS affects different aspects of their daily life in a
typical 24-hour period over the previous 2 weeks. Each
question is rated on a scale from 1 to 5, with 1 indicating
absence of difficulty in the given task and 5 the most severely debilitating. Questions pertain to sleep, hand sensation (i.e., numbness and tingling), and ability to grasp or
hold objects.

Functional measures
A questionnaire to assess hand function in subjects with
CTS was used in this study.11 The Functional Status Scale
(FSS) consists of eight questions regarding the difficulty of
performing various daily tasks, such as writing, buttoning
clothes, and opening jars on a typical day during the previous 2 weeks. Subjects score each task on a scale from 1 to
5, with 1 representing no difficulty and 5 representing an
inability to perform the task owing to hand or wrist symptoms. Both the FSS and the SSS have been reported to be
reproducible, internally consistent, and sensitive to clinical
change.11
Functional measures were further assessed by the
Grooved Pegboard test. The Grooved Pegboard test
(Lafayette Instruments, Lafayette, IN) is a timed procedure
that requires the subject to align 25 grooved pegs into a
board with specific peg orientation. Care was taken to ensure the subject used only finger and wrist movements to
place the pegs, per the manufacturers instructions. Scores
were achieved by adding the time to perform the test (in seconds) plus the number of pegs drops plus the number of pegs
placed in the pegboard.

Statistical measures
Subject demographic characteristics were analyzed with
an unpaired t test. Outcome measures of strength, function,
and symptom severity were assessed by repeated measures
analyses of covariance (RM-ANCOVA), using StatView for
Windows Software (SAS Institute, Cary, NC). ANCOVA
analysis was selected, given the baseline strength differences
between groups resulting from unequal gender distribution
of the treatment groups.33 The second baseline measure
(baseline 2), which was determined immediately prior to the
treatment phase, was used as the covariate. A paired t test
with a Bonferroni transformation was used for post-hoc
within-group comparisons. Data are presented as the
mean  95% confidence interval (CI) after adjusting for the
covariate. A priori -level of 0.05 was established to determine statistical significance.

For the 27 participants who completed the study, there

was no measurable difference between groups (GM vs. TM)
in reported age (p  0.50) or years since symptom onset
(p  0.14) (Table 1). Participants reported an average of 5.4
years since symptom onset (range, 130); median age was
48.6 years (range, 2378). Gender distribution differed
slightly between groups; in the GM group, there was 1 male
and 12 females; the gender distribution for the TM group
was 4 males and 10 females.
No significant difference was detected between baseline
1 and 2 for either group on measures of strength or function. However, the imbalance in gender among groups resulted in the TM group exhibiting greater grip and pinch
strength upon entry into the study; this difference has been
accounted for in the analysis by using values from baseline
2 as the covariate.

Strength
The main effect of time indicated that grip strength (Fig.
1) improved over the course of the study (p  0.001); the
interaction indicated that the TM group experienced a significantly greater strength increase compared to the GM
group (p  0.04). A 17.3% improvement in maximal isometric grip strength was detected for the TM group with an
increase from 25.1 to 29.5 kg (p  0.001; 95% CI 27.731.3
kg) noted over the course of the study. For participants who
received GM, a statistically nonsignificant increase from
25.1 to 26.3 kg (a 4.8% increase) in grip strength was observed (p  0.21). Improvement in grip strength for the TM
group was first detected after the 7th massage session and
was maintained following the 11th massage and at least 4
weeks after the last treatment (p  0.01, for all time points).
No statistical strength gain was observed between the 7th
and 11th treatment sessions.
The normative grip strength for an age-matched healthy
population obtained from a published meta-analysis is 32.4
kg (95% CI 27.437.4).34 Figure 2 presents a comparison
of grip strength for study participants to the normative value.
At baseline, subjects in the present study reported a grip
strength of 77.6% of the normal population, which was below the 95% CI. At study follow-up, grip strength was
88.8% of the normal population for subjects receiving TM
TABLE 1. DESCRIPTIVE CHARACTERISTICS
OF THE STUDY PARTICIPANTS

General
Targeted

Age (years)  SD

Female

Male

Years with
CTS ( SD)

50.3  15.1
47.0  8.80

12
10

1
4

5.6  7.3
3.5  3.1

SD, standard deviation; CTS, carpal tunnel syndrome.

263

TARGETED VERSUS GENERAL MASSAGE FOR CTS

FIG. 1. Grip strength was measured by using a Baseline hand

dynamometer (Model #12-0247; Fabrication Enterprises, White
Plains, NY). Grip strength improved across the study time frame
(p  0.001), with a greater increase in grip strength for the targeted massage group (p  0.04). Data are presented as the mean 
95% confidence interval after adjusting for the covariate effect of
the baseline 2 time point. *Indicates a significant difference from
baseline 2 value, at p  0.01.

treatment, whereas the GM group reported 79.9%. The TM

group, but not the GM group, ended the massage phase with
grip strength within the 95% CI of the normal population.
Figure 3 presents maximal isometric pinch strength for the
TM and GM treatment groups. No significant difference was
detected between the two treatment groups for key-grip pinch
strength (p  0.11), although pinch strength for all subjects
increased over time (p  0.001). Pinch strength increased
from 6.6 kg at baseline 2 to a peak of 8.3 kg (p  0.01; 95%
CI 7.78.9) for the TM group and to 7.2 kg (p  0.15; 95%
CI 6.67.8) for the GM group after the 11th massage. These
changes represent 24.8% and 9.4% increases, respectively,
over baseline. A 21% improvement over baseline was also
noted at the 4-week follow-up for the TM group (p  0.01).

The average score on this subscale at baseline 2 was 1.9. A

significant main effect of time was detected for massage
therapy over the course of the study (p  0.001), although
no interaction was detected (p  0.34). However, simple effects for the TM group indicated progressively improved
scores on functional measurements across the course of the
study (p  0.016), whereas the GM group did not vary from
baseline measures (p  0.10). The TM group reported its
lowest scores at the 4-week follow-up (1.6  0.2); the GM
group reported its lowest scores following the 11th treatment (1.7  0.2).
The Grooved Pegboard test provided an objective measure of hand dexterity by requiring subjects to place asymmetrical pegs into a grooved pegboard, using only finger
and wrist movement. All subjects placed the allotment of 25
pegs into the board with 01 dropped pegs per session; in
no case was more than 2 pegs dropped during a test. A reduction in pegboard score was detected across time (p 
0.001), with scores from the TM group decreasing from 104
at baseline 2 to 98 ( 4.8) and in the GM group from 104
to 95 ( 5.2) following the massage treatment phase. At follow-up, scores were 97 and 98 for the TM and GM groups,
respectively. No difference was detected between the two
massage procedures (p  0.41).

DISCUSSION
Two massage protocols were tested for their effectiveness at improving hand-specific strength and function and
reducing symptoms associated with CTS. Both massage protocols were equally effective at improving measures on subjective tests, such as the Levine Symptom Severity and

Symptoms
A subjective evaluation of CTS symptom severity was
determined by using the SSS questionnaire. At baseline 2,
the average score on this subscale was 2.3, which improved
to 1.9 (95% CI 1.72.1) and 1.8 (95% CI 1.62.0) for the
GM and TM groups, respectively (Fig. 4). Massage therapy
reduced symptom severity across time (p  0.001), although
no difference between the two protocols was detected (p 
0.80). A significant difference from baseline was detected
after the 11th treatment session and at 4 weeks post-treatment for both treatment groups (p  0.001).

Function
A subjective measure of hand function was assessed with
the Levine Functional Status Scale questionnaire (Fig. 5).

FIG. 2. Grip-strength data at baseline and following the 11th

massage are presented in relation to published age-matched normative values. The shaded region represents the mean  95% confidence interval (CI) for the normative population obtained from a
recent meta-analysis.34 At study start, grip strength for study subjects was 77.6% of the age-matched normal population, which increased to 88.8% and 79.9% for the targeted (TM) and general
massage groups, respectively. Following the 11th massage treatment, mean grip strength for the TM group was within the 95%
CI of the normal population.

264

FIG. 3. Pinch strength was measured by using a Baseline pinch

gauge (Model #12-0201; Fabrication Enterprises, White Plains,
NY). Pinch strength improved across the study time frame (p 
0.001); no difference was detected between the groups (p  0.11).
Data are presented as the mean  95% confidence interval after
adjusting for the covariate effect of the baseline 2 time point. *Indicates a significant difference from baseline 2 value, at p  0.01.

Functional Status scales. However, a change in strength

measures was noted only for subjects who received the TM
protocol. A significant gain over baseline was detected in
the TM group for both grip (17.3%) and key pinch (24.8%)
strength measurements, yet no change over baseline was
noted for subjects who received GM (4.8% and 9.4%, respectively). For the TM group, a significant change in grip
strength was detected following 7 massage sessions, whereas
the gain for key pinch strength was detected following the
11th session. Further, at the end of the massage treatments,
grip strength for the TM group now fell within a 95% CI of
a published normative population.34 Importantly, gains observed on both subjective and objective tests persisted at
least 4 weeks after the end of massage treatment.
Both massage procedures were administered by experienced massage therapists and contained techniques intended
to improve blood flow, facilitate lymphatic drainage, and reduce muscular tension, which could decrease neurovascular
compression; therefore, it is not surprising that gains were
witnessed with both protocols. The TM protocol used a more
aggressive approach, which included techniques to soften fibrotic tissue, separate fascial adhesions, and reduce myofascial trigger point activity in soft tissues directly associated with the carpal tunnel. While the wrist is the most
frequent site targeted to alleviate CTS, a double crush condition, defined by nerve entrapment at multiple sites along
the median nerve pathway, may exist and can contribute to
symptoms.35,36 The TM protocol attempted to reduce potential compression along the median nerve pathway from
the cervical spine to the wrist. The TM protocol also used

MORASKA ET AL.
a more specific approach than the GM procedure toward reducing fluid volume and lymphatic drainage of the hand,
arm, and axilla regions. These more aggressive, defined approaches may have resulted in the faster improvement in
strength measures for the TM group and may have provided
separate or additive affects on hand function.
The GM group did not specifically address points of nerve
entrapment along the upper extremity; rather, the massage
strokes used were more intended to reduce muscular tension
and increase circulation of the back and upper body. While
the GM treatment was effective at improving subjective measures, the strength measures were less responsive to this treatment. Bilateral application of the GM protocol may have
skewed the results as the function, and symptom questionnaires do not specifically focus the subject to the primary
symptomatic side; thus, small bilateral improvement may
more strongly bias these measures. Alternatively, while massage duration was 30 minutes per session for either treatment
group, the bilateral application in the GM group allowed for
less treatment time per extremity, which may explain the
smaller strength gains that were observed. Both treatment therapies were well received by the participants, and in an exit interview with 11 randomly selected individuals, all reported a
favorable response toward the use of massage for CTS.
Surgical procedures to alleviate symptoms of CTS often
result in a worsening of symptoms for a period of time, although less-invasive surgical procedures offer better postoperative results.37 Open carpal tunnel release surgery has
been reported to be ineffective at improving grip or pinch

FIG. 4. The Symptom Severity Scale questionnaire by Levine et

al.11 was used to measure subjective reports of symptoms associated with carpal tunnel syndrome. Scores improved across the study
time frame (p  0.001); no difference was detected between the
groups (p  0.80). Data are presented as the mean question score 
95% confidence interval after adjusting for the covariate effect of
the baseline 2 time point. *Indicates a significant difference from
baseline 2, at p  0.01.

265

TARGETED VERSUS GENERAL MASSAGE FOR CTS

FIG. 5. The Functional Status Scale questionnaire by Levine et

al.11 was used to measure subjective reports of hand function associated with carpal tunnel syndrome. Scores improved across the
study time frame (p  0.001); no difference was detected between
the groups (p  0.34). Data are presented as the mean question
score  95% confidence interval after adjusting for the covariate
effect of the baseline 2 time point. *Indicates a significant difference from baseline 2, at p  0.01.

strength above preoperative levels immediately following

surgery, and reports of strength deficiency has been noted
as much as 25 or 52 weeks postsurgery.3840 Of particular
concern is a significant decrease in hand strength that is
noted for at least 5 weeks postsurgery.39 Our study findings
contrast with surgical procedures, in that we found a significant increase in strength measures for the TM group
within 4 weeks of treatment. While strength gains reported
in our study were relatively modest (17.324.8%), they were
similar to results recently presented following chiropractic
adjustments for CTS.16
The questionnaire developed by Levine et al. for judging
symptom severity and functional status is a frequently used
assessment tool in those with CTS.11 Subjects in our study
reported similar or slightly lower scores on these assessments at baseline than cited by other research groups.41,42
This suggests that the subjects enrolled in this study may
have had less severe symptoms of CTS upon study entry,
yet the percentage of improvement in scores following massage treatment approximated changes for these evaluations
at 1 month following surgery.43 Our study compares well
with a recent publication by Burke et al., in which a conservative care treatment intervention was administered to patients with CTS by chiropractors, using either a Graston Instrumentassisted soft-tissue mobilization or manual
soft-tissue mobilization.16 The procedures used in that study
mimicked several techniques employed in our study, including friction massage and myofascial release, but differed
slightly in the areas treated and range of techniques used.

However, the percent improvement in grip and key grip, as

well as the symptom and functional scales, mirrored the
changes observed in the present study, which corroborates
the use of manually directed therapies for CTS.
We attempted to minimize the personal interaction between subject and therapist by limiting conversation and rotating different therapists to administer massage. The intent
of this was to reduce subject bias toward a therapist, which
may influence subjective reporting of symptoms. Further
studies will need to be conducted to more clearly identify
the treatment effect of massage and determine which aspects
of massage are the most beneficial. While the identification
of the contribution provided by each technique is important
to optimize the massage procedure, it is also worthy to note
that the massage protocols used in this study represent massage therapy as practiced, which has recently been highlighted by the National Institutes of Health as important in
treatment-based studies in complementary and alternative
medicine.44 The pilot study design employed in this study
allowed us to compare the effectiveness of two massage
therapy protocols to each other as well as to baseline measurements, although it lacked a nontreatment control group
from which to draw conclusions regarding efficacy. Still,
our results indicate that further investigation into massage
therapy for management of symptoms associated with CTS
is warranted.

CONCLUSIONS
Conservative care for patients with CTS is a desired management approach prior to surgical intervention; yet conservative care for this condition typically is limited to rest,
splinting, and anti-inflammatory medication. The lack of evidence for an effect from alternative treatments may explain,
in part, the limited opportunities available to the patient with
CTS. The results from this study suggest that massage therapy may be a useful part of a conservative care treatment
regimen, although additional research support is needed. It
is hoped that this study will provide a foundation for the application of massage therapy in clinical or research settings
for compression neuropathies such as CTS.

ACKNOWLEDGMENTS
Financial support for this study was provided by a grant
from the Massage Therapy Foundation (Evanston, IL). The
authors would like to acknowledge the contribution and participation of the following individuals in this project: Rob
Killam, Nate Butryn, Jammie Sidley, Melissa Harth, Bev
Boyer, Ina Rochelle, Christopher Quinn, Eric Schaetzel, and
Marianne Fitzgerald, and would also like to thank the Boulder College of Massage Therapy for their assistance in
scheduling and the use of their clinic facilities.

266

MORASKA ET AL.

REFERENCES
1. Goodyear-Smith F, Arroll B. What can family physicians offer patients with carpal tunnel syndrome other than surgery?
A systematic review of nonsurgical management. Ann Fam
Med 2004;2:267273.
2. Love C. Carpal tunnel syndrome. J Orthopaed Nurs 2003;7:
3342.
3. Szabo RM, Chidgey LK. Stress carpal tunnel pressures in patients with carpal tunnel syndrome and normal patients. J Hand
Surg [Am] 1989;14:624627.
4. Nathan PA, Meadows KD, Istvan JA. Predictors of carpal tunnel syndrome: An 11-year study of industrial workers. J Hand
Surg [Am] 2002;27:644651.
5. Kao SY. Carpal tunnel syndrome as an occupational disease.
J Am Board Fam Pract 2003;16:533542.
6. Fagarasanu M, Kumar S, Narayan Y. Measurement of angular wrist neutral zone and forearm muscle activity. Clin Biomech 2004;19:671677.
7. Webster BS, Snook SH. The cost of compensable upper extremity cumulative trauma disorders. J Occup Med 1994;36:
713717.
8. Giannini F, Cioni R, Mondelli M, et al. A new clinical scale
of carpal tunnel syndrome: Validation of the measurement and
clinical-neurophysiological assessment. Clin Neurophysiol
2002;113:7177.
9. Neurology AAO. Practice parameter for carpal tunnel syndrome.
Report of the quality standards subcommittee of the American
Academy of Neurology. Neurology 1993;43:24062409.
10. Padua L, Padua R, Nazzaro M, et al. Incidence of bilateral
symptoms in carpal tunnel syndrome. J Hand Surg (Br) 1998;
23:603606.
11. Levine DW, Simmons BP, Koris MJ, et al. A self-administered questionnaire for the assessment of severity of symptoms
and functional status in carpal tunnel syndrome. J Bone Joint
Surg Am 1993;75:15851592.
12. Magee DJ. Orthopedic Physical Assessment, 3rd ed. Philadelphia: W.B. Saunders, 1997.
13. Werner RA, Andary M. Carpal tunnel syndrome: Pathophysiology and clinical neurophysiology. Clin Neurophysiol 2002;
113:13731381.
14. Bland JD. The value of the history in the diagnosis of carpal
tunnel syndrome. J Hand Surg (Br) 2000;25:445450.
15. Vasen AP, Kuntz KM, Simmons BP, et al. Open versus endoscopic carpal tunnel release: A decision analysis. J Hand
Surg (Am) 1999;24:11091117.
16. Burke J, Buchberger DJ, Carey-Loghmani MT, et al. A pilot
study comparing two manual therapy interventions for carpal
tunnel syndrome. J Manipulative Physiol Ther 2007;30:5061.
17. Field T, Diego M, Cullen C, et al. Carpal tunnel syndrome
symptoms are lessened following massage therapy. J Bodywork Movement Ther 2004;8:914.
18. Garfinkel MS, Singhal A, Katz WA, et al. Yoga-based intervention for carpal tunnel syndrome: A randomized trial. JAMA
1998;280:16011603.
19. Kostopoulos D. Treatment of carpal tunnel syndrome: A review of the nonsurgical approaches with emphasis in neural
mobilization. J Bodywork Movement Ther 2004;8:28.
20. Tal-Akabi A, Rushton A. An investigation to compare the effectiveness of carpal bone mobilisation and neurodynamic mo-

21.
22.

23.

24.

25.

26.

27.
28.
29.

30.
31.
32.

33.

34.

35.
36.
37.

38.

39.

40.

bilisation as methods of treatment for carpal tunnel syndrome.

Man Ther 2000;5:214222.
Kerwin G, Williams CS, Seiler JG, 3rd. The pathophysiology
of carpal tunnel syndrome. Hand Clin 1996;12:243251.
Allampallam K, Chakraborty J, Robinson J. Effect of ascorbic acid and growth factors on collagen metabolism of
flexor retinaculum cells from individuals with and without
carpal tunnel syndrome. J Occup Environ Med 2000;42:251
259.
Castelli WA, Evans FG, Diaz-Perez R, et al. Intraneural connective tissue proliferation of the median nerve in the carpal
tunnel. Arch Phys Med Rehabil 1980;61:418422.
Cobb TK, An KN, Cooney WP, et al. Lumbrical muscle incursion into the carpal tunnel during finger flexion. J Hand
Surg [Br] 1994;19:434438.
Lazaro RP. Neuropathic symptoms and musculoskeletal pain
in carpal tunnel syndrome: Prognostic and therapeutic implications. Surg Neurol 1997;47:115117; discussion, 117119.
Moraska A. Therapist education impacts the massage effect
on postrace muscle recovery. Med Sci Sports Exerc 2007;
39:3437.
Chaitow L, DeLany J. Clinical applications of neuromuscular
technique. Edinburgh/New York: Churchill Livingstone, 2000.
Childs SG. Double crush syndrome. Orthop Nurs 2003;22:
117121.
Chikly B. Silent Waves: Theory and Practice of Lymph
Drainage Therapy: With Applications for Lymphedema,
Chronic Pain, and Inflammation, Scottsdale, AZ: I.H.H.,
2001.
Cailliet R. Neck and arm pain, 3rd ed. Philadelphia: F.A.
Davis, 1991.
Barnes J. Myofascial release in the treatment of thoracic outlet syndrome. J Bodywork Movement Ther 1996;1:5357.
Bechtol CO. Grip test. The use of a dynamometer with adjustable handle spacings. J Bone Joint Surg Am 1954;36A:
820824.
Overall JE, Ashby B. Baseline corrections in experimental and
quasiexperimental clinical trials. Neuropsychopharmacology
1991;4:273281.
Bohannon RW, Peolsson A, Massy-Westropp N, et al. Reference values for adult grip strength measured with a jamar dynamometer: A descriptive meta-analysis. Physiotherapy 2006;
92:1115.
Pratt N. Anatomy of nerve entrapment sites in the upper quarter. J Hand Ther 2005;18:216229.
Schoen DC. Upper extremity nerve entrapments. Orthop Nurs
2002;21:1531.
Kozin SH, Pagnanelli DM. Grip strength after carpal tunnel
release: Role of the transverse carpal ligament. Am J Orthop
2002;31:571574.
Klein RD, Kotsis SV, Chung KC. Open carpal tunnel release
using a 1-cm incision: Technique and outcomes for 104 patients. Plast Reconstr Surg 2003;111:16161622.
Olsen KM, Knudson DV. Change in strength and dexterity after open carpal tunnel release. Int J Sports Med 2001;22:
301303.
Trumble TE, Diao E, Abrams RA, et al. Single-portal endoscopic carpal tunnel release compared with open release: A
prospective, randomized trial. J Bone Joint Surg Am 2002;
84A:11071115.

TARGETED VERSUS GENERAL MASSAGE FOR CTS

41. Bradley MP, Hayes EP, Weiss AP, et al. A prospective study
of outcome following mini-open carpal tunnel release. Hand
Surg 2003;8:5963.
42. Irvine J, Chong SL, Amirjani N, et al. Double-blind, randomized, controlled trial of low-level laser therapy in carpal tunnel syndrome. Muscle Nerve 2004;30:182187.
43. Zyluk A, Strychar J. A comparison of two limited open techniques
for carpal tunnel release. J Hand Surg (Br) 2006;31:466472.
44. NCCAM Stakeholder Dialogue. Online document at:
www. Nccam.Nih.Gov/dialogue/. Accessed on October 28, 2007.

267
Address reprint requests to:
Albert Moraska, Ph.D.
School of Nursing
University of Colorado at Denver and Health
Sciences Center
4200 East Ninth Avenue, CB-288
Denver, CO 80262
E-mail: moraska@alum.rpi.edu