Parkinson’s disease belongs to a group of conditions neurological in nature called movement disorders. It is characterized by muscle rigidity, tremor, a slowing of physical movement (bradykinesia) and, in extreme cases, a loss of physical movement (akinesia). The primary symptoms are the results of decreased stimulation of the motor cortex by the basal ganglia, normally caused by the insufficient formation and action of dopamine, which is produced in the dopaminergic neurons of the brain (Parkinson’s Disease, 2008).

PD is the most common cause of chronic progressive Parkinsonism which refers to the syndrome of tremor, rigidity, bradykinesia and postural instability. While many forms of Parkinsonism are “idiopathic”, “secondary” cases may result from toxicity most notably of drugs, head trauma, or other medical disorders. The disease is named after English physician James Parkinson, who made a detailed description of the disease in his essay: “An Essay on the Shaking Palsy” written in 1817 (Parkinson, 1817).

Treatment of PD can be treated temporarily with two drugs that will penetrate the blood brain barrier which are Levodopa and Carbidopa (Werner, 2007). However, the patient usually develops a resistance to these medications, and they have various side effects that can outweigh the need for drug therapy. Other drugs have been used to slow the metabolism of dopamine so whatever the body does manufacture will remain in the system longer.

Physical, speech, and occupational therapies are often deployed to maintain the health and general functioning levels of the patient for as long as possible. The old adage of use it or lose it is what physicians deploy as a means to prolong the functional use of motor control over the body.

Massage as a treatment to PD has also been used to prevent the stiffness and rigidity of voluntary muscles. Massage can be used with stretching and Range of motion exercises to increase flexibility and prolong the functional use of voluntary muscles. Patients that employ massage can also reduce anxiety and onset of depression due to the disease. The therapist should work in conjunction with the patients primary physician because the need for the need of some kinds of medication. The therapist should take extreme care because patients with PD do not have the range of motion that most other people do. Most therapists employ a mat and use the floor to work with these types of clients. The session should also be shortened so that the patient can receive the most benefit from the treatments.

According to a 2002 study conducted by the Touch Research Institute at the University of Miami, along with staff from the university’s neurology department and Duke University’s pharmacology department, Parkinson’s disease symptoms are reduced by massage therapy (Nicole Cutler, 2007).

In this study, the group of adults with Parkinson’s disease who received two massages a week for five weeks experienced improved daily functioning, increased quality of sleep and decreased stress-hormone levels. The massage consisted of 15 minutes in the prone position, focusing on the back, gluteal region, thoracic region, adductors, quads, hamstrings, calves and feet; and 15 minutes in the supine position, focusing on the thighs, lower legs, feet, hands, forearms, upper arms, neck, face and head (Nicole Cutler, 2007).

While several different massage modalities have been quantifiably researched in the context of Parkinsonism, including Trager, Alexander Technique and Swedish massage, all modalities report improvement in function, from the reduction of rigidity and improvement of sleep, to the reduction of tremor and increase of daily activity stamina (Nicole Cutler, 2007).

Studies from various resources state that the therapist should not be afraid of working with clients suffering from Parkinson’s disease. The pathology of this condition and the success reported with massage therapy make physical manipulation of the musculoskeletal system an ideal Parkinsonism management component. Since the disease is primarily a dysfunction of the nerves and massage affects the soft tissues, nerves, and ligaments of the body it is an ideal candidate for working along the physician to ease the pain and suffering of the patient.  Being familiar with this disease and welcoming those affected can bring an enormous amount of satisfaction to any compassionate therapist.

The patient’s sense of wellbeing can also be achieved by use of lymphatic drainage, reflexology, PNF/MET/Stretching, shiatsu, Swedish, and trigger point therapy. Reflexology is indicated with special emphasis on head, endocrine system, and solar plexus points. Swedish is used to help reinforce a parasympathetic state which helps with uncontrolled muscular contraction, but it is also vital to work in conjunction or as part of a health care team. Deep Tissue Massage in conjunction with a health care team can help to improve patient’s awareness with slow and methodical pressure in the soft tissues of the muscles (Werner, 2007).

At this time a cure is not available for this disease; extensive research has been done lately with outcomes that only help the symptoms. Massage is just one of those ways to aid in the relief of the symptoms of the disease in my opinion simply calming the nervous system and assisting in stretches based on the articles and information that I have read on the topic would aid in minimizing the symptoms so that the patient can control and hold on to the range of motion that they presently have and prolong the symptoms from taking control and diminishing their quality of life.

Cubital tunnel syndrome is characterized by the compression on the ulnar nerve between the two heads of the flexi carpi ulnaris (FCU) by the aponeurotic band or the space within the tunnel decreases by as much as 55% when the elbow is flexed. During flexion the ulnar nerve is increasingly pulled taut, which aggravates the symptoms. Subluxation of the ulnar nerve as the elbow moves into flexion could also produce pain as well. Diagnosis is from doing elbow flexion test symptoms should appear within 60 seconds. You can also use the Froment’s sign or Guyon’s canal syndrome test and finally the testing of the ulnar nerve itself. 

Treatment of the Cubital tunnel syndrome in massage is deep stripping or massage with active engagement to help reduce the overall tension in the muscles of the FCU. Paying particular attention not to add compression to the ulnar nerve, deep stripping should be done to relax the muscles that may be hypertensive that flex the elbow.

Pronator tunnel syndrome is characterized by the compression of the median nerve by the pronator teres muscle.  Also known as pronator syndrome can be caused by median nerve compression by other structures in the elbow such as the ligament of Struthers or the bicipital aponeurosis. Compression can be caused by hypertonicity or fibrous bands within this muscle which in turn presses on the nerve. Diagnosis can be made through the use of the pronator teres test, and the pinch grip test.

Treatment of pronator tunnel syndrome is to focus on reducing the compression of the median nerve. Massage is helpful and can be directly applied to the pronator teres muscle. Trigger point therapy on the aggravating areas to the pronator teres muscle and surrounding muscles. Deep stripping or pin-and-stretch methods are also useful. Stretching is useful by decreasing the nerve compression by improving flexibility in the pronator teres muscle.

Radial tunnel syndrome is characterized by the compression of a branch of the radial nerve that travels through several fibroosseous tunnels in the elbow region. Radial tunnel Syndrome affects the terminal motor branch of the radial nerve called the posterior interossesous nerve (PIN). Compression in this region can cause atrophy, weakness, and compromise almost completely the motor fibers. Diagnosis can be made through the upper limb neurodynamic test of the radial nerve.

Treatment of radial tunnel syndrome is done by massage therapy as a beneficial role in treating RTS. Paying attention to the wrist and finger extensors in the forearm, as well as the separator muscles of the forearm should be done. Deep longitudinal stripping techniques on these muscles will help free neural restrictions in the distal region of the radial nerve and decrease tension. Deep Broadening techniques for the wrist extensors are also helpful.  The overall need to reduce the compression of the radial nerve should ultimately be your goal.

The first three of these syndromes primary focused on the elbow region of the arm the third and final syndrome focuses on the wrist. The wrist region of the arm has had much more research done on it and is more often diagnosed by physicians to have surgery done. I am mentioning carpal tunnel syndrome of course.

Carpal tunnel syndrome characteristics are compression of the median nerve under the transverse carpal ligament. This tunnel also has various ligaments which control the functions of the fingers of the hand. The condition develops when the space within the tunnel diminished by compression against the transverse carpal ligament. The nerve is the most superficial structure that goes through the tunnel and is therefore at risk of compression.  Inflammation of ligaments or tendons that run through this tunnel is what caused the compression. Overuse will eventually cause tendons to thicken and cause pressure on the median nerve as well. Diagnosis can be made through Phalen’s test, Tinel’s sign (a tapping on the carpal tunnel itself), and tethered median nerve stress test.

Treatment of Carpal tunnel syndrome through massage should focus on relieving pressure on the median nerve that goes thorough the carpal tunnel. This can be done by deep longitudinal stripping and active engagement methods applied to the fingers and wrist and finger flexors in the forearm. Myofascial methods may also be beneficial for stretching the fascial tissues lying over the carpal tunnel, which can help to reduce symptoms. Care should also be taken not to aggravate the symptoms by compression in the affected area directly.

Characteristics of soft-tissue impingements occur in the shoulder as tissues are compressed underneath the coracoacromial arch.  Impingement can result purely from the structure of the coracoacromial arch, but can also occur from repetitive motions, especially from flexion and internal rotation of the humerus.  In some cases bone spurs or osteophytes develop on the underside of the acromion process and serve to further compress the room for the nerve and impinge tissues in the area. Myofascial trigger points or hypertonic muscles in the shoulder region can also cause dysfunctional biomechanical issues and lead to impingement problems in the shoulder.

There are no clear observable signs that someone may have shoulder impingement syndrome. There however, may be inflammation, visible indicators may be absent. When conducting movement active range of motion testing clear signs to smoothness in motion or the lack of smoothness in movement can take place during an evaluation. There also may be clear visible apprehension when attempting to perform abduction or flexion of the shoulder.

Compensating for movement can cause irregular patterns of motion which are evident as the client attempts to avoid actions that clearly provide pain in movement. Postural distortions such as upper thoracic kyphosis and medially rotated glenohumeral joint should be noted as they change glenohumeral actions which lead to impingement.

Patients that usually would see this type of syndrome come from two different sides of the spectrum in age the younger crowd, and an older crowd. The causes in the two age groups are usually different. The younger crowds usually see this syndrome from repetitive motion while doing abduction of the shoulder for long periods of time such as people working in factory or athletics. The older crowd would see this syndrome from a completely different set of circumstances. The older crowd may develop impingement with less activity due to hooked acromion, bone spurs, osteophytes, or overall tissue degeneration.

If is difficult to produce the pain of the impingement because of its location under the acromion process. However, if the impingement affects the distal supraspinatus tendon or the subacromial bursa, tenderness is common inferior to the acromion process on the lateral shoulder. Excess edema or other palpable signs of inflammation such as heat are normally not identifiable because of the depth of the tissues involved. Palpating the anterior shoulder region, particularly if performed with the shoulder in flexion may cause pain in the shoulder.

Diagnosing the condition can be done through several testing methods suing Active Range of motion, Passive Range of motion and muscle resistive testing. Any of the testing will cause pain when the nerve is further compressed by the action of movement in the shoulder. The special tests that can be performed are the Hawkins-Kennedy Impingement Test, Empty Can Test, and Neer’s Impingement Test.

The Hawkins-Kennedy Impingement Test is performed while the patient is facing the therapist. The therapist brings the patient’s shoulder and elbow into 90 degrees of flexion. From this point the humerus is medially rotated by the therapist until the end range of motion is met. If this movement reproduces the client’s primary discomfort, there is a good chance that tissue is impinged under the coracoacromial arch. This does not completely rule out the exact tissues affected because numerous tissues can be compressed in the final position of the arm.

The second test that can be conducted is the Empty Can Test, which is normally performed bilaterally, even when one shoulder is symptomatic. The non-affected side is used for compression. If pain is reproduced at any of the points during the test, continuing the test is unnecessary because of the pain that will be produced by this motion.  The client faces the therapist and brings the arms both at the same time to 45 degrees of horizontal adduction. While the position is held patient is asked about discomfort or pain that may be involved in holding the position. From this position the patient is asked to medially rotate the arms as if to pour the liquid out of the cans.  At the end of the motion the therapist should ask about pain levels or discomfort.  While the patient holds the final position while the therapist pushes down both arms with moderate effort.  If pain is reproduced in this position the test is positive.

The third test that can be performed is the Neer Impingement Test, while the patient is facing the therapist.  The therapist brings the arm into full forward flexion. The therapist needs to watch for signs of apprehension and ask about the pain levels or discomfort during the movement. Pain that is reproduced that is the same in the primary complaint indicates a positive test.

Suggested treatment involves soft tissue impingement in the coracoacromial arch to relieve the compression of the tissues is to reduce compression in the area.  One can look for other trigger points that may be causing muscles to be hypertonic or have Myofascial trigger points.  Massage and stretching should be used to address the situation. Treating the surrounding muscles may also be helpful in addressing the situation or complaint.

How to perform test: This test is helpful to discriminate between Achilles tendon disorders and retrocalcaneal bursitis. The client is prone during this test. The therapist squeezes the sides of the tendon superior to the calcaneus to attempt to reproduce the chief complaint from the patient. Pressure can be applied to each side of the Achilles tendon, squeezing towards the middle. Pressure should be applied straight down on top of the tendon from posterior to anterior in movement. Pressure should also be applied superior to the location of the retrocalcaneal bursae so the Achilles tendon is the only structure being compressed.

If the patient experiences pain when you squeeze the Achilles tendon from both sides it decreases the chance that pain originates from structures directly posterior to the calcaneus. I would expect no pain to be experienced during this test. If pain is experienced massage application to the calf muscles to reduce tension and tensile forces on the tendon. Don’t immobilize the tendon adhesions could form and lead to additional problems. Cold application prior to a deep friction reduce the intensity of the discomfort, and re-apply cold after treatment to reduce an accelerated response to the friction.

Passive Range of motion testing is when the therapist has asked the patient to make the limb under test limp and not to assist the therapist in the motion being performed. Passive range of motion focuses on inert tissues because contractile tissues that are not used during passive motion are primarily those that you are testing. As a therapist moves the dysfunctional limb through the plain of motion attention should be made to the tissues to check for binding, restriction, and crepitus in the movement. The therapist should note levels of pain involved, checking for end feel which varies from patient to patient.

Manual resistive tests or isometric muscle contractions are so the therapist can correctly evaluate proper function of the contractile tissues during movement. Manual resistive tests are conducted to confirm and elaborate on findings from Active Range of Motion and Passive Range of Motion tests. During these test there should be no active movement at the joint. To conduct a manual resistive test you first need to determine the movement of the joint is it hinges, ball and socket, saddle. Then the therapist should select the plain of motion that they wish to test. The patient should be told to move the joint in that plain there may be too much pain for the patient to move the joint. This test may still be necessary to determine the issue that should be worked on.

The different type of tests are used to determine was muscle is dysfunctional and how to treat the muscle tissue. Passive tests allow the therapist to determine if soft tissue is not allowing for proper function of movement at a joint within a plane of motion. Active Range of motion testing allow us to assess if there is dysfunction in the movement and determine which muscles are used to make that movement happen. Muscle resistive tests allow us to determine what muscle tissue is dysfunctional while the movement is offering. This allows the therapist insight into the muscle contractile tissue and determines dysfunction that would not show up on active or passive range of motion tests.

The order that the test should be performed Active Range of motion is done first, which allows the therapist to watch and determine what movements that the patient can do on their own. Passive Range of Motion tests are then performed to allow for testing of muscle tissues that would hinder the range of motion.  Then finally Muscle Reactive Tests are used to if something is wrong with the muscle tendon connections of the inert tissue so that proper treatment can be applied to the patient.

The differences in the tests and pain involved. Pain with active range of motion and no pain with passive range of motion can indicate that contractile tissues are dysfunctional.  No pain with passive range of motion and no pain with active range of motion, but having pain with MRT tests would indicate that during active motion and passive motion that not enough muscle fibers are firing to indicate that pain would occur. Leaving musculotendinous junction would be injured and needed attention in the form of RICE.

Myositis Ossificans means muscle inflammation with bone formation. It’s not so much as inflammation as it is bone growth in muscle or soft tissues. The condition often affects adolescents and young adults, and it usually occurs in the quadriceps and brachialis. Treatment tends to be conservative, in the subacute phase is passive stretching to employ and restore range of motion, followed by exercise to restore muscle strength. Massage treatment is locally contraindicated and massage around the boney growth and stimulate the body’s own mechanisms to reabsorb the useless deposit.

Postural Deviations although through of as straight the spine is curved in the cervical, thoracic, and lumbar regions giving the body the ability to absorb shocks or jolts of the body.  If the natural curves are overdeveloped, depending on the regions can produce humpback, swayback, or scoliosis. An important thing is to difference between structural and functional problems. In the early stages it is usually soft tissue that is pulling the bones out of natural curvature and massage can be done to correct the soft tissue dysfunctions that pull the bone out of natural alignment. Massage will not make any of these conditions worse, and may well offer relief by simply reducing some of the tension that both causes and accompanies spinal imbalances. If the therapist is very skilled and the circumstances are just right, massage may be able to set the stage for permanent change in the bony alignment.

Osteoarthritis also called degenerative joint disease is a condition where the synovial joints, especially weight bearing joints, loose healthy cartilage. This condition is directly affected by wear and tear on the join and age of the joint structures.  This condition is by far the most common type of arthritis in the world affecting 20/40 million Americans. Men and women are affected in equal numbers usually over the age of 75. Osteoarthritis is an occupational hazard for massage therapists, occurring at the saddle joint of the thumb. Massage is indicated for this condition for pain relief in the surrounding muscles and to maintain range of motion through gentle stretching and passive range of motion exercises.

Marfan Syndrome is the result of a genetic mutation which leads to the production of dysfunctional fibrillin, a key connective tissue fiber.  This is a autosomal defect, which is not gender specific, and each child of a parent with Marfan Syndrome has a 50/50 chance of having it. Symptoms include flat chest with protruding sternum or sunken sternum which is common, heart problems, eye disorders, and nervous system anomalies and also a part of the syndrome. An example of the symptoms would be abnormally long fingers, flat feet, hernias, and hammertoes.  Deep tissue is contraindicated. Swedish massage minus tapotement, friction, deep effleurage and petrissage can be done. Lymphatic drainage is supportive, along with shiatsu, and reflexology.

Bursitis, which is simply inflammation of the bursae, is small sacs of connective tissue throughout the human body. Normally the human body has about 160 different bursae, but the body can produce new ones if an area needs additional protection. Bursitis comes in all shapes and sizes and can also be called, housemaid’s knee, student’s elbow, and Weaver’s bottom which is bursitis on the ischial tuberocity. Bursitis is locally contraindicated specially in the acute phase. If local areas can be released without irritating the area, some range of motion may be restored, but you must take care not to irritate the bursa again. Massage is indicated when bursitis does not involve an infection, massage is certainly indicated. You should also look for compensation patterns that may contribute to pain.

Thoracic outlet syndrome (TOS) is a neurovascular entrapment. The nerves of the brachial plexus or the blood vessels running to or from the arm are impinged or impaired at one or more of three places: between the anterior and medial scalene, between the clavicle and the first rib, or under the coracoids process. Unless the TOS is related to issues other than muscular imbalance, massage is unlikely to make much lasting difference, however, if it is related to muscular problems, it can respond very well to bodywork. The client should also learn some stretches and strengthening exercises for pectoralis minor, its antagonists, and the scalene.

Tinea cruris otherwise known as Jock Itch is not exclusive to the groin.  It can be found on the upper thigh and buttock regions. It is a fungal infection; massage therapist should avoid them carefully. Some controversy exists over the skin around the groin and the relationship between tinea cruris and tinea candidiasis, better known as a yeast infection. Body lice or most specifically pubic lice in comparison are an animal infestation or a parasitic infestation.  Pubic lice, which is closely related to head lice and is dealt with in the same manner as head lice is also massage contraindicated.

Tinea cruris otherwise known as jock itch and pubic lice has similarities in that they will both make the patient itch in the groin area to temporarily relieve the symptom of pain that is caused by the fungus or parasite. The itching though can cause the condition to worsen. Jock itch since it is a fungal pathology can be spread through contact with other parts of the body. Just the same as public lice (crabs) can be spread from one part of the body to anther through contact. 

Treatment of tinea cruris (jock itch) can be frustrating. Topical applications of fungicidal cream or powder are the normal treatment, but oral medications are recommended for stubborn or hard to reach infections.  Athlete’s foot which is the same strain as tinea cruris can be difficult to treat because it likes dark, warm, and moist areas of the body in which to thrive.  It should be treated with an antifungal cream or powder not to forget the toenails and fingernails of the patient which may be hard to reach but can be carriers of the fungal growth.

The treatment of public lice (crabs) is similar to head lice and should use the same treatment protocol. The sheets of any massage client suspected of a crab infestation should be isolated from all others and disinfected as soon as possible.  Massage is contraindicated in this case. Parasitic infestation carries a powerful social stigma that is negatively associated with poor hygiene or poverty.  However,  because anybody can have this problem, and people in touch professions are in a position to cause a lot more damage with it than anyone else the therapist should be respectful and remember that it could happen to anyone.

Signs and symptoms of pubic lice (crabs) are tiny white crabs about 1mm in diameter. They also leave nits, but they are so small that they are barely visible without magnification. The Primary symptom is itching uncontrollable itching. The patient may not even be conscious that they are itching.  Compared to tinea cruris infections vary considerably depending on the causative agent and where they appear the patient may have lesions and be unaware of them. Massage therapist should avoid them cautiously.   Some suggest that when the scrotum as well as the skin around the groin is infected. The likely cause is an imbalance in the internal yeast imbalance. When the infection spares the scrotum the cause is an agent typical of Trichophyton,  Epidermophyton, or Microsporum. 

Massage is contraindicated for infections locally in every phase. But a small infestation can be considered safe to work with as long as lesions are treated and covered. For clients with in Florida the Genitals are to be covered at all time anyhow, but special care should be taken if you need to work on the adductors, gluteal region, hamstrings, or quadriceps.

How to perform test: The client is in the supine position. The ankle is moved into maximum dorsiflexion and eversion while the toes are held in hyperextension.  Hold this position for 5 – 10 seconds.  While tapping on the nerve you have a sharp neurological sensation on each tap it indicates hypersensitivity of the nerve and should be used in conjunction with other tests when possible.

The sharp neurological pain can indicate Tarsal tunnel syndrome.  I would expect no pain to be experienced during this test.  Massage can be helpful for nerve pathologies such as TTS, but should not be heavy to not apply deep pressure on the nerve because additional damage could occur.