Case Discussion: Bilateral Upper Extremity Numbness & Tingling

I performed this evaluation prior to taking the SFMA course and many of the residency lectures, so it is not exactly how I do my evaluations presently, but it is still an interesting case I wanted to present. This individual had a referral that indicated upper extremity numbness with the patient being a female in her upper 50's. With upper extremity numbness, there are several sources we should immediately start thinking of: pathologies affecting peripheral nerves, nerve roots, or potentially within the spinal cord. Obviously this means checking cervical, thoracic, and complete upper extremity involvement. What stood out immediately to me with this patient was her excessive thoracic kyphotic and forward head posture. With society's attachment to the computer screen, this is a common finding in all patients, so posture is commonly addressed. However, this individual would be placed beyond this "norm."

Subjective Interview
As usual, the subjective interview should play a large role of your examination. Here you typically gain about 90% of the information essential to your evaluation. This patient's primary complaints were bilateral numbness & tingling down the entirety of both arms and "Carpal Tunnel Syndrome," both of which had increased in frequency and intensity over the last few months. The patient's job involves about 8 hours of computer work each day. Her symptoms were increased by working and decreased by rest. The patient had also been seeing a hand therapist at another clinic to treat her "Carpal Tunnel Syndrome." The treatment there was consisting of using wrist splints at night, wrist stretches, and some massage to her hands according to the patient's reports. The patient reported to me that she had not seen any results from the hand therapy yet and was skeptical about physical therapy in general at this point. The patient told me she had even been considering some type of surgery, because it was affecting her so much. The patient denied any S&S of cauda equina syndrome, B&B changes, significant changes in weight over the last 6 months, or night pain. With the finding of bilateral involvement, we do need to be cautious due to the risk of central involvement - this can be associated with serious pathology. With the combination of thoracic kyphosis/forward head posture and bilateral symptoms (and lack of non-musculoskeletal symptoms), my primary hypothesis was a form of postural dysfunction resulting in Cervical Radiculopathy. Some other potential hypotheses included: Thoracic Outlet Syndrome, T4 Syndrome, and bilateral peripheral neuropathy. Thoracic Outlet Syndrome, like Cervical Radiculopathy, can be related to abnormal posture due to the effect thoracic kyphosis and protracted scapulae have on shrinking the thoracic outlet, compressing the brachial plexus.  T4 Syndrome was included in my hypotheses because a common symptom is bilateral non-dermatomal neural symptoms. Peripheral neuropathy is pretty self-explanatory as to why it was included.

Objective Examination:
Cervical ROM: flexion 35 degrees, extension 45 degrees, rotation 55 degrees bilateral, SB 30 degrees on L and 20 degrees on R.

Shoulder ROM: WNL bilateral except 80 degrees of IR on L and 45 degrees on R.

Shoulder Strength: 5/5 bilateral except 3+/5 flexion and 4/5 ER bilat.

Wrist Strength: 4/5 flexion and extension bilat.

Neural Screen: C3-4 dermatomes intact bilaterally. C5-T1 dermatomes diminished bilaterally. C5 reflexes 2+ bilat. (+) Radial/Ulnar/Median ULNTs bilat.

Joint Mobility: Hypomobility noted throughout thoracic spine, especially at mid- to upper-locations.

Special Tests: (+) Spurling's Test, (-) Cervical Distraction Test, (-) Painful Arc Sign, (-) Infraspinatus Test, (-) Hawkins-Kennedy Test, (-) Vertebrobasilar Insufficiency Test, (+) ROOS Test, (+) Costoclavicular Test.

Clinical Reasoning:
My examination actually did not narrow down my hypotheses to one alone. With 3/4 positive tests in the Cervical Radiculopathy Cluster, there is a +LR of 6.1 that Cervical Radiculopathy is a contributing factor: (+) Spurling's Test, (+
) Median ULNT, (+) < 60 degrees rotation to affected side, and (-) Cervical Distraction Test. While the Thoracic Outlet Tests do not have any diagnostic accuracy reported that we are aware of, the positive findings of the test combined with the significant thoracic kyphotic and protracted shoulder posture keep Thoracic Outlet Syndrome as a possibility. While T4 Syndrome typically has some reports of a mechanism of injury such as lifting an object awkwardly, the combination of non-dermatomal paresthesia and hypomobile mid-thoracic spine keep  T4 Syndrome as a possibility as well. This often happens where we are unable to pinpoint the true "diagnosis"; however, what really matters is that we identify the primary impairments contributing to the problem and treat those! In this case my most significant findings were: abnormal posture (forward head/thoracic kyphosis/protracted shoulders) - consider the weak postural muscles associated with this, hypomobile thoracic spine, neural tension, and decreased shoulder IR ROM. Another factor we definitely need to consider is the patient's job that requires 8+ hours of computer work a day as this will definitely impact our prognosis.

Same Day Treatment:
Having recently completed the IASTM Technique course prior to this evaluation, I was eager to trial some IASTM on this patient due to the significant neural tension findings. The patient was extremely skeptical at first (she actually referred to the EDGE Tool as my "belt buckle." I told her I would only perform it on one UE, so that she could judge the effects compared to no treatment on the opposite side (other than the HEP I was going to distribute). I performed IASTM on her dorsal/ventral forearm and medial upper arm. The HEP I distributed to the patient included supine chin tucks to strengthen the deep neck flexors, and hourly cervical retractions and scapular retractions to improve posture/relieve tension on overstressed structures while working. Of course, the patient was educated regarding proper posture and the effect excessive computer work has on posture and the patient's symptoms, as well.

Second Visit:
At the second visit, the patient reported she noticed a significant reduction in numbness & tingling on the side IASTM was performed compared to the opposite side. Additionally, the patient reported some relief with the performance of HEP. This is huge, because I now had patient "buy-in." This treatment session I performed the same IASTM treatments to both upper extremities, some cervical and shoulder mobilizations to improve mobility, manipulations to thoracic spine, and some general postural strengthening exercises. 

Following Visits:
The patient again reported significant improvement in her numbness and tingling by her third visit, so much so that she stopped hand therapy for her "carpal tunnel syndrome" because she felt my treatment was having a more significant impact and she didn't want to waste her insurance visits with the hand therapy. I should note that I have been putting Carpal Tunnel Syndrome in quotations, because I was never certain the patient had that at all. Even though this patient did have prolonged computer work associated with the pathology, I have found that it is often over-diagnosed and the origin of the pathology may be located proximally. She may have had the diagnosis; however, she was already being treated for this by the hand therapist so I was going to focus more proximally. The patient was treated a total of 12 visits with similar treatment sessions to the second day; however, I would gradually alter the ratio of manual treatment to exercise (increasing exercise) to make the gains more permanent. By the 8th visit, the patient had no symptoms, but the patient wanted a few additional visits to "lock in" the changes. The treatment plan was lengthened compared to what I originally planned due to a couple additional development of symptoms. The patient came in a couple times with "upper trap pain" and L buttock pain. The upper trap pain was found to be an elevated 1st rib and was treated with a seated anterolateral grade III mob. Cervical retraction with sidebend was used to lock in the changes. The left buttock pain was found to be sacroiliac joint dysfunction that was negative on all provocation tests. Following a couple muscle energy techniques, pain was completely eliminated. Additionally, the patient fractured a toe one day between sessions. Needless to say, this patient had a lot going on; however, at discharge she was completely symptom-free and independent with her HEP to hopefully stay symptom-free!

-Chris

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