Case Discussion: Neck Pain with N&T in L Forearm

Subjective

I recently presented an interesting case to my fellowship class. On 4/3/15 the patient presented to my PT clinic with L medial scapular border and L cervical pain with N&T along radial border of L forearm. The patient was a 45 year old female. The symptoms were intermittent symptoms and began 4 months prior with insidious onset. Symptoms were increased by sleeping, prolonged sitting, and having her L arm unsupported. Symptoms were improved with arm support and being active. Pain intensity was described as dull and was 2/10 at the time of the evaluation on NPRS and 6/10 at its worst. Patient denied any N&V, fever, significant changes in weight in last 6 months, B&B problems, and S&S of cauda equina syndrome. Patient’s job requires prolonged sitting at a computer, with turning her head to the L frequently. Patient also has to fly across the country every week for work. Patient denied any significant PMHx, past surgical history, and taking any medications.

Objective

Postural Assessment: Forward head posture. Rounded shoulders with bilat scapula depressed and downwardly rotated L>R. Excessive kyphosis at CT junction.
                          
Active Range of Motion:
    -Cervical spine: Cervical Flexion/Extension/bilat Rotation DP (Dysfunctional Painful)
    -Cervical Retraction with SB DP to L
    -Thoracic spine: Rotation DN (Dysfunctional Non-Painful) to L
    -Right UE: Flex/Abd/ER FN (Functional Non-Painful), Ext/Add/IR DP
    -Left UE: Flex/Abd/ER DN, Ext/Add/IR DP
    -Elbow and Hand: WNL

Passive Range of Motion:
    -Cervical Spine: Cervical Flex/Ext/L Rotation DP
    -Cervical Rotation R FN
    -Thoracic Spine: Rotation DN to L.

Joint Mobility: Hypomobility with left sideglides throughout cervical spine; Hypomobility with PA assessment of T1-T3; Hypomobility with PA assessment from T6-T8.

MMT:
    -Shoulder Flex/Ext/Abd/ER/IR: 5/5 bilat
    -SA 3-/5 on L and 4-/5 on R
    -MT ⅘ bilat
    -LT ⅗ on L and 3+/5 on R
    -Rhomboids 4-/5 on L and ⅘ on R

Neurovascular screening: Vascular deferred (not applicable). Neuromuscular: Decreased sensation along L radial forearm and lateral 3 fingers.

Special Testing:
    (+) Neck Flexor Muscle Endurance Test
    (+) ULNT (Median)
    (+) ULNT (Ulnar)
    (+) Spurling’s Compression Test
    (-) ULNT (Radial)
    (+) Cervical Distraction Test

Cervical Radiculopathy Cluster:

    (+) ULNT (Median on L)
    (+) Spurling's Compression Test on L
    (+) Cervical Distraction Test
    (+) <60 deg Rotation to L

4/4 = +LR 30.3

Treatment Day 1

My primary focus for the treatment was to educate the patient on proper posture and regular performance of repeated motions. Her symptoms centralized with repeated cervical retraction with SB to the L, so this was prescribed 10reps/hour. Manual treatment included: Supine Thoracic Manipulation: Grade V to T2 and T6, IASTM to L volar forearm and L UT/scalenes/SO and manual median/ulnar nerve glides 20x3 on L. Exercise included: Upper Extremity Ergometer: x4 minutes (2 forward, 2 backward); Lvl 1, Wall Shrugs: 10” x10, Wall Push Up Plus: 2x10, Supine Chin Tuck: 10” x10, Prone ITY: 10” x10 bilat and Quad Rock Back: 2x10.

Treatment Day 2 (1 week later)

The patient reported she performed her exercises, but was not compliant with the prescribed frequency. She stated that she was sleeping better than she had in months. Pain was rated 1/10 at the time of this session and 3/10 at its worst in the last week. The patient continued to have a directional preference of cervical retraction with L SB, so she was instructed to continue with this for her HEP. Manual treatment included: Prone grade III PA mobs to T2-8, Seated CT Junction Distraction Manipulation Grade V, Grade III OscillatoryUpglides to C6-C7 on R followed by MET for flexion 6sec x3, Grade III Flexion mob to OA joint bilat, IASTM to L volar forearm and L UT/scalenes/SO. Exercise included: Upper Extremity Ergometer: x4 minutes (2 forward, 2 backward); Lvl 1, Wall Shrugs: 10” x10, Wall Push Up Plus: 2x10, Supine Chin Tuck: 10” x10, Prone ITY: 10” x10 bilat, Quad Rock Back: 2x10, Prone CT Retraction Isometric: 10” x10, Scaption with Protraction: 2x10, and Supine Chin Tuck with Rotation: 2x10.

Treatment Day 3 (2 weeks later)

The patient reported she rarely did her exercises over the last 2 weeks, so her symptoms have increased, but a bad day includes pain at its worst 3/10 on NPRS. The patient was educated again on the importance of compliance with HEP in order to decrease her symptoms. The patient continued to have a directional preference of cervical retraction with L SB, so she was instructed to continue with her HEP. Additiionally, upon reviewing the technique of cervical retraction with SB, the patient was not getting to end-range, so this was corrected. Manual treatment included: IASTM to L median nerve distribution, Grade III oscillatory upglides to R C6-7 followed by MET for flexion on R C6-7, Grade III distraction mob to R OA, Inf grade III mob to L C6-7 followed by MET 6sec x3, Seated grade V distraction manipulation to CT. Exercise included: Upper Extremity Ergometer: x4 minutes (2 forward, 2 backward); Lvl 1, Wall Shrugs: 10” x10, Wall Push Up Plus: 2x10, Supine Chin Tuck: 10” x10, Prone ITY: 10” x10 bilat, Quad Rock Back: 2x10, Prone CT Retraction Isometric: 10” x10, Scaption with Protraction: 2x10, Supine Chin Tuck with Rotation: 2x10, Lumbar Locked Low Trap Isometric: 10” x10, Quadruped Cervical Rotation with Chin Tuck: 10x bilat, and Quad Rock Back with Thoracic Kyphosis: 10x.

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Treatment Day 4 (1 weeks later)

The patient reported that she no longer had any pain and only developed some mild N&T in her forearm when she would sit with poor posture for prolonged periods. Manual treatment included: IASTM to L volar forearm, Grade III upglides to L C6-7 with L UE in median nerve tensioned position (no symptoms after) followed by MET and grade III upglides for flexion on R C6-7, manual median nerve glides on L 20x3. Exercise included: Upper Extremity Ergometer: x4 minutes (2 forward, 2 backward); Lvl 1, Wall Shrugs: 10” x10, Wall Push Up Plus: 2x10, Supine Chin Tuck: 10” x10, Prone ITY: 10” x10 bilat, Quad Rock Back: 2x10, Prone CT Retraction Isometric: 10” x10, Scaption with Protraction: 2x10, Supine Chin Tuck with Rotation: 2x10, Lumbar Locked Low Trap Isometric: 10” x10, Quadruped Cervical Rotation with Chin Tuck: 10x bilat, and Quad Rock Back with Thoracic Kyphosis: 10x. the patient's HEP was progressed to include some of these exercises including continuing with her repeated motions HEP when symptomatic and how to progress to retractions. With the patient's work involving prolonged sitting, she is at risk for developing these symptoms again, so she will likely have to continue with her HEP. The patient was discharged to indept management.

Conclusion

Overall, this case was not too complicated. With the patient's intermittent symptoms, there was a high likelihood of her responding to repeated motions. The toughest part, as usual, was patient compliance. Both frequency in exercises and proper technique are often where the deficits occurs. The patient had to be re-educated on proper form and truly getting to end-range. When communication is intact, repeated motions can make treatment significantly easier for certain populations.

-Chris