Dynamic Neuromobilization for the Treatment of Thoracic Outlet Syndrome Courtney Convey and Dr. Erickson

Abstract

Title: Dynamic Neuromobilization for the Treatment of Thoracic Outlet Syndrome Background: Dynamic neuromobilization is a treatment technique utilized by physical therapists to promote normal physiological function of nerves. It is assumed that dynamic neuromobilization acts to reduce nerve adhesions to surrounding soft tissue structures; however, support for this technique is primarily anecdotal. Case Description: The patient was a middle aged female who sought physical therapy service for diagnosis of left thoracic outlet syndrome (TOS). She had numbness, tingling, and coolness throughout her left upper extremity limiting her ability to dress herself, sleep, and participate in her usual fitness routine. Physical therapy interventions consisted of dynamic neuromobilization, thoracic spine and rib cage mobilization, median nerve glide/flossing, stretching, and exercise. Outcomes: The patient attended eight physical therapy sessions and demonstrated a significant decrease in numbness and tingling throughout her left upper extremity isolated to her thumb approximately 25% of the time with overhead activities allowing her to return to her fitness and wellness routine. Performance improved on the following objective measures: Quick DASH, posture, scalene and pectoralis muscle tension, upper limb tension tests, cervical compression and distraction, vascular thoracic outlet test, and thoracic and rib cage mobility. Discussion: Dynamic neuromobilization may be utilized to improve physiological function of nerves to decrease symptoms of thoracic outlet syndrome including numbness and tingling throughout the upper extremity. Physical therapists can include dynamic neuromobilization in combination with other conventional treatment for TOS to decrease nerve related pain improving patient’s functional abilities. Randomized clinical trials are needed to evaluate the efficacy of dynamic neuromobilization in patient with thoracic outlet syndrome. Keywords: dynamic neuromobilization, nerve mobilization, thoracic outlet syndrome Type of Clinical Analysis: Intervention

Purpose: The purpose of this case report is to describe outcomes following the use of dynamic neural mobilization and a neural flossing home exercise program for a patient with thoracic outlet syndrome.

Case Description

The patient was a middle-aged female who was seeking physical therapy for numbness and tingling in her left lateral upper arm, lateral forearm, and thumb with an occasional sensation of coolness throughout her left upper extremity. She had a MD diagnosis of left rotator cuff and capsule strain six months prior that she sustained while blocking an oncoming ball from her face with a tennis racket during a tennis match. She received chiropractic care and a corticosteroid injection on the left subacromial bursa for her prior injury with relief from pain. Despite a

reduction in pain, a new onset of symptoms including numbness, tingling, and coolness throughout her left upper extremity occurred five months after her initial rotator cuff injury. Her primary physician prescribed topical voltaren for her nerve related pain and was recommended by her primary physician to utilize physical therapy services. Pain caused functional limitations of reaching behind her back for dressing and reduced sleep quality. In addition, the patient was unable to participate in her previous physically active lifestyle including tennis, body pump classes, elliptical training, and golf. Review of systems was negative and the patient’s goals included decreasing the numbness and tingling throughout her arm to improve sleep quality and to safely return to previous active lifestyle.

Examination

Quick DASH The Quick Disabilities of the Arm, Shoulders, and Hand questionnaire (quick DASH) generated a score of 24 which equates to a 29.55% disability. The Quick DASH yields a specificity of 0.77 and a sensitivity of 0.8.1

Observation and Palpation Observation findings included moderate forward head posture with no observed swelling or skin color changes throughout her left upper extremity. Palpation of her neck and left upper extremity revealed significant tissue tension in the left scalenes and pectoralis minor with moderately pain provoking trigger points located throughout the muscle bellies. ROM and Strength GH and cervical ROM screen findings included bilateral GH ROM and cervical flexion within normal limits and cervical extension limited to 35 degrees with left upper extremity tingling reproduced. Upper manual muscle testing, as described by Reese, was performed and primary findings identified moderate strength in all directions (Table 1).2 Light tough sensation was intact throughout the patient’s left upper extremity. Cervical Special Tests Compression and distraction test in a seated position were positive (Figure 1 and 2). Distraction yields a specificity of 0.90 and a sensitivity of 0.44 when performed in a supine position.3 Bilateral Spurling’s test was negative with a specificity of 0.74 and a sensitivity of 0.5 (Figure 3).3 Repeated cervical motions was selected to determine directional preference with both cervical retraction and protraction resulting in decreased intensity and location of numbness and tingling in the patient’s left upper extremity. Upper Limb Neurodynamic Tension Test Upper limb neurodynamic tension testing was performed to stress the neurological structures and rule in/out the possibility of neural tension as a contributing factor (Table 2, Figures 4-6). The patient demonstrated a positive radial, median, and ulnar nerve tension test determined positive when contralteral side flexion increased symptoms and ipsilateral side flexion decreased symptoms.

Vascular Thoracic Outlet Test The Allen test was selected to determine the possibility of vascular thoracic outlet syndrome. The patient demonstrated a positive Allen test with duration of 30 seconds before her radial pulse returned (Figure 7).4 Joint Play Assessment Thoracic, rib, and cervical spine joint play assessment was performed, in prone. Posterior to anterior glides were moderately hypomobile from C5 – T5, without pain. Gross anterior-posterior joint play assessment of the rib cage demonstrated moderate hypomobility throughout, without pain. Diagnostic Testing Cervical spine radiographs revealed no signs of cervical rib, but reduced cervical lordosis, suggestive of spasm. Moderate disc space narrowing at C5 – C6 and C6 – C7 with mild narrowing of C7 – T1. Hypertrophy of the transverse processes at C7 bilaterally. Clinical Impression

The patient’s primary findings included positive upper limb neurodynamic tension tests (ULTT), positive Allen test for vascular thoracic outlet syndrome, positive cervical compression and distraction, negative Spurling’s test, and negative dermatome and myotome screen. Findings from the initial examination support the initial clinical impression of thoracic outlet syndrome of both vascular and neurogenic origin. Cervical special tests, compression/ distraction and Spurling’s, yielded conflicting evidence to rule in or out cervical radiculopathy. Therefore, based upon negative myotome and dermatome testing it was concluded that the cervical nerve roots were not the underlying cause of symptoms. The results of the examination confirmed that the patient was appropriate for physical therapy services with no need for further testing or referral. The patient agreed to attend physical therapy for 2x a week for 3 weeks followed by 1 x a week for 3 weeks. Therapy interventions included nerve mobilization, pectoralis minor and scalene stretching, thoracic and cervical spine and rib cage mobilization, scapular strengthening, and activity modification. Follow-up assessment occurred at discharge, with ULTT of the median nerve assessment at each therapy visit.

Intervention

Dynamic neuromobilization was performed as described and demonstrated in Carroll University PTH 507/607: Musculokeletal Systems Disorder I and II (M. Erickson, oral communication). The intervention theoretical goal purpose was to promote normal physiological function of nerves. The patient was positioned in right side lying while the physical therapist performed passive range of motion of the patient’s left upper extremity, manipulating each joint in varying directions and combinations to mobilize the peripheral nerves off the brachial plexus (Figures 8-10). Movement was initiated at the patient’s proximal joints within a small range of motion while gradually progressing towards the inclusion of distal upper extremity joints throughout a greater range of motion. Duration progressed from five to eight minutes.

Posterior to anterior thoracic spine and rib cage mobilization was performed with the patient positioned in prone. Intensity was initially grade II due to painful end feels as progressed to Grade III as pain subsided to improve mobility. A half foam roller was also utilized in clinic and the patient was instructed to perform as part of home exercise program (Figure 11). Median nerve glide/flossing technique has been shown to provide significantly larger nerve excursion than other UE nerve gliding techniques5. It was prescribed as part of the home exercise program with the patient supine. The movement was left shoulder girdle depression, elbow, wrist, and digit extension to the onset of a moderate tingling sensation with simultaneous cervical lateral flexion. This was followed by left digit, wrist, and elbow joint flexion and contralateral cervical lateral flexion. This cycle was performed continually for 30 seconds and progressed to two minutes (Figures 12 – 13). Additional home exercises are listed in Table 3. The aim of first three exercises was to decrease muscle tension in pectoralis major, pectoralis minor, and scalene to decrease nerve compression. The remaining three exercises were initiated near the end of the patient’s plan of care as symptom intensity decreased to strengthen scapular musculature. Outcomes

The patient reported she was 99% back to normal with residual tingling in left thumb during upper extremity arm movements above shoulder height approximately 25% of the time. Quick DASH score at discharge improved from 24/55 which equates to a 29.55% disability to 12/55 which equates to a 2.27% disability. She no longer displayed forward head posture and demonstrated minor tension in left scalenes and pectoralis minor with no pain provoking trigger points. Upper limb tension testing was no longer positive for median, radial, and ulnar nerves with some minor tingling experienced in her thumb with full wrist extension during median nerve testing. Cervical extension remained limited to 35 degrees with no symptom reproduction and manual muscle testing scores remained constant with the exception of a significant improvement in left shoulder external rotation strength from 4/5 to 5/5. Cervical compression was no longer positive and cervical distraction was positive demonstrated through elimination of the residual thumb tingling the patient occasionally experienced. The Allen test was negative demonstrated with a pulse return within seven seconds. Joint play assessment demonstrated moderately hypomobile posterior to anterior glides from T1-T6 without pain and no mobility restriction of the rib cage. Reflection

Writing a case study analysis has provided me with a good opportunity to identify my strengths and weakness in regards to patient management. I believe my greatest overall strength was my comprehensive evaluation of my patient. I was dedicated to developing a good understanding of my patient’s values to better understand her experience with the injury, learning style, primary concerns, and goals. I understood thoracic outlet syndrome is often associated with a wide range of impairments and contributing factors; therefore, I performed a thorough examination to identify primary impairments to better direct my plan of care. After a literature search and discussion with Dr. Erickson I learned that dynamic neuromobilization is not a known

intervention within physical therapy literature. Therefore, I selected a nerve flossing home exercise program for my patient as this technique is well supported in research to promote normal physiological function of nerves. I also collaborated with physical therapists in the clinic to broaden my understanding of physical therapy treatment options for TOS. I believe a weakness of my case was failure to consistency quantify both subjective and objective data. Due to a 30 minute time constraint for treatment sessions I often felt pressed for time and failed to be thorough in this area. There were several instances throughout the writing process where I had to later consult my patient to obtain more quantified subjective and objective measurements with prompting from my advisor. Another weakness was my failure to select the gold standard for vascular TOS testing. I selected the Allen test because it was the only test I could remember in the moment without having research to support my decision. Lastly, this project has made me more aware of my tendency to be wordy when communicating my thoughts in writing. I have a difficult time conveying my information in a concise format and required many draft submissions throughout the process. This is a valuable project that helped me develop into a better professional. It was a worthwhile exercise to communicate my patient management as this is a skill I will need throughout my career. I appreciated having an attentive mentor who provided me with helpful recommendations to challenge me to communicate in a concise manner. Creating an outline prior to writing was a useful new writing strategy for me that helped me better organize my thoughts. I believe the project was an appropriate length and challenge given my preparation to graduate in the upcoming month.

Appendix

Table 1: Manual Muscle Grades Movement Initial

MMT Score Discharge MMT Score

L Shoulder flexion 4+/5 4+/5 R Shoulder flexion 4+/5 4+/5 L Shoulder abduction 4+/5 4+/5 R Shoulder abduction 4+/5 4+/5 L Shoulder internal rotation 4+/5 5/5 R Shoulder internal rotation 4+/5 5/5 L Shoulder external rotation 4/5 5/5 R Shoulder external rotation 4+/5 5/5 L elbow flexion 5/5 5/5 L elbow extension 4+/5 5/5 Figure 1:

Figure 2:

Figure 3:

Table 2: Upper Limb Neurodynamic Tension Tests Median Radial Ulnar Shoulder Depression and

abduction (110°) Depression and abduction (110°)

Depression and abduction (90°), hand to ear

Elbow Extension Extension Flexion Forearm Supination Pronation Pronation Wrist Extension Flexion and Ulnar

Deviation Extension and Radial Deviation

Fingers and Thumb Extension Flexion Extension Shoulder - Medial Rotation Lateral Rotation Cervical Spine Contralateral Side

Flexion Contralateral Side Flexion

Contralateral Side Flexion

Figure 4:

Figure 5:

Figure 6:

Figure 7:

Figure 8:

Figure 9:

Figure 10:

Figure 11:

Figure 12:

Figure 13:

Table 3: Home Exercise Program Exercise Description

Pectoralis major stretch

Standing with arms abducted to 90 degrees with elbows trapped against doorframe. Step forward lightly with one leg. Hold for 30 seconds, 2 repetitions, 1-2x day.

Pectoralis minor stretch

Standing with arms abducted to 150 degrees with elbows trapped against doorframe. Step forward lightly with one leg. Hold for 30 seconds, 2 repetitions, 1-2x day.

Scalene stretch Seated with left shoulder girdle depression and cervical spine extension, left rotation, and right lateral flexion. Hold for 30 seconds, 2 repetitions, 1-2x day.

Prone rows Prone on mat table with left arm hanging over side of table. Arm is brought up by extending elbow resulting in scapular adduction and depression. 3 sets of 10 reps 5x a week

Prone extension Prone on mat table with left arm hanging over side of table and arm brought into extension. 3 sets of 10 reps 5x a week

Seated shoulder external rotation with theraband

Seated bilateral shoulder external rotation with therband held in both hands. 3 sets of 10 reps 5x a week

Table 4: Primary Outcome

Test Baseline After Intervention QUICK Dash 24 (29.55%) 12 (2.27%) ULTT Positive Negative Cervical Compression Positive Negative Cervical Distraction Positive Positive Allen Test Positive (30 seconds to pulse

return) Negative (7 seconds to pulse

return) MMT Left Shoulder

External Rotation 4/5 5/5

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