Thoracic Outlet Syndrome: UQ Neural Mob & Mgmt of Pt w/ Brachial Plexopathy Flashcards
(100 cards)
1
Q
Brachial Plexus Visual
A
see pics
2
Q
Brachial Plexus Anatomy
A
C5-T1
3
Q
2
Brachial Plexus Anatomy
A
- 5 Roots (ventral rami)
- 3 Trunks
- 3 ANT Divisions, 3 POST Divisions
- 3 Cords
- Terminal Branches
-
MARMU
- Musculocutaneous
- Axillary
- Radial
- Median
- Ulnar
-
MARMU
4
Q
Roots:
A
C5-T1
5
Q
Trunks (3)
A
Upper
Middle
Lower
6
Q
Trunks
Upper Trunk
A
formed from C5 and C6
Combines w/ Middle Trunk to form Lateral Cord
7
Q
Trunks
Middle Trunk
A
Formed from C7
Combines w/ Upper Trunk to form Lateral Cord
8
Q
Trunks
Lower Trunk
A
Formed from C8 and T1
Anterior Division becomes Medial Cord
9
Q
Divisions (2)
A
ANTERIOR
POSTERIOR
10
Q
Divisions
Anterior
A
contribute to nerves that innervate FLEXORS
11
Q
Divisions
Posterior
A
contribute to nerves that innervate EXTENSORS
12
Q
Divisions
Posterior Divisions of all three trunks form the _____
A
Posterior Cord
13
Q
Cords (3)
A
Lateral
Posterior
Medial
14
Q
Cords
Lateral
A
formed from the Upper and Middle Trunks
Musculocutaneous and Median nerves→ major P-nerves
15
Q
Cords
Posterior
A
Formed from the Posterior Divisions of all three Trunks
Radial and Axillary→ major P-nerves
16
Q
Cords
Medial
A
formed from the Anterior Division of the Lower Trunk
Ulnar and Median→ major P-nerves
17
Q
Thoracic Outlet divided into 4 Regions:
Medial→Lateral
A
- Sternocostovertebral Space
- Scalene Triangle (Scalene Groove)
- Costoclavicular Space
- Pec Minor Space
18
Q
Sternocostovertebral Space
Boundaries:
Contents:
A
-
Boundaries
- Ant→ sternum
- Post→ spinal column
- Lateral→ first rib
-
Contents
- Roots of plexus
- Subclavian aa/vein, jugular vein, neck lymphs
- Apex of lung and pleura
- Sympathetic trunk
19
Q
Scalene Triangle (Scalene Groove)
Boundaries
Contents
A
-
Boundaries
- Ant→ Ant Scalene
- Post→ Middle Scalene
- Base→ First rib
-
Contents
- Roots and Trunks of the plexus
- Subclavian aa
20
Q
Costoclavicular Space
Boundaries
Contents
A
-
Boundaries
- Sup→ coracoid process
- Ant→ pec minor
- Post→ chest wall
-
Contents
- Cords of plexus
- Subclavian aa/vein
21
Q
What is Thoracic Outlet Syndrome (TOS)?
A
Collection of disorders; describes patho condition of an anatomical space
22
Q
TOS can include BOTH of these things:
A
- Subclavian aa and/or vein
- Brachial Plexus
23
Q
TOS Subgroups
10%pts vs. 90%pts
A
-
10%
- Arterial vascular
- Venous vascular
- True neurologic
- Traumatic neurovascular
-
90%
- Disputed: MOST COMMON type of TOS pt
24
Q
MOST COMMON type of TOS pt?
A
Disputed ~90%
25
TOS affects more _____ than \_\_\_\_\_
affects **women** more than men
26
Most experts believe only the _______ is involved in **majority of TOS cases**
Brachial Plexus
27
Compression Sites:
## Footnote
**Sternocostovertebral Space**
* **Pathology:** compression caused by **tumors→**
* Lung (Pancoast Tumor; other space occupying lesions of lungs)
* Thymus
* Thyroid & Parathyroids
* Lymph nodes
28
Compression Sites:
## Footnote
**Scalene Groove (Scalene Triangle)**
**what does NOT pass through here**
Subclavian vein does NOT pass thru Scalene groove
29
Compression Sites:
## Footnote
**Scalene Groove**
**what IS common in this space?**
Scalene involvement
30
Compression Sites:
## Footnote
**Scalene Groove**
**Vulnerable tissues in this site:**
* Brachial plexus (common)
* **ventral rami of C5-T1**
* Subclavian **artery**
31
Compression Sites:
**Scalene Groove (Triangle)**
**Patho:** compression/entrapment
* **Patho:** compression/entrapment caused by:
* Variations in Scalene anatomy
* Presence of **interdigitating fibrous bands→ Roos' bands**
32
Compression Sites:
## Footnote
**Costoclavicular Space**
**Bw where and where?**
**Also called?**
Bw **clavicle and 1st rib**
## Footnote
**aka “nutcracker”**
33
Compression Sites:
**Costoclavicular Space**
Patho: compression bw **clavicle and 1st rib**
* Patho: compression bw clavicle and 1st rib caused by:
* **Shoulder girdle depression 2\* to mm weakness/dyskinesia**
* **\*\***postural syndromes
* Upper, Middle, Lower traps
* Serratus anterior
* Rhomboids
* **Shoulder girdle depression 2\* to Pec minor contraction**
* **Exostosis, tumors, fx of clavicle**
* **Fx of 1st rib**
34
Compression Sites:
**Costoclavicular Space**
**In relation to this:** Presence of **cervical rib**
* .3% pop
* 10% of .3% are problematic
* Incidence in **women=2x that of men**
* Only 10% become symptomatic usually **after** **trauma**
35
Compression Sites:
**Coracoid Process/Pec Minor Interval**
**Patho:** compression of **Cords** and **vasculature**
* **Patho:** compression of **Cords** and **Vasculature caused by:**
* HyperABD of arm
* Hypertrophy of the **Pec minor**
* Shortening/tightness of the **Pec minor**
36
Palpation Lab
## Footnote
**Rules/Guidelines to follow:**
See pics
37
Palpation:
## Footnote
**Trunks of the BP**
* Loc'd in the **Anterior Cervical Triangle→ ABOVE mid-pt of clavicle**
* Neural tissue selectively tensioned by **elevation/depression of shoulder w/ Elbow Ext**
38
Palpation:
## Footnote
**Cords of the BP**
* Loc'd in line w/ the **mid-pt of clavicle and axilla _just below_ coracoid process**
* **\*NOTE:** you will NOT feel neural tissue→ BUT you will elicit response
39
Palpation:
## Footnote
**Median and Ulnar Nerves in the _Distal Axilla/Prox. Humerus_**
* Loc'd in the **interval created bw biceps and triceps**
* ID nerve bundle w/ varying deg's of tension added by **shoulder, neck, elbow motions**
40
Palpation:
## Footnote
**Radial Nerve**
* **Prox portion** as it **exits from Triangular Space**
* **Boundaries:**
* Inf border of Teres major
* Long head of Triceps
* Medial head of Triceps
41
**Examination of the Pt w/ Brachial Plexopathy:**
**History**
**\*Localization of sx's variable and can include:**
* HA→ U/L or B/L, **usually occipital region**
* Facial pain→ **side of face from angle to jaw to zygomatic region to ear**
* Pain along **Trapezius ridge** and **down medial border of scapula (BIG ONE) to Inf angle**
* Chest wall pain→ from **sternum to axilla to epigastric reg.**
* Arm/Hand involvement based on **extent and loc. of patho.**
42
**Examination of the Pt w/ Brachial Plexopathy:**
**\*NOTE:** pts often seen in ER for WHAT?
* **suspected MI**
* **Dx'd w/ Costal chondritis**
* **gastritis**
43
**Examination of the Pt w/ Brachial Plexopathy:**
**Onset**
* USUALLY related to **cervical trauma OR UE trauma**
* \*traction injuries
* Can be delayed mo's due to **adhesion formation** bw plexus and surrounding tissues or perinueral scarring
* Repetitive motion
* Postural stresses\*\*\*
* Insidious
44
**Examination of the Pt w/ Brachial Plexopathy:**
**Behavior of Sx's**
**Describe pts w/ Brachial plexopathy vs. Cervical disc patho and OH activities**
* **Pts w/ Brachial Plexopathy**
* WORSE w/ OH activities
* **Pts w/ Cervical Disc Patho**
* BETTER w/ OH activities
\*THINK ABOUT YOUR SPECIAL TESTS!!!!
45
**Examination of the Pt w/ Brachial Plexopathy:**
**Behavior of Sx's**
* Hx of dropping obj's
* Cramping of **hand intrinsics** when writing
* Walking w/ “Dead Arm”
* Intolerance of bra, purse, bag straps on **involved side**
* anything over shoulder→ **downward force→ tractions nerves**
46
**Examination of the Pt w/ Brachial Plexopathy:**
**Observation**
**Need to see the pt in what postures/positions?**
NEED to see patient from **mid-sternum up from front, FULL back from rear**
47
**Examination of the Pt w/ Brachial Plexopathy:**
**Observation→ Posture**
**NOTE any of following:**
* FHP w/ poss. shift from midline and rotation comp.
* Lowered sternum, kyphosis
* Shoulder held elevated and ADD'd or depressed
* Scapular winging\*\*\* (COMMON)
* Loss of concavity in supraclavicular fossa
* **Neurogenic swelling** of side of face, neck or **in supraclavicular fossa**
48
**Examination of the Pt w/ Brachial Plexopathy:**
**Observation→ Posture**
NOTE **color changes in involved UQ if present:**
* Hand **red and warm to cold and cyanotic→** Sympathetic instability
* Side of face AND ear red, flushed
49
**Examination of the Pt w/ Brachial Plexopathy:**
**Observation→ Posture**
**Breathing Pattern**
Diaphragm (belly) vs. Upper Chest (apical)
50
What should you always do w/ **EVERY suspected Brachial Plexopathy pt?**
CLEAR C/S FIRST!!!!!
51
**Examination of the Pt w/ Brachial Plexopathy:**
**Observation→**
**C/S Screening**
**\*Always clear C/S first!!!**
* ROM, asymmetries; **sx behavior w/ rep'd motions**
* **+ Spurlings→ nerve root injury**
52
**Examination of the Pt w/ Brachial Plexopathy:**
**Observation→**
**Shoulder Jt Screening**
Always screen shoulder to det. if coming from joint
53
Special Tests for **TOS**
## Footnote
**5:**
1. Roo's
1. performed 3mins, but **pts w/ plexopathy often do not tolerate \>1min**
2. Wright's Test (HyperABD Test)\*\*
3. Costoclavicular Test (Military Bracing Test)\*\*
4. Shoulder Girdle Passive Elevation Test
5. Adson's Maneuver\*\*
1. turn the head + ext one
\*\*→ **Vascular compression tests→** questionable 2\* to high positive results in normals
1. Wright's
54
Special Tests for TOS
## Footnote
**Vascular compression tests**
* Wright's Test (HyperABD Test)
* Costoclavicular Test (Military Bracing)
* Adson's Maneuver
55
Sensation Testing:
## Footnote
**W/ Brachial Plexopathy, the _________ digit will often show differential sensation**
3rd Digit\*\*\*
56
Sensation Testing
Dec'd sensitivity to pinprick along **MEDIAL HALF 3rd Digit→**
**Medial Cord** involvement
| (Medial→ Medial)
57
Sensation Testing
Dec'd sensitivity to pinprick along **LATERAL HALF of 3rd Digit→**
**Lateral Cord involvement**
**(Lateral→Lateral)**
58
Differentiating Brachial Plexopathy vs. **Carpal Tunnel/Cubital Tunnel Syndrome**
Brachial Plexopathy→ **3rd Digit**
Carpal/Cubital Tunnel→ **4th Digit=differential sensation**
59
Strength Testing
## Footnote
**In a myotomal screen, focus on WHAT mm's?**
**LOWER Trunk involvement**
Hand intrinsics
## Footnote
**Dorsal and Volar interosseus mm's**
**assesses Lower Trunk involve.**
60
Brachial Plexopathy and Tinel's Test
use it!!
palpation sites
look for spread of sx's **distally and proximally**
61
Palpation
look for **tenderness or spread of sx's _along neural paths_**
62
Brachial plexopathy/TOS and **Pec minor tightness**
Check it!!!!!!
63
Upper Limb Neurodynamic Tests
## Footnote
**what are they?**
Set of **Four basic tests** to bias the **cervical nerve roots, brachial plexus, median n., radial n., ulnar n.**
## Footnote
**aka ULNT Tests**
64
Brachial Plexus Neurodynamic Test
## Footnote
**BPNT**
\***Important points to remember for BPNT**
* DO NOT DEPRESS SHOULDER→ only block elevation
* Keep pts arm in line w/ **midpoint of axilla;** do not drop into horiz. Ext or lift the pts arm into horiz. Flex
* Change to **inverted pistol grip @ 45\* shoulder pos.→** midpoint bw 1/5 and 2/5
* pause @ ea of the above steps to check pts status before moving to next step
* once sx's occur or intensify there is **no need to push further into test\*\*\*\***
65
**BPNT:**
**Test Data Points**
Onset, Stop Point, Tx Zone
* **S1→** onset or change of pts sx's
* **S2→** definite STOP point in the test based on pts discomfort lvl
* **Tx Zone→** motion available **bw S1 & S2**
66
**Median Neurodynamic Test (MNT)**
Developed as alternative pos for **biasing Median N.** for pts w/ shoulder co-morbs **that would not tolerate 110\* of ABD**
67
Radial Neurodynamic Test (RNT)
**Radial N. bias has _same starting pos as Median N. Test_**
68
Important points to remember for **Median & Radial Neural Dynamic Tests \*\*\*\*\***
* **Depress pts shoulder slowly ~1 in**
* watch face for s/s discomfort before continuing
* Keep pts arm in **coronal (frontal) plane**
* Pause @ ea step to check status before continuing
* Use **S1 and S2 Test Data Points (see prev cards)** w/ these tests as described in other cards
69
Ulnar Neurodynamic Test (UNT)
Important points to remember for **Ulnar Neurodynamic Test**
* **DO NOT DEPRESS SHOULDER, only block elevation\*\*\***
* Prevent your pt from **laterally flexing neck AWAY from side being tested** as you bring their hand to side of their face
* Keep your pts arm in the **midline axillary plane;** avoid tendency to move into Horiz. Flex during test
* Use **S1 and S2 test data points** w/ this test as described in other cards
70
Neurodynamic Testing/ULNT:
## Footnote
**Documenting Findings**
* Standardization of testing tech.
* **Goal→** Reproduce pts **primary** complaint/sx's
* Ea test carried out in consistent sequence **to onset OR change of pts sx's**
* List sx's produced, location, and **last step performed that produced pts sx's**
71
Neurodynamic Testing/ULNT:
## Footnote
**Documenting Findings**
**Modifying the Grading Scale**
Use +/- modifiers on the grading scales **if the test pos. findings are bw grade pos's**
**Ex.** if the BPNT test pos for pt was beyond 3/5 but **less than halfway** to 4/5 they would be a 3+/5. If they were **beyond halfway, but not to** 4/5, they would be a 4-/5
72
**Indications** for Neurodynamic Testing
ULTTs
* pain/parasthesias of **neural origin** deduced via exam and hx
* tension point pain
* limtd mobility of the NS
* inj of tissue close to nerve beds, i.e. **lateral epicondylitis (radial nerve), medial epicondylitis (ulnar nerve)**
* chronic inflexibility
* post-op spine pts
73
**Contraindications** for Neurodynamic Testing
ULTTs
* acute inflamm infection involving SC or NS
* Acute/recent onset of **hard neuro signs**
* loss of DTRs
* localized mm weakness (severe)
* Cauda equina s/s
* recent onset B&B probs
* saddle anasthesia
* SC instability
74
**Precautions** for Neurodynamic Testing
ULTTs
* malignancy
* be aware of stress to anatomical structures during test
* **BPNT:** shoulder impinge concerns
* irritability lvl of pts NS→ do not push too far
* presence of **stable** hard neuro s/s
* health issues impacting **connect tissue, immune issues, etc.**
* IDDM/NIDDM
* HIV
* MS
* Vert basilar aa insuff (VBI) signs in **EXT combined w/ ROT**
* dizzy
* nausea
* syncopal episodes
* circulatory disturbs
* Frank cord injury (cord contusion)
75
**Interpretation of Exam Findings in Pts w/ Brachial Plexopathy**
Dx might be **brachial plexopathy** (as opposed to **distal nerve entrapment) IF:**
* hx of multiple nerve decompress procedures on **same extremity**
* Failure of nerve decompress sx to relieve sx's
* **EMG/NCV** usually show **radiculopathy or distal nerve entrap** due to **double crush injury**→ So these tests will be **NEGATIVE** due to inability to detect C or a-delta (small diameter) fiber damage
* Sx's that cross **mult. derms or p-nerve distributions**
76
Localizing BP injury based on s/s
## Footnote
**Upper Trunk Inj's (and Cervical Plexus)**
* Pt c/o **pain in occipital/subocc area,** across **trapezius ridge, down med border scap\*\*, HA, TMJ, ear**
* EXAM→ you may see **drooped shoulder, upper traps, rhomboids, serratus ant→ scap dyskinesia**
* Sx's usually intensified w/ **percussion over supraclavicular fossa**
77
Localizing BP injury based on s/s
Upper Trunk (cervical plexus)
Think….
Scapular sx's/dyskinesia one\*\*\*\*
78
Localizing BP injury based on s/s
**Lower Trunk Injuries (_and_ Medial Cord)**
***the Intrinsic hand mm's one*****\*\***
* Combo of **dull ache/parasthesias of the 4th/5th fingers and medial forearm**
* Pts c/o **hand fatigue and loss of penmanship** or inability to write for ext pds time
* Pts drop obj's
* EXAM→ **weakness of intrinsic hand mm's**
* **APB**
* **OP**
* **D/V interossei**
79
Localizing BP injury based on s/s
Lower Trunk inj's (_and_ Medial Cord)
THINK….
Hand intrinsic mm's one 1
80
**Localizing BP injury based on s/s**
**Medial Cord Injuries**
***the chest wall one*** **\*\*\***
* **Chest wall pain,** parasthesia radiating into the **medial aspect of upper arm, forearm, and 4th/5th digits**
* EXAM→ Pain w/ pressure over the **infraclavicular fossa.** Medial upper arm, forearm, **ulnar side of 3rd finger (medial→medial), and 4th/5th digits** show **dec sensitivity to pin prick. Chest wall tender to palpation**
* **Ulnar N. Involvement ONLY→** 4th finger shows differential sensitivity→ **ulnar side LESS sensitive vs. radial side**
81
Localizing BP injury based on s/s
**Lateral Cord Injuries**
***medial anticubital region elbow one*****\*\*\***
* Pts demo parasthesias of **thumb, index, radial side of 3rd finger (lateral→lateral)**
* Freq c/o **discomfort in medial anticubital region of elbow**
82
Localizing BP injury based on s/s
**Posterior Cord Injuries**
***lateral epicon one, tender radial N. one*****\*\*\***
* Pain in **upper arm (triceps) lateral epicondyle and anticubital region,** parasthesias of the **dorsal side of thumb, index, 3rd finger**
* EXAM→ tenderness and/or Tinel's sign @ the **posterior aspect of the shoulder** at the **triangular space**
* Tender/Tinel's sign along **radial N.**
83
Prognosis/Staging of Condition for Brachial Plexus Injury
## Footnote
**Depends on…**
* **Lvl of irritability:**
* Constant vs. intermittent
* ease of provocation during ADLs/exam
* How quick sx's calm w/ change of pos
* Once provoked, how refractory are sx's?
* **Roos' test + @ \< or \> 30s**
* BPNT \< or \> 3/5→ @ least 3=better prognosis vs. \<3
* **Lg. tx zone=better prognosis**
* Do sx's improve or centralize w/ **rep'd cervical mvmts?**
* could be cervical radiculopathy
* Is pt able to maintain corrected posture?
* **better prognosis w/ better posture**
84
Tx for pt w/ Brachial Plexopathy:
## Footnote
**Tx/Goals _1st Visit:_**
* Pt education
* Diaphragmatic breathing
* Basic HEP
* posture correction
* scap mobility and kinematics w/ prox. gliding
* tray nerve glides\*\*
* protective box\*\*
* Teach stable sleeping pos's
85
Tx for pt w/ Brachial Plexopathy:
## Footnote
**Tx/Goals _2nd Visit:_**
* Assess effectiveness of HEP + your instructions
* **review** as needed
* **modify** as needed
* Begin to **address deficits found during eval.**
* posture
* scap kinematics
* **scap clocks**
* **capital D's**
* **Brueggers**
* **scalene tightness→ self-stretching**
* **pec minor tightness→ self-stretching**
* **elevation+retraction to lift clavicle off plexus**
* Add to HEP if effective and pt can demo indep. doing so
86
Tx for pt w/ Brachial Plexopathy:
## Footnote
**Tx/Goals _3rd Progression:_**
* Assess + Review→ correct or modify where needed
* **Begin PT intervention**
* nerve glides+stretches
* scalene stretching w/ or w/out 2nd rib stab.
* Pec minor lift/stretching
* **Begin stretching scap control mm's if tol'd**
* rhomboids and mid traps
* Serratus anterior
* Modify HEP
87
Tx for pt w/ Brachial Plexopathy:
## Footnote
**Tx/Goals _4th Progression:_**
* Assess and Review→ correct or modify where needed
* Add advanced tx techs where needed
* **nerve glides w/ pec minor release**
* **IVF opening tech's w/ nerve glides**
* **Inf glides of 1st rib**
* **clavicle mobs**
* Adv'd **scap ex's** and modify HEP
88
**Modify, Mix and Progress program based on _responses and re-assessment_**
***\*\*FOCUS ON:***
* Postural symmetry and awareness
* Plexus mobility
* Breathing patterns
* Tolerance to exercise
* Lvl of irritability w/ ADLs
89
When would you use Neural **Gliding** vs. Stretching?
MORE irritation, LESS mobility
90
When would you use Neural **Stretching** vs. Gliding?
LESS irritable pts
91
Neural **Gliding**
* alternatively applying a **stress** that moves the neural tissue **first in one direction, then opp.**
* occurs by simultaneously applying **distal force** on the neural tissue while **releasing tension proximally,** then **reversing process→** nerve is always on tension in one spot, slack in another
92
Neural **Gliding Key Points:**
* **Optimal for HIGHER lvls neural irritation**
* Mobility bw **neural tissue** and **mechanical interface** altered
* **Tethering and adhesions** result from bleeding around neural tissue in nerve bed OR inflamm rxn bw neural tissue and interface
* **Restoring normal mob. via gliding is the _Tx of Choice_\*\*\*\*\*\***
93
Neural Stretching
## Footnote
**\*LESS irritable pts**
* Produced by **simultaneously** **applying stress to opp ends of neural tissue -→ on _tension_ the whole time**
* LOW lvl neural irritation cond→ **sense tightness more than pain**
* restoring **norm. elasticity** via stretching **may be more effective**
94
Basic Nerve **Gliding** or **Flossing**→ **Median N. Based (Median & Lateral Cord)**
see pics + Instructions
handshake one
95
Basic Nerve **Stretching→ Median N. based (Median & Lateral Cord)**
see pics + Instructions
96
Soft Tissue Tech's to **Enhance Neural Mobilization:**
## Footnote
**Trans-axillary Pec minor lift w/ _Stretch_**
see pics + Instructions
97
Trans-axillary lift w/ **nerve glide/stretch**
see pics + Instructions
98
Scalene Mobilization
see pics + Instructions
99
Key Considerations for **Neural/Soft Tissue/Jt Mob Techniques**
* Always **pre-test** to establish **baseline** of neural mobility
* Perform a **post-tx neural mobility test** to establish **tx effect**
* If NO change→ may need to select an **alt. tx tech.**
* Many of these techs can be mod'd and use as **HEP** for pt
100
Brachial Plexopathy **HEP Ideas**
* The **Capital D**
* **Purpose→** Posture Correction
* 5-10x/hr
* The **“Tray”** Nerve glides
* **Purpose→** Nerve Gliding
* 3reps 3x/day (more often as sx's improve)
* **Variation for Radial N: Radial Nerve Glide→ The “Box” (see pics)**
* **Purpose→** Protection of injured nerves
* as injured nerves heal= inc size of “box”
* The **“Vanna White” or “Spidermans"**
* **Purpose→** Nerve Gliding and Stretching
* 3reps 3x/day
* more often as sx's improve
