Kelsey Renwick. Clinical Case Report Competition. West Coast College of Massage Therapy Victoria Part-Time. Third Place Winner

Transcription

1 Registered Massage Therapists of British Columbia Clinical Case Report Competition West Coast College of Massage Therapy Victoria Part-Time April 2014 Third Place Winner Kelsey Renwick The effects of massage therapy and decreasing thoracic outlet syndrome symptoms P: F: massagetherapy.bc.ca RMTBC 2014

2 Conflict of Interest The author and patient were previously acquainted before the start of the case study. Although previously acquainted, there was no conflict of interest and a therapeutic relationship was developed throughout the course of the case study. The patient committed to the study and was informed of procedures prior to commencing, and was aware her identity would be kept confidential. Acknowledgments I would like to thank my case advisor Dean Robertson for his advice and ideas as well as the rest of the supervisors for their input and motivation. I would also like to thank my patient, who volunteered her time, effort, and positive attitude. Without her this case study would not have been possible.

3 Table of Contents Title Page....1 Acknowledgments 2 Conflict of Interest....2 Abstract Introduction...6 Methods and Procedures...8 Client History...8 Assessment Treatment Reassessment Results Discussion Conclusion References Appendix A: Orthopedic Tests Appendix B: Initial and Final Assessment Pictures Appendix C: Treatment Breakdown Appendix D: Anatomy Pictures Patient Consent Form Clinic Notes

4 Abstract Objective: The objective of this case study was to determine if massage therapy is an effective choice when there is a compression of the brachial plexus, causing Thoracic Outlet Syndrome (TOS) symptoms. The main choice of techniques used was myofascial release, and General Swedish Massage (GSM) techniques. Background: TOS is a common disorder, occurring mainly in athletes who play over hand sports, or workers who do lots of overhead work. The brachial plexus is often compressed due to constant overhead movements, resulting in numbness and tingling down the arm and into the 4 th and 5 th metacarpal joints. The patient being a twenty-year old female, complained of numbness and tingling bilaterally in both her hands and arms. Methods: A total of thirteen hands on treatments were conducted over an eight-week period, focusing on decreasing hyper tonicity bilaterally in the and Pectoralis Minor muscles to relieve neurological symptoms. A postural assessment using a plumb line was used for the initial and final assessment, cervical spine ranges of motion and a selection of orthopedic tests. Myofascial and GSM techniques were preformed each treatment, predominantly focusing on the cervical spine, anterior chest, and forearm musculature. Results: The patient s neurological symptoms decreased immensely, and she was able to perform certain actions (abduction, external rotation and extension) with no feeling of numbness or tingling at all. Most orthopedic tests that were strongly positive prior to massage intervention became negative during the final assessment.

5 Conclusion: Massage therapy was found to be an effective modality in decreasing neurological symptoms due to a compression of the brachial plexus. Keywords: Thoracic Outlet Syndrome, compression, brachial plexus, impingement, neurological symptoms, myofascial release, General Swedish Massage, upper extremity, bilateral Introduction Thoracic Outlet Syndrome (TOS) is a compression disorder of the brachial plexus and potentially the subclavian vasculature (Rattray, 2000). The brachial plexus arises from the cervical spine, traveling through various musculatures, below the clavicle towards the axilla,

6 down the arm, and terminating at the phalanges see Figure 10 in appendix D. Compression occurs because of increased pressure on structures in the thoracic outlet, which consists of muscles, nerves, bones and vasculature. The lower trunks of the brachial plexus, C8-T1 nerve roots, are the most commonly affected, which leads to pain and numbness in the posterior neck, shoulder, medial arm, forearm, and radiates into the ulnarly innervated digits of the hand (Goodman, 2009). TOS causes neuropraxia, which results in the loss of conduction at the compression spot, resulting with no axonal degeneration (Rattray, 2000). When a nerve is compressed most people report paresthesias and pain in the arm (Goodman, 2009). There are three major locations that are prone to impingement: the intrascalene triangle (Anterior Scalene, Middle Scalene and the first rib), costoclavicular space (clavicle and first rib), and the coracopectoral space (under the coracoid process of the scapula and the Pectoralis Minor muscle) please see Figure 11 in appendix D. The trunks of the brachial plexus pass through the intrascalene triangle, and impingement occurs if this space is narrowed, leading to potential neurological or vascular symptoms (Rattray, 2000). Impingement of the Costoclavicular space leads to the vascular symptoms of TOS. The subclavian artery and vein are more susceptible to impingement as the space varies in size due to the position of the shoulder and possible anatomical abnormalities (Rattray, 2000). As the neurovascular bundle passes through the coracopectoral space it can be compressed during certain movements, such as Glenohumeral joint (GH) abduction and maximal extension. There are many contributing factors associated with TOS. Postural variations and stress are most commonly found to be the cause (Goodman, 2009). Postural variations such as anteriorly rounded shoulders, and head forward carriage can cause shortening of Scalene, Levator

7 Scapulae, Subscapularis and Pectoralis Minor muscles, which leads to a decrease of space in the thoracic outlet please see Figure 9 in appendix D. If there is increased pressure on the shoulder girdle such as carrying a heavy bag with a strap, which could result in pressure on the thoracic outlet or potential traction to the brachial plexus (Kisner, 2012). Hypertrophy of the can be caused from over usage of the respiratory muscles due to bronchitis, pneumonia, asthma and emphysema; paradoxical breathing is often present (Rattray, 2000). Injuries resulting with scar tissue formation, inflammation, adhesions or fractures to the clavicle can result in a decrease of motility to the nerves and potential damage to the plexus and surrounding vessels (Kisner, 2009). Congenital factors associated with compression of the brachial plexus involve, a cervical rib or a long transverse process of the C7 vertebra (Kisner, 2012). Overhead sports (such as racquet sports, volleyball etc.) and heavy lifting aggravate and produce symptoms in the upper plexus (Goodman, 2009). Nerve compressions can be treated manually or surgically, with massage therapy playing a key role in the manual aspect. In relation to nerve compression, the use and effectiveness of massage therapy to help relieve symptoms would be beneficial to the profession as this is a common disorder that occurs in the population. This case study was conducted to demonstrate that myofascial release techniques, with integrated GSM techniques, would benefit and over all decrease the bilateral symptoms of Thoracic Outlet Syndrome. Methods and Procedures Client History The patient of this study is a 20-year-old female student, who has bilateral neurological symptoms involving compression of her brachial plexus. The neurological symptoms are felt

8 when the patient externally rotates and extends her GH, or abducts the GH joint; symptoms increase when wrist is extended. With extension and external rotation the patient feels the symptoms on the palmer aspect of her second, fourth, and fifth phalanges. Abduction results in symptoms appearing in the axilla, Triceps, and Biceps Brachii, as well the fourth and fifth phalanges. The symptoms were described by the patient as a heaviness as well as numbness and sharp, shooting tingling ranging from a seven to eight out of ten on the pain scale see appendix A. It was noted that the patient s sleeping position was having the left hand under the pillow with the right leg hip hiked, and occasionally would experience neural symptoms at night due to the fact that the left shoulder was overstretched. The patient had no previous injuries to her cervical spine (C/S), or her GH joint, but has had chronic recurring pain and stiffness bilaterally in her cervical spine, mainly the right side. On palpation it was noted that the Scalene and Sternoclediomastiod (SCM) muscles were hypertoned and the patient felt that she had limited range of motion of her C/S. The patient has no known cervical ribs, although presented with a family history of her grandmother having two. The patient reported that she had headaches rarely, approximately five times a year, mostly stemming from the sub-occipital muscles and were usually stress induced tension headaches. The patient visits a Registered Massage Therapist once a month for maintenance treatments on her neck, as well as recently getting treatment from a Chiropractor twice a week (the patient was instructed to withhold treatments throughout the duration of this case study, although had eight treatments, most pertaining to the lumbar spine). The patient was diagnosed in 1998 with exercise-induced asthma, which is also triggered with sickness or allergies. The asthma does not occur day to day, and the patient has an inhaler (Salbutamol) for when needed. Attacks are often experienced at random. She has noticed that she

9 tends to breathe more from her chest and not so much with her Diaphragm, as she finds it uncomfortable due to her asthma. The patient also mentioned she has undiagnosed Raynaud s Disease, which is cold weather induced. Her hands experience cyanosis bilaterally, usually occurring in all five phalanges as well as the entire hands. Sometimes the patient experiences this in her feet as well. The patient has a family history of cardiovascular problems such as valve replacements and stints, but she has not been diagnosed with any of these at this time. There has been no history of smoking. Assessment The initial assessment took place on September 12 th, In the postural scan the patient showed bilateral anterior rotated shoulders with the left shoulder slightly more superior then the right. Both knees showed hyperextension with a slight valgus angle. It was also observed that there was approximately 9.5 centimeters of head forward carriage projected from the plumb line please see Figure 5 and 7 in appendix B. The patient complained of tightness and stiffness in the C/S, this was assessed using a verbal analogue using the pain scale please see appendix A. A gonimometer (see appendix A) was used on the initial assessment to measure range of motion of the GH and C/S please see appendix A for normal ranges. The patient had neural symptoms in flexion, abduction, internal and external rotation, in the right GH joint and external rotation and abduction in the left GH joint all amounting to seven-eight out of ten on the neural pain scale. Minimal ranges were also seen in flexion, abduction, extension and adduction in both the right and left GH. C/S range of motion showed minimal ranges in all motions, with bilateral rotations and side flexion having the most limitations. C/S presented with no neural symptoms but with pain, which was assessed by using the verbal pain scale.

10 Orthopedic tests were performed to determine what was causing the neural symptoms. These tests included Adson s Maneuver, Wrights Hyperabduction, and Allen s test, which are common TOS tests. Median, radial, and ulnar Upper Limb Tension tests were performed to determine which nerve roots were affected. Other orthopedic tests performed included Costoclavicular Syndrome and Halstead to check for neural symptoms. Capillary Refill and Roo s were performed in order to see if the patient had any vascular symptoms as well as any neural symptoms see appendix A for orthopedic testing results. A series of manual muscle tests were performed as well to indicate which muscles were weak, or which were associated with the pain in the C/S. Over the course of the 13 hands on treatments Adson s and Allen s were used approximately every treatment. After the seventh treatment, all of the Upper Limb Tension tests were performed pre and post treatment. Progress was seen as early as the third hands on treatment. Charts of the orthopedic testing results can be found in appendix 1. Treatments Thirteen sixty-minute hands on treatments took place twice a week for the first ten treatments and then progressed to once a week for the last three treatments. There were two, 70 minute assessments that took place initially and for the final fifteenth session. All thirteen treatments were in the supine position working on the C/S, anterior chest, and bilateral arms. Treatments two to four, twelve, and thirteen included Pectoralis Minor and Major work. Treatments five to thirteen included work on bilateral arms and forearms. All treatments were otherwise the same. Treatments would start with myofascial release (MFR) techniques to the C/S, including a sub-occipital release in order to relax the body and C/S musculature. This technique would be

11 held for approximately one to three minutes depending on when the release was felt. Next, the Scalene muscles would be palpated and the subject would be instructed to place her hands on her stomach and take five deep diaphragmatic breaths, pushing the air into her hands, while still maintaining the hold on the, all the while waiting for a release. GSM techniques were used on the C/S in order to flush out the area, and decrease the hyper tonicity in the SCM and Scalene musculature. A series of thumb, fingertip, and knuckle kneading and stroking were applied. A muscle squeeze was applied to the SCM in order for the musculature to release, therefore gaining better access to the. Contract-relax and isolytic release techniques for the Scalene muscles were introduced in treatments nine to thirteen. The patient was to actively side flex and rotate to the ipsilateral side as far as they could and then resist the pressure of the therapist for five seconds, rest for seven seconds, and repeat twice with the last resting period being held for thirty seconds. This would occur bilaterally. The isolytic release was done passively and actively for three times each, bilaterally. The patient s head would be passively held, and laterally flexed to the opposite side while doing a downward strip of the Scalene musculature, mainly the anterior Scalene. This would be done in the same manner only getting the patient to actively do the side flexion motion. Multiple MFR techniques were applied in order to open up the anterior chest and promote a posterior rotation of the GH joints. An arm pull traction technique was used, with one hand on the Pectoralis musculature and the other applying traction at the mid-humerus, creating a myofascial pull. This would be held for approximately one hundred and twenty seconds or until a release was felt and would be performed bilaterally. Next, the MFR technique used was called reshaping, and would be performed on the Pectoralis Minor muscle by inserting both thumbs into

12 the axilla and then grabbing the rest of the muscle on the anterior chest, applying pressure and holding. With this technique the sheering moved inferiorly down the muscle and applying a slight bend in it as well, creating space around the corocoid process, which is the attachment point of the Pectoralis Minor. Micro-sheering was performed on the Pectoralis Major, by using the middle and index fingers of both hands and applying a MFR sheer. GSM was used to flush as well as to break down adhesions found in the Pectoralis musculature and Subclavius mainly using the muscle stripping techniques. During the treatments that involved the arms and forearms, MFR techniques were used such as sheering, cross-hands and v-stroking to break up adhesions and decrease potential entrapment of the nerves in the forearm. Applying pressure on the tendons and having the patient actively flex and extend her wrist applied Isolytic release to the common flexor and extensor tendons. GSM techniques such as knuckle and forearm stroking and kneading were used. Passive range of motion of wrist, elbow and GH joint and traction to the wrist were applied. This was all performed bilaterally on both arms. In six of the treatments the Diaphragm was worked on with MFR techniques. One hand was placed under her back, in line with where the diaphragm sits, and the other resting inferiorly to the ribs on top of the diaphragm, and held for three to five minutes, waiting for a release or movement. Muscle stripping was also used to break down multiple adhesions in the diaphragm. This was preformed in hopes of taking pressure off the Scalene muscles, as they are a part of the muscles of inspiration see appendix C for treatment breakdown. The patient was given a homecare regime, which included hydrotherapy and remedial exercises to do on a daily basis, in correlation with the massage treatments. Contrast using hot and cold were to be applied to the forearms and the. Starting with heat for three minutes,

13 and then cold for one minute repeating this for three cycles and making sure to end with cold. Heat was given to the patient to apply to the Pectoralis muscles once a day, for a maximum of 20 minutes. The patient was given two stretches after the first treatment, the first was for the Pectoralis muscles, using a doorway or wall, having the elbow bent at ninety degrees with the forearm on the door frame, and turning the torso to the opposite side, feeling a stretch in the anterior chest. The second stretch was for the SCM muscle, stabilizing by holding the chair with one hand, and then extending the C/S, side bend the head to the opposite shoulder, and then rotate the head back the midline, and bringing the chin in towards the chest. A Scalene stretch was added, stabilizing on a chair with the opposite hand, other hand on head, side flexion to that side, and then bring chin into chest slightly to increase the stretch. All stretches were to be held for thirty seconds, twice a day with no pain. The patient was also given the exercise called neural flossing. The arm is to be abducted and slightly extended, or until neural symptoms are felt, and then the wrist is to be flexed and extended. The flossing was to be done for a total of thirty seconds, twice a day, and to be done with no pain. Diaphragmatic breathing was given to the patient to do once a day, for five breaths. The patient was encouraged to place hands on stomach, ribs and back in order to practice breathing into those areas. Reassessment The final assessment took place on November 7 th, Ranges of motion for the GH and the C/S were taken again using the Goniometer. All previous orthopedic testing was repeated in order to find out what the final results were, and if the symptoms had decreased throughout the thirteen treatments. The patient was also put into the positions and preformed the motions that

14 previously brought on the neural symptoms, and it was recorded what the outcome was. Overall the patient was asked if they felt their symptoms had decreased or if they had improved. Results The patient s symptoms had decreased immensely by the end of the thirteen hands on treatments. The Scalene and Pectoralis muscles had decreased hyper tonicity, and the overall tissue quality felt more moveable. The TOS symptoms were decreasing as early as the third treatment as the Adson s test had been negative in the post treatment of the right side. The Upper Limb Tension test for the Ulnar nerve decreased during the ninth treatment, and Allen s started to see negative results on the tenth treatment. Overall GH and C/S range of motion improved greatly. C/S ranges were brought to the maximum range, with no pain. Tension in the C/S has decreased but subject described the C/S as still being stiff. GH ranges improved considerably, all neural symptoms disappeared, only abduction on both sides had a minimal amount (one out of ten on the pain scale). (See appendix A for full results) The patient stated that neural symptoms were minimal, and was now able to hold the GH extension, external rotation, and wrist extension position without discomfort. The patient remarked that the symptoms on the left side were almost gone, where as the right still has more, but very minimal symptoms. Neural symptoms were no longer felt in axilla or the phalanges with external rotation and extension but the patient could feel very minimal fuzzy symptoms in the forearm and upper arm. With abduction symptoms were only occurring minimally in the Biceps Brachaii and Triceps. The final postural scan showed an improvement, the shoulders were now more posteriorly rotated, with the chest looking more open. The head forward carriage has decreased by.5 of a centimeter, resulting in 9 centimeters of head forward carriage please see Figure 6 and 8 in

15 appendix B. By the tenth treatment, the patient was able to go from two treatments a week, down to once a week and did not break the pain tension cycle. Discussion The results of this study indicate that the use of MFR and GSM techniques are beneficial in releasing the compression of the brachial plexus in a TOS subject. By using MFR techniques the patients anteriorly rotated shoulders became more posteriorly rotated, which allowed more space for the brachial plexus, and thus relieving compression. Notably, a correction of posture played a role in relieving symptoms and for further improvement it would be advisable for the patient to do strengthening exercises for the back and continue stretching the anterior chest in order to prevent a kyphotic posture and future compression. The patient was compliant following the homecare given specific to the neural symptoms, which was the neural flossing technique, but was unsuccessful with the other homecare exercises provided to her. The patient was asked prior to each treatment how the homecare regime was going and by the eighth interview it was reported that the subject was not keeping up with the SCM stretch and Pectoralis stretch as much as the neural flossing and Scalene stretches. If the patient had been more proactive with the homecare, there could have been more room for potentially better results. The patient was also advised to withhold getting treatments from her Chiropractor and RMT for the duration of this case study in order to keep the variables as low as possible. However, the patient continued to see her chiropractor for a total of eight treatments. In the regards to changing the treatments, spending more time on the Diaphragm, with MFR and strengthening exercises would have been beneficial to the patient due to her asthma. Strengthening her diaphragm could potentially aid in decreasing the extra stress put on the Scalene and Pectoralis muscles as it would encourage the subject to breath into her abdomen and

16 not consistently into her chest. With a decrease of stress on her and Pectoralis Minor muscle, the hyper tonicity would potentially decrease, causing less compression symptoms. It would be advisable for the patient to continue getting massage therapy treatment once a week, and paying attention to strengthening her Diaphragm and continue to maintain the muscles of respiration. Conclusion This case study proved that using MFR and GSM techniques could decrease neurological symptoms due to compression of the brachial plexus. Performing myofascial techniques beginning at the C/S and following the nerve path down the arm provided a positive result in relieving symptoms, decreasing pain and tension in the C/S and anterior chest. The main focus was to decrease the tension in the and Pectoralis Minor muscles and progress was seen by the fourth treatment, when the patient extended her GH joints, neurological symptoms had decreased since the first initial assessment. By treatment seven, the patient could extend the GH joints with no symptoms except with wrist extension, and by the thirteenth treatment neurological symptoms were minimal to none. It would be advised to explore the idea of further studies on the impacts and effects of massage therapy on compression syndromes of the brachial plexus. References Goodman, C. C., & Fuller, K. S. (2009). The Peripheral Nervous System. Pathology: Implications for the Physical Therapist (3rd ed., pp ). Philadelphia: Saunders. Hertling, D., & Kessler, R. M. (2006). Shoulder and Shoulder Girdle. Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods (4 th ed., pp. 317-

17 319). Philadelphia: J.B. Lippincott. Kisner, C., & Colby, L. A. (2012). Peripheral Nerve Disorders and Management. Therapeutic Exercise: Foundations and Techniques (6 th ed., pp ). Philadelphia: F.A. Davis. Lowe, S. (2013). Musculoskeletal Anatomy & Kinesiology Lab 2: Manual Muscle Testing Magee, D. J. (2008). Shoulder. Orthopedic Physical Assessment (5 th ed., pp ). St. Louis, Mo.: Saunders Elsevier. Morphopedics. (n.d.). Thoracic Outlet Syndrome -. Retrieved December 22, 2013, from Rattray, F. S., & Ludwig, L. (2000). Thoracic Outlet Syndrome. Clinical Massage Therapy: Understanding, Assessing and Treating Over 70 Conditions (pp ). Toronto: Talus Inc.. "Repetitive Strain Injuries (RSI)." Repetitive Strain Injuries (RSI) Carpal Tunnel Syndrome Symptoms Treatment COEN Baltimore Neurology Maryland COEN Center for Occupational and Environmental Neurology. N.p., n.d. Web. 22 Dec < TOS - Thoracic Outlet Syndrome. (n.d.). TOS - Thoracic Outlet Syndrome. Retrieved December 22, 2013, from

18 Appendix A: Orthopedic Testing Verbal analogue of the pain scale Zero being no pain and ten being the worst pain you ve felt Goniometer A device used to measure angles; visual of how much movement is at a joint. Table 1.0: Cervical Spine Normal Range of Motion (Magee, 2007) Flexion Extension Right side bend side bend Right rotation rotation

19 Table 2.0: Glenohumeral Joint Normal Range of Motion (Magee, 2007) Flexion Extension Abduction Adduction Internal Rotation External Rotation Table 3.0: GH Active Range of Motion First Assessment Range of Motion Right GH GH Flexion 165 7/10 neural 170 Extension Abduction 175 8/10 neural 170 8/10 neural Adduction Internal Rotation 85 7/10 neural 85 External Rotation 80 7/10 neural 80 7/10 neural Table 4.0 GH Active Range of Motion Final Assessment Range of Motion Right GH GH Flexion Extension Abduction 180 1/10 neural 180 1/10 neural Adduction Internal Rotation External Rotation Table 5.0: Cervical Spine Active Range of Motion: * Initial and final assessments were preformed with the use of a Goniometer

20 Treatment Flexion Extension Right Side flex Side flex Right Rotation Rotation Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post 1 Assessment / / / / / / / / / / / / / Assessment / Manual Muscle Test

21 Grade 5 Normal 100% = range of motion against gravity, max resistance Grade 4 Good 75% = Complete range of motion against gravity, moderate resistance Grade 3 Fair 50% = Complete range of motion against gravity Grade 2 Poor 25% = Complete range of motion, gravity eliminated Grade 1 Poor trace = slight contraction, no joint movement Grade 0 Zero = no contraction palpable Table 6.0: First Assessment Muscle Side Grade Pain Sternocleidomastoid Right 4 1/ Levator Scapulae Right 5 1/ Right Pectoralis Major Right Pectoralis Minor Right Triceps Right Biceps Right Upper Trapezius Right Rhomboids Right Table 7.0: Final Assessment Muscle Side Grade Pain Sternocleidomastoid Right Levator Scapulae Right Right Pectoralis Major Right Pectoralis Minor Right Triceps Right Biceps Right Upper Trapezius Right Rhomboids Right

22 Table 8.0: Wrights Test Side Test Results First Assessment Right Positive - pulse instantly disappeared Positive pulse instantly disappeared Final Assessment Right Negative pulse still palpable Negative pulse still palpable Table 9.0: Capillary Refill Test Side Test Results First Assessment Right Positive 5+ seconds for refill to occur Positive 5+ seconds for refill to occur Final Assessment Right 0.98 seconds for refill 1.56 seconds for refill Table 10.0: Costoclavicular Syndrome Test Side Test Results First Assessment Right Positive pulse instantly disappeared Positive pulse instantly disappeared Final Assessment Right Negative 1/10 neural in middle finger Negative 1/10 neural in middle finger Table 11.0: Halstead Test Side Test Results First Assessment Right Positive pulse decreased, 7/10 Positive pulse decreased, 7/10 Final Assessment Right Negative Negative Table 12.0: Roo s Test Side Test Results First Assessment Right Positive Positive, fatigued faster Final Assessment Right Positive, less symptoms, equal fatigue, same color in hands Positive, less symptoms, equal fatigue, same color in hands.

23 Table 13.0: Median Nerve Upper Limb Tension Test Side Test Results Pre Treatment Post Treatment First Assessment Right Positive into fingers/hand Positive into fingers/hand Treatment 8 Right Positive, Positive, symptoms decreased symptoms decreased Positive, Positive, symptoms decreased symptoms decreased Treatment 9 Right Positive into Positive into elbow elbow only Positive into wrist and elbow Positive into wrist and elbow Treatment 10 Right Positive into palm Positive into palm Positive into elbow and fingers Positive into elbow and fingers Treatment 12 Right Positive into Positive into elbow elbow Positive into Positive into elbow elbow Treatment 13 Right Positive into Positive into elbow elbow Positive into Positive into elbow elbow Final Assessment Right Positive into elbow Positive into elbow Table 14.0: Radial Nerve Upper Limb Tension Test Treatment Side Test Results Pre Treatment Post Treatment First Assessment Right Positive Positive Treatment 8 Right Positive, symptoms decreased Positive, symptoms decreased Positive, symptoms decreased Positive, symptoms decreased Treatment 9 Right Positive into forearm extensors Positive into forearm extensors Positive into forearm Positive into forearm

24 extensors extensors Treatment 10 Right Positive into extensors Positive into forearm extensors Positive into extensors Positive into forearm extensors Treatment 12 Right Positive into extensors Positive into forearm extensors Positive into extensors Positive into forearm extensors Treatment 13 Right Positive into extensors Positive into forearm extensors Positive into extensors Positive into forearm extensors Final Assessment Right Positive into extensors Positive into extensors Table 15.0: Ulnar Upper Limb Tension Test Treatment Side Test Results: Pre treatment Post Treatment First Assessment Right Positive Positive Treatment 8 Right Positive Decreased symptoms Positive Decreased symptoms Treatment 9 Right Positive, decreased Decreased symptoms since last treatment Positive, decreased Decreased symptoms since last treatment Treatment 10 Right Positive, minimal Negative Positive, minimal Negative Treatment 12 Right Negative Negative Negative Negative Treatment 13 Right Negative Negative Negative Negative Final Assessment Right Negative Negative Table 16.0: Phalens Test Side Test Results First Assessment Right Negative Negative Final Assessment Right Negative Negative Table 17.0: Reverse Phalens Test

25 Side Test Results First Assessment Right Negative Negative Final Assessment Right Negative Negative Table 18.0: Tinells Test Side Test Results First Assessment Right Negative Negative Final Assessment Right Negative Negative Table 19.0: Allen s Test Treatment number Side Result Pre Treatment First Assessment Right Positive Post Treatment Positive Treatment 3 Right Positive Positive Positive Positive Treatment 4 Right Positive Positive Positive Positive Treatment 5 Right Positive Positive Positive Positive Treatment 6 Right Positive Positive Positive Positive Treatment 7 Right Positive Positive Positive Positive Treatment 9 Right Positive Positive Positive Positive Treatment 10 Right Positive Positive Positive Positive Treatment 11 Right Positive Negative Positive Positive Treatment 12 Right Positive Positive Negative Negative Treatment 13 Right Positive Negative Negative Negative Treatment 14 Right Negative Negative Negative Negative Final Assessment Right Negative Negative Table 20.0: Adson s Test

26 Treatment Number Side Result Pre Treatment Post Treatment First Assessment Right Positive pulse disappeared Positive pulse decreased Treatment 3 Right Positive Positive Positive Positive Treatment 4 Right Positive pulse Negative decreased Positive pulse disappeared Positive pulse disappeared Treatment 5 Right Negative Negative Negative Negative Treatment 6 Right Negative Negative Negative Negative Final Assessment Right Negative Negative Appendix B: Initial and Final Pictures

27 Figure 2: Initial Anterior View Figure 1: Final Anterior View Figure 3: Initial Posterior View Figure 4: Final Posterior View

28 27 ure 6: Initial Assessment Right Figure 5: Final Assessment Right w View Figure 8: Initial Assessment View Figure 7: Final Assessment View Appendix C: Treatment

29 28 Table 21.0: Treatment breakdown Treatment Areas Worked Techniques Used 1 Assessment Only 2 September 13 th, September 16 th, September 19 th, th September 24 th, 2013 Sub occipitals SCM Pectoralis Minor and Major Subclavius Suboccipitals SCM Pectoralis Minor and Major Subclavius Suboccipitals Pectoralis Minor and Major Biceps Deltoids Suboccipitals Biceps Deltoids Forearm Extensors Forearm Flexors Sub occipital release C/S ROM Scalene release Fascial traction Reshaping Cervical diaphragm Subclavius grab Muscle squeeze to SCM Pincher Grip to SCM Trigger point release GSM Subocciptal release C/S ROM Scalene release Fascial traction Reshaping Cervical diaphragm Subclavius grab Muscle squeeze to SCM Pincher Grip to SCM Trigger point release GSM Subocciptal release C/S and GH ROM Scalene release Fascial traction Reshaping Bear claw Cervical diaphragm Arm pull Trigger point release Scalene stretch MFR sheering GSM Subocciptal release C/S and GH ROM Scalene release MFR: Cross hands Sheering Wrist traction Isolytic release to forearm

30 29 6th September 26 th, th October 1 st, th October 3 rd, th October 8 th, 2013 Suboccipitals Forearm Extensors Forearm Flexors Diaphragm Suboccipitals Forearm Extensors Forearm Flexors Diaphragm Suboccipitals Forearm Extensors Forearm Flexors Pectoralis Minor and Major Diaphragm Suboccipitals Forearm Extensors Forearm Flexors extensors GSM Subocciptal release C/S and GH ROM Scalene release MFR: cross hands Shearing Skin rolling to forearms Diaphragm release (to diaphragm Wrist traction Isolytic release to forearm flexors GSM Subocciptal release C/S and GH ROM MFR: Cross hands Sheering Skin rolling to forearms Diaphragm release Wrist traction Isolytic release to forearm flexors GSM Subocciptal release C/S and GH ROM Scalene release Arm pull MFR: cross hands Sheering Skin rolling to forearms Diaphragm release Wrist traction Isolytic release to forearm flexors GSM Subocciptal release C/S and GH ROM Scalene release MFR: cross hands Shearing Skin rolling Diaphragm release Wrist traction Isolytic release to forearm

31 30 10 th October 10 th, th October 15 th, th October 23 rd, th October 31 st, 2013 Suboccipitals Forearm Extensors Forearm Flexors Diaphragm Suboccipitals Forearm Extensors Forearm Flexors Diaphragm Suboccipitals Forearm Extensors Forearm Flexors Deltoids Biceps Pectoralis minor and major Suboccipitals Forearm Extensors Forearm Flexors flexors, extensors and Contract relax to GSM Subocciptal release C/S and GH ROM Arm pull MFR: cross hands Shearing Skin rolling V stroking Diaphragm release Wrist traction Isolytic release to forearm flexors, extensors and Contract relax to GSM Subocciptal release C/S and GH ROM MFR: cross hands Shearing Skin rolling V stroking Diaphragm release Wrist traction Isolytic release to forearm flexors, extensors and Contract relax to GSM Subocciptal release C/S and GH ROM Arm pull Skin rolling V stroking Wrist traction Isolytic release to forearm flexors, extensors and Contract relax to GSM Subocciptal release C/S and GH ROM Fascial traction Reshaping

32 31 14 th November 6 th, November 7 th, 2013 Deltoids Biceps Pectoralis minor and major Suboccipitals Forearm Extensors Forearm Flexors Deltoids Biceps Pectoralis minor and major Assessment Only Arm pull Wrist traction Isolytic release to forearm flexors, extensors and Contract relax to Scalene stretch GSM Subocciptal release C/S and GH ROM Fascial traction Reshaping Arm pull Wrist traction Isolytic release to forearm flexors, extensors and Contract relax to Scalene stretch GSM

33 32 Appendix D: Anatomy Pictures Figure 9. Postural abnormalities in relation to TOS Retrieved from: Figure 10. Brachial plexus anatomy Retrieved from: Figure 11. Brachial plexus compression areas Retrieved from: