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Koppenhaver SL, Morel T, Dredge G, Baeder M, Young BA, Petersen EJ, Fernández-de-Las-Peñas C, Gill N. The validity of the cervical rotation lateral flexion test in predicting benefit after manipulation treatment to the first and second rib. Musculoskelet Sci Pract 2022; 62:102629. [PMID: 35872564 DOI: 10.1016/j.msksp.2022.102629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 07/07/2022] [Accepted: 07/14/2022] [Indexed: 12/14/2022]
Abstract
STUDY DESIGN Prospective cohort study. BACKGROUND The cervical rotation lateral flexion (CRLF) test is frequently used in clinical practice to determine whether a thrust manipulation targeting the first rib should be performed. OBJECTIVES To evaluate the predictive validity of the CRLF test and manual examination in determining whether patients with neck pain are likely to benefit from manipulative treatment to the first and second rib. METHODS A physical examination incorporating the CRLF test was performed on 50 participants with neck pain followed by manipulation treatment to the first and second ribs. Clinical improvement was assessed immediately and one week after treatment. Participants who experienced at least a 30% improvement in their Neck Disability Index (NDI) score were considered "improved." Predictive validity was assessed by calculating sensitivity, specificity, and negative and positive likelihood ratios. RESULTS Neither the CRLF test nor manual examination were predictive of clinical improvement after manipulative treatment to the first and second rib. However, being male, of older age, and exhibiting T1 and/or T2 restricted end-feel were associated with improved neck related-disability at one-week follow-up. CONCLUSION The CRLF test does not appear to be helpful in determining whether patients with neck pain are likely to benefit from manipulative treatment to the first and second rib. Other factors from the history and clinical examination may be more helpful when selecting manipulative treatment including age and gender and possibly the presence of T1/T2 restricted end-feel.
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Affiliation(s)
| | - Tracy Morel
- U.S. Army-Baylor University Doctoral Program in Physical Therapy, San Antonio, TX, USA
| | - Garry Dredge
- U.S. Army-Baylor University Doctoral Program in Physical Therapy, San Antonio, TX, USA
| | - Michele Baeder
- U.S. Army-Baylor University Doctoral Program in Physical Therapy, San Antonio, TX, USA
| | - Brian A Young
- Baylor University Doctoral Program in Physical Therapy, Waco, TX, USA
| | - Evan J Petersen
- Bowling Green State University, Doctoral Program in Physical Therapy, Bowling Green, OH, USA
| | - César Fernández-de-Las-Peñas
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos (URJC), Alcorcón, Madrid, Spain
| | - Norman Gill
- U.S. Army-Baylor University Doctoral Program in Physical Therapy, San Antonio, TX, USA
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Panther EJ, Reintgen CD, Cueto RJ, Hao KA, Chim H, King JJ. Thoracic outlet syndrome: a review. J Shoulder Elbow Surg 2022; 31:e545-e561. [PMID: 35963513 DOI: 10.1016/j.jse.2022.06.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 06/06/2022] [Accepted: 06/27/2022] [Indexed: 02/01/2023]
Abstract
Thoracic outlet syndrome (TOS) is a rare condition (1-3 per 100,000) caused by neurovascular compression at the thoracic outlet and presents with arm pain and swelling, arm fatigue, paresthesias, weakness, and discoloration of the hand. TOS can be classified as neurogenic, arterial, or venous based on the compressed structure(s). Patients develop TOS secondary to congenital abnormalities such as cervical ribs or fibrous bands originating from a cervical rib leading to an objectively verifiable form of TOS. However, the diagnosis of TOS is often made in the presence of symptoms with physical examination findings (disputed TOS). TOS is not a diagnosis of exclusion, and there should be evidence for a physical anomaly that can be corrected. In patients with an identifiable narrowing of the thoracic outlet and/or symptoms with a high probability of thoracic outlet neurovascular compression, diagnosis of TOS can be established through history, a physical examination maneuvers, and imaging. Neck trauma or repeated work stress can cause scalene muscle scaring or dislodging of a congenital cervical rib that can compress the brachial plexus. Nonsurgical treatment includes anti-inflammatory medication, weight loss, physical therapy/strengthening exercises, and botulinum toxin injections. The most common surgical treatments include brachial plexus decompression, neurolysis, and scalenotomy with or without first rib resection. Patients undergoing surgical treatment for TOS should be seen postoperatively to begin passive/assisted mobilization of the shoulder. By 8 weeks postoperatively, patients can begin resistance strength training. Surgical treatment complications include injury to the subclavian vessels potentially leading to exsanguination and death, brachial plexus injury, hemothorax, and pneumothorax. In this review, we outline the diagnostic tests and treatment options for TOS to better guide clinicians in recognizing and treating vascular TOS and objectively verifiable forms of neurogenic TOS.
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Affiliation(s)
- Eric J Panther
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Christian D Reintgen
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Robert J Cueto
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Kevin A Hao
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Harvey Chim
- Department of Plastic and Reconstructive Surgery, University of Florida, Gainesville, FL, USA
| | - Joseph J King
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL, USA.
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A Correlation between Upper Extremity Compressive Neuropathy and Nerve Compression Headache. Plast Reconstr Surg 2021; 148:1308-1315. [PMID: 34847118 DOI: 10.1097/prs.0000000000008574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Compressive neuropathies of the head/neck that trigger headaches and entrapment neuropathies of the extremities have traditionally been perceived as separate clinical entities. Given significant overlap in clinical presentation, treatment, and anatomical abnormality, the authors aimed to elucidate the relationship between nerve compression headaches and carpal tunnel syndrome, and other upper extremity compression neuropathies. METHODS One hundred thirty-seven patients with nerve compression headaches who underwent surgical nerve deactivation were included. A retrospective chart review was conducted and the prevalence of carpal tunnel syndrome, thoracic outlet syndrome, and cubital tunnel syndrome was recorded. Patients with carpal tunnel syndrome, cubital tunnel syndrome, and thoracic outlet syndrome who had a history of surgery and/or positive imaging findings in addition to confirmed diagnosis were included. Patients with subjective report of carpal tunnel syndrome/thoracic outlet syndrome/cubital tunnel syndrome were excluded. Prevalence was compared to general population data. RESULTS The cumulative prevalence of upper extremity neuropathies in patients undergoing surgery for nerve compression headaches was 16.7 percent. The prevalence of carpal tunnel syndrome was 10.2 percent, which is 1.8- to 3.8-fold more common than in the general population. Thoracic outlet syndrome prevalence was 3.6 percent, with no available general population data for comparison. Cubital tunnel syndrome prevalence was comparable between groups. CONCLUSIONS The degree of overlap between nerve compression syndromes of the head/neck and upper extremity suggests that peripheral nerve surgeons should be aware of this correlation and screen affected patients comprehensively. Similar patient presentation, treatment, and anatomical basis of nerve compression make either amenable to treatment by nerve surgeons, and treatment of both entities should be an integral part of a formal peripheral nerve surgery curriculum.
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Mastromarchi P, May S. First rib dysfunction in patients with neck and shoulder pain: a Delphi investigation. J Man Manip Ther 2021; 29:181-188. [PMID: 32956019 PMCID: PMC8183555 DOI: 10.1080/10669817.2020.1824470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND First rib dysfunction is a possible cause of symptoms in patients with neck and/or shoulder pain. OBJECTIVES To explore therapists' perceptions of useful diagnostic criteria to identify first rib dysfunction. METHODS A Delphi survey over four rounds involving international manual therapy experts who were asked to agree on which items were most useful in identifying first rib dysfunction. RESULTS Consensus (>70% agreement) was reached on key aspects of first rib dysfunction being first rib mobility restriction, upper limb symptom distribution, and a subclassification into two subgroups was suggested. The main clinical findings suggested were: painful and restricted neck movements and shoulder girdle loading activities; positive Upper Limb Neural Test 1; direct palpation of first rib, neural structures, and scalene muscles; pain and hypomobility of first rib accessory movements with improvement after mobilization. The cervical rotation lateral-flexion test was considered a useful, although not widely used test among the experts. Its diagnostic accuracy and interpretation in isolation was questioned. CONCLUSIONS This Delphi study produced a cluster of clinical tests aimed to identify first rib dysfunction in patients with neck and/or shoulder conditions. However, these need to be tested out in further research to establish reliability and validity.
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Affiliation(s)
| | - Stephen May
- Independent Physiotherapy Consultant, Sheffield, UK
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Al-Jundi W, Park WM. Digital ischaemia of the upper limbs in middle age: consider arterial thoracic outlet syndrome until proven otherwise! Rheumatol Adv Pract 2020; 5:rkaa045. [PMID: 33615125 PMCID: PMC7884024 DOI: 10.1093/rap/rkaa045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/05/2020] [Indexed: 11/19/2022] Open
Abstract
Objectives Patients presenting with digital upper limb ischaemia are occasionally referred to rheumatology services to rule out vasculitis. We aimed to present two cases of delayed diagnosis of arterial thoracic outlet syndrome (aTOS) in middle-aged patients presenting with digital ischaemia in order to raise awareness of this important pathology that requires timely surgical intervention. Methods Two cases of progressive ischaemia of the right upper extremity caused by primarily undiagnosed compression of the subclavian artery by an accessory cervical rib are presented. The case notes, radiological images, intra-operative and postoperative findings for both patients were reviewed. Patients were followed up after ≥6 months to assess prognosis. Results Both patients had a working diagnosis of Buerger’s disease and had been treated with prostaglandin infusions before establishment of the diagnosis of arterial thoracic outlet syndrome. Both patients were heavy smokers, and one patient had bilateral symptoms and a history of axial SpA and positive HLA-B27. Late presentation in one patient led to the loss of three fingers and the need for plastic reconstructive surgery after cervical rib resection and revascularization. In the other patient, surgical thrombectomy of the upper limb arteries along with resection of a cervical rib and repair of the subclavian artery with an interposition graft were necessitated to heal digital ulcers successfully. Conclusion A high index of suspicion of aTOS should be maintained in middle-aged patients presenting with digital or upper limb ischaemia even in the presence bilateral symptoms or relevant risk factors of other diagnoses, such as smoking or a positive rheumatological history.
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Affiliation(s)
- Wissam Al-Jundi
- Norwich Vascular Unit, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
| | - WooSup Michael Park
- Heart and Vascular Institute, Cleveland Clinic Abu-Dhabi, Abu-Dhabi, United Arab Emirates
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Muellner J, Kaelin-Lang A, Pfeiffer O, El-Koussy MM. Neurogenic thoracic outlet syndrome due to subclavius posticus muscle with dynamic brachial plexus compression: a case report. BMC Res Notes 2015; 8:351. [PMID: 26268814 PMCID: PMC4535788 DOI: 10.1186/s13104-015-1317-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Accepted: 08/04/2015] [Indexed: 11/17/2022] Open
Abstract
Background Neurogenic thoracic outlet syndrome is an underestimated cause of brachial weakness and pain. The subclavius posticus muscle (SPM) is an aberrant muscle originating from the medial aspect of the first rib reaching to superior border of the scapula, which may cause, depending on its activation, dynamic compression of the brachial plexus. Case presentation In the present study, we report about a 32-year-old male caucasian patient with weakness in radial deviation of his left hand. An isolated macrodactyly of his left middle finger had been operated twice. Electroneurography showed a carpal-tunnel-syndrome (CTS) on the left side. MRI of the brachial plexus revealed an additional muscle in the costoclavicular space, identified as SPM. To our knowledge, this is the second case report of a neurogenic thoracic outlet syndrome due to SPM, and the first case described with isolated macrodactyly and CTS in the same patient. Conclusion If complaints about hand weakness are only reported in cases of distinct hand positions, a dynamic compression of the brachial plexus by SPM may be the cause. A neurogenic thoracic outlet syndrome may facilitate the development of CTS.
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Affiliation(s)
- Julia Muellner
- Department of Neurology, University Hospital Bern, Freiburgstrasse 100, 3010, Bern, Switzerland.
| | - Alain Kaelin-Lang
- Neurocenter of Southern Switzerland, Opsedale Civico, Via Tesserete 46, 6900, Lugano, Switzerland.
| | - Oliver Pfeiffer
- Department of Neuroradiology, University Hospital Bern, Bern, Switzerland.
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Outcomes following the conservative management of patients with non-radicular peripheral neuropathic pain. J Hand Ther 2015; 27:192-9; quiz 200. [PMID: 24685569 DOI: 10.1016/j.jht.2014.02.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 02/04/2014] [Accepted: 02/17/2014] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Prospective cohort. INTRODUCTION There is limited evidence for conservative management of patients with non-radicular peripheral neuropathic pain (PNP). PURPOSE To investigate the effectiveness of a comprehensive treatment approach on pain and disability in patients with non-radicular PNP and to determine if improvements are maintained following the discontinuation of therapy. METHODS Patients received a multi-modal therapeutic intervention. Outcome measures were the shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QDASH), Numeric Pain Rating Scale (NPRS), and grip strength. Follow-up data were collected 5 ± 2 months post-discharge. RESULTS There was a significant improvement in the QDASH and mean pain (p < .001). There was no significant change in grip strength (p > .13). Follow-up data suggest that pain and disability scores are maintained (p < .001). CONCLUSION A comprehensive, conservative treatment program has a positive and lasting effect on pain and disability scores in patients with non-radicular PNP. LEVEL OF EVIDENCE IIIa.
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An Association between Carpal Tunnel Syndrome and Migraine Headaches-National Health Interview Survey, 2010. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2015; 3:e333. [PMID: 25878944 PMCID: PMC4387155 DOI: 10.1097/gox.0000000000000257] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 11/13/2014] [Indexed: 12/31/2022]
Abstract
Background: Migraine headaches have not historically been considered a compression neuropathy. Recent studies suggest that some migraines are successfully treated by targeted peripheral nerve decompression. Other compression neuropathies have previously been associated with one another. The goal of this study is to evaluate whether an association exists between migraines and carpal tunnel syndrome (CTS), the most common compression neuropathy. Methods: Data from 25,880 respondents of the cross-sectional 2010 National Health Interview Survey were used to calculate nationally representative prevalence estimates and 95% confidence intervals (95% CIs) of CTS and migraine headaches. Logistic regression was used to calculate adjusted odds ratios (aORs) and 95% CI for the degree of association between migraines and CTS after controlling for known demographic and health-related factors. Results: CTS was associated with older age, female gender, obesity, diabetes, and smoking. CTS was less common in Hispanics and Asians. Migraine was associated with younger age, female gender, obesity, diabetes, and current smoking. Migraine was less common in Asians. Migraine prevalence was 34% in those with CTS compared with 16% in those without CTS (aOR, 2.60; 95% CI, 2.16–3.13). CTS prevalence in patients with migraine headache was 8% compared with 3% in those without migraine headache (aOR, 2.67; 95% CI, 2.22–3.22). Conclusions: This study is the first to demonstrate an association between CTS and migraine headache. Longitudinal and genetic studies with physician verification of migraine headaches and CTS are needed to further define this association.
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Loyd BJ, Gilbert KK, Sizer PS, Atkins LT, Sobczak S, Brismée JM, Pendergrass TJ. The relationship between various anatomical landmarks used for localizing the first rib during surface palpation. J Man Manip Ther 2014; 22:129-33. [PMID: 25125934 DOI: 10.1179/2042618613y.0000000064] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
OBJECTIVES To assess the relationship between anatomical landmarks used to locate the first rib during surface palpation. One currently cited technique suggests locating the width of the transverse processes (TPs) of the first cervical vertebrae (C1) to determine the estimated width of the first thoracic vertebrae (T1) TP, allowing for subsequent palpation of the first rib laterally to the transverse process of T1. Based on anatomical structural relationships, the authors propose an additional method of locating the first rib, lateral to T1 TP, by palpating through the trapezius muscle at the width of the mastoid process (MP). METHODS Overlying tissue of the bilateral MP, C1 TPs, and T1 TPs of 28 cadavers were removed. Measurements of the left to right spans at the following structures were collected using a digital caliper: mastoid process, C1 TP, and T1 TP. Measurements were used to determine the agreement between each anatomical structural span. RESULTS The mean absolute difference (standard deviation, SD) between C1 TP span versus T1 TP span was 3.9 (±2.58) mm with an intraclass correlation coefficient (ICC) of 0.88 (95% CI = 2.9-4.9). The mean absolute difference between MP span and T1 TP span was 35.4 (±6.46) mm with an ICC of 0.71 (95% CI = 33.0-37.8). DISCUSSION This study confirms the anatomical accuracy and feasibility of using the C1 TP span to determine the general width of the T1 TP span while palpating for the first rib just lateral to the T1 TP. Additionally, this study demonstrates that the more easily palpated mastoid process serves as an effective landmark to identify a width sufficiently lateral to the T1 TP, appropriate for first rib palpation through the trapezius muscle.
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Affiliation(s)
- Brian J Loyd
- Clinical Anatomy Research Laboratory, Center for Rehabilitation Research, Texas Tech University Health Sciences Center, USA
| | - Kerry K Gilbert
- Clinical Anatomy Research Laboratory, Center for Rehabilitation Research, Texas Tech University Health Sciences Center, USA
| | - Phillip S Sizer
- Clinical Anatomy Research Laboratory, Center for Rehabilitation Research, Texas Tech University Health Sciences Center, USA
| | - Lee T Atkins
- Clinical Anatomy Research Laboratory, Center for Rehabilitation Research, Texas Tech University Health Sciences Center, USA
| | - Stéphane Sobczak
- Laboratory of Anatomy, Biomechanics and Organogenesis (LABO), Faculté de Médecine, Université Libre de Bruxelles (ULB), Belgium
| | - Jean-Michel Brismée
- Clinical Anatomy Research Laboratory, Center for Rehabilitation Research, Texas Tech University Health Sciences Center, USA
| | - Timothy J Pendergrass
- Clinical Anatomy Research Laboratory, Center for Rehabilitation Research, Texas Tech University Health Sciences Center, USA
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