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MSPT II > Thoracic Outlet Syndrome: UQ Neural Mob & Mgmt of Pt w/ Brachial Plexopathy > Flashcards

Thoracic Outlet Syndrome: UQ Neural Mob & Mgmt of Pt w/ Brachial Plexopathy Flashcards

1
Q

Brachial Plexus Visual

A

see pics

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2
Q

Brachial Plexus Anatomy

A

C5-T1

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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
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4
Q

Roots:

A

C5-T1

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5
Q

Trunks (3)

A

Upper

Middle

Lower

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6
Q

Trunks

Upper Trunk

A

formed from C5 and C6

Combines w/ Middle Trunk to form Lateral Cord

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7
Q

Trunks

Middle Trunk

A

Formed from C7

Combines w/ Upper Trunk to form Lateral Cord

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8
Q

Trunks

Lower Trunk

A

Formed from C8 and T1

Anterior Division becomes Medial Cord

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9
Q

Divisions (2)

A

ANTERIOR

POSTERIOR

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10
Q

Divisions

Anterior

A

contribute to nerves that innervate FLEXORS

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11
Q

Divisions

Posterior

A

contribute to nerves that innervate EXTENSORS

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12
Q

Divisions

Posterior Divisions of all three trunks form the _____

A

Posterior Cord

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13
Q

Cords (3)

A

Lateral

Posterior

Medial

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14
Q

Cords

Lateral

A

formed from the Upper and Middle Trunks

Musculocutaneous and Median nerves→ major P-nerves

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15
Q

Cords

Posterior

A

Formed from the Posterior Divisions of all three Trunks

Radial and Axillary→ major P-nerves

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16
Q

Cords

Medial

A

formed from the Anterior Division of the Lower Trunk

Ulnar and Median→ major P-nerves

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17
Q

Thoracic Outlet divided into 4 Regions:

Medial→Lateral

A
  1. Sternocostovertebral Space
  2. Scalene Triangle (Scalene Groove)
  3. Costoclavicular Space
  4. Pec Minor Space
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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
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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
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20
Q

Costoclavicular Space

Boundaries

Contents

A
  • Boundaries
    • Sup→ coracoid process
    • Ant→ pec minor
    • Post→ chest wall
  • Contents
    • Cords of plexus
    • Subclavian aa/vein
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21
Q

What is Thoracic Outlet Syndrome (TOS)?

A

Collection of disorders; describes patho condition of an anatomical space

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22
Q

TOS can include BOTH of these things:

A
  1. Subclavian aa and/or vein
  2. Brachial Plexus
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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
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24
Q

MOST COMMON type of TOS pt?

A

Disputed ~90%

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25
Q

TOS affects more _____ than _____

A

affects women more than men

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26
Q

Most experts believe only the _______ is involved in majority of TOS cases

A

Brachial Plexus

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27
Q

Compression Sites:

Sternocostovertebral Space

A
  • Pathology: compression caused by tumors→
    • Lung (Pancoast Tumor; other space occupying lesions of lungs)
    • Thymus
    • Thyroid & Parathyroids
    • Lymph nodes
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28
Q

Compression Sites:

Scalene Groove (Scalene Triangle)

what does NOT pass through here

A

Subclavian vein does NOT pass thru Scalene groove

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29
Q

Compression Sites:

Scalene Groove

what IS common in this space?

A

Scalene involvement

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30
Q

Compression Sites:

Scalene Groove

Vulnerable tissues in this site:

A
  • Brachial plexus (common)
    • ventral rami of C5-T1
  • Subclavian artery
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31
Q

Compression Sites:

Scalene Groove (Triangle)

Patho: compression/entrapment

A
  • Patho: compression/entrapment caused by:
    • Variations in Scalene anatomy
    • Presence of interdigitating fibrous bands→ Roos’ bands
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32
Q

Compression Sites:

Costoclavicular Space

Bw where and where?

Also called?

A

Bw clavicle and 1st rib

aka “nutcracker”

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33
Q

Compression Sites:

Costoclavicular Space

Patho: compression bw clavicle and 1st rib

A
  • 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
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34
Q

Compression Sites:

Costoclavicular Space

In relation to this: Presence of cervical rib

A
  • .3% pop
    • 10% of .3% are problematic
  • Incidence in women=2x that of men
  • Only 10% become symptomatic usually after trauma
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35
Q

Compression Sites:

Coracoid Process/Pec Minor Interval

Patho: compression of Cords and vasculature

A
  • Patho: compression of Cords and Vasculature caused by:
    • HyperABD of arm
    • Hypertrophy of the Pec minor
    • Shortening/tightness of the Pec minor
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36
Q

Palpation Lab

Rules/Guidelines to follow:

A

See pics

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37
Q

Palpation:

Trunks of the BP

A
  • Loc’d in the Anterior Cervical Triangle→ ABOVE mid-pt of clavicle
  • Neural tissue selectively tensioned by elevation/depression of shoulder w/ Elbow Ext
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38
Q

Palpation:

Cords of the BP

A
  • 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
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39
Q

Palpation:

Median and Ulnar Nerves in the Distal Axilla/Prox. Humerus

A
  • 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
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40
Q

Palpation:

Radial Nerve

A
  • Prox portion as it exits from Triangular Space
  • Boundaries:
    • Inf border of Teres major
    • Long head of Triceps
    • Medial head of Triceps
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41
Q

Examination of the Pt w/ Brachial Plexopathy:

History

*Localization of sx’s variable and can include:

A
  • 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
Q

Examination of the Pt w/ Brachial Plexopathy:

*NOTE: pts often seen in ER for WHAT?

A
  • suspected MI
  • Dx’d w/ Costal chondritis
  • gastritis
43
Q

Examination of the Pt w/ Brachial Plexopathy:

Onset

A
  • 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
Q

Examination of the Pt w/ Brachial Plexopathy:

Behavior of Sx’s

Describe pts w/ Brachial plexopathy vs. Cervical disc patho and OH activities

A
  • Pts w/ Brachial Plexopathy
    • WORSE w/ OH activities
  • Pts w/ Cervical Disc Patho
    • BETTER w/ OH activities

*THINK ABOUT YOUR SPECIAL TESTS!!!!

45
Q

Examination of the Pt w/ Brachial Plexopathy:

Behavior of Sx’s

A
  • 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
Q

Examination of the Pt w/ Brachial Plexopathy:

Observation

Need to see the pt in what postures/positions?

A

NEED to see patient from mid-sternum up from front, FULL back from rear

47
Q

Examination of the Pt w/ Brachial Plexopathy:

Observation→ Posture

NOTE any of following:

A
  • 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
Q

Examination of the Pt w/ Brachial Plexopathy:

Observation→ Posture

NOTE color changes in involved UQ if present:

A
  • Hand red and warm to cold and cyanotic→ Sympathetic instability
  • Side of face AND ear red, flushed
49
Q

Examination of the Pt w/ Brachial Plexopathy:

Observation→ Posture

Breathing Pattern

A

Diaphragm (belly) vs. Upper Chest (apical)

50
Q

What should you always do w/ EVERY suspected Brachial Plexopathy pt?

A

CLEAR C/S FIRST!!!!!

51
Q

Examination of the Pt w/ Brachial Plexopathy:

Observation→

C/S Screening

*Always clear C/S first!!!

A
  • ROM, asymmetries; sx behavior w/ rep’d motions
  • + Spurlings→ nerve root injury
52
Q

Examination of the Pt w/ Brachial Plexopathy:

Observation→

Shoulder Jt Screening

A

Always screen shoulder to det. if coming from joint

53
Q

Special Tests for TOS

5:

A
  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
Q

Special Tests for TOS

Vascular compression tests

A
  • Wright’s Test (HyperABD Test)
  • Costoclavicular Test (Military Bracing)
  • Adson’s Maneuver
55
Q

Sensation Testing:

W/ Brachial Plexopathy, the _________ digit will often show differential sensation

A

3rd Digit***

56
Q

Sensation Testing

Dec’d sensitivity to pinprick along MEDIAL HALF 3rd Digit→

A

Medial Cord involvement

(Medial→ Medial)

57
Q

Sensation Testing

Dec’d sensitivity to pinprick along LATERAL HALF of 3rd Digit→

A

Lateral Cord involvement

(Lateral→Lateral)

58
Q

Differentiating Brachial Plexopathy vs. Carpal Tunnel/Cubital Tunnel Syndrome

A

Brachial Plexopathy→ 3rd Digit

Carpal/Cubital Tunnel→ 4th Digit=differential sensation

59
Q

Strength Testing

In a myotomal screen, focus on WHAT mm’s?

LOWER Trunk involvement

A

Hand intrinsics

Dorsal and Volar interosseus mm’s

assesses Lower Trunk involve.

60
Q

Brachial Plexopathy and Tinel’s Test

A

use it!!

palpation sites

look for spread of sx’s distally and proximally

61
Q

Palpation

A

look for tenderness or spread of sx’s along neural paths

62
Q

Brachial plexopathy/TOS and Pec minor tightness

A

Check it!!!!!!

63
Q

Upper Limb Neurodynamic Tests

what are they?

A

Set of Four basic tests to bias the cervical nerve roots, brachial plexus, median n., radial n., ulnar n.

aka ULNT Tests

64
Q

Brachial Plexus Neurodynamic Test

BPNT

A

*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
Q

BPNT:

Test Data Points

Onset, Stop Point, Tx Zone

A
  • 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
Q

Median Neurodynamic Test (MNT)

A

Developed as alternative pos for biasing Median N. for pts w/ shoulder co-morbs that would not tolerate 110* of ABD

67
Q

Radial Neurodynamic Test (RNT)

A

Radial N. bias has same starting pos as Median N. Test

68
Q

Important points to remember for Median & Radial Neural Dynamic Tests *****

A
  • 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
Q

Ulnar Neurodynamic Test (UNT)

A

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
Q

Neurodynamic Testing/ULNT:

Documenting Findings

A
  • 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
Q

Neurodynamic Testing/ULNT:

Documenting Findings

Modifying the Grading Scale

A

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
Q

Indications for Neurodynamic Testing

ULTTs

A
  • 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
Q

Contraindications for Neurodynamic Testing

ULTTs

A
  • 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
Q

Precautions for Neurodynamic Testing

ULTTs

A
  • 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
Q

Interpretation of Exam Findings in Pts w/ Brachial Plexopathy

Dx might be brachial plexopathy (as opposed to distal nerve entrapment) IF:

A
  • 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
Q

Localizing BP injury based on s/s

Upper Trunk Inj’s (and Cervical Plexus)

A
  • 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
Q

Localizing BP injury based on s/s

Upper Trunk (cervical plexus)

Think….

A

Scapular sx’s/dyskinesia one****

78
Q

Localizing BP injury based on s/s

Lower Trunk Injuries (and Medial Cord)

the Intrinsic hand mm’s one**

A
  • 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
Q

Localizing BP injury based on s/s

Lower Trunk inj’s (and Medial Cord)

THINK….

A

Hand intrinsic mm’s one 1

80
Q

Localizing BP injury based on s/s

Medial Cord Injuries

the chest wall one ***

A
  • 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
Q

Localizing BP injury based on s/s

Lateral Cord Injuries

medial anticubital region elbow one***

A
  • Pts demo parasthesias of thumb, index, radial side of 3rd finger (lateral→lateral)
  • Freq c/o discomfort in medial anticubital region of elbow
82
Q

Localizing BP injury based on s/s

Posterior Cord Injuries

lateral epicon one, tender radial N. one***

A
  • 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
Q

Prognosis/Staging of Condition for Brachial Plexus Injury

Depends on…

A
  • 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
Q

Tx for pt w/ Brachial Plexopathy:

Tx/Goals 1st Visit:

A
  • 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
Q

Tx for pt w/ Brachial Plexopathy:

Tx/Goals 2nd Visit:

A
  • 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
Q

Tx for pt w/ Brachial Plexopathy:

Tx/Goals 3rd Progression:

A
  • 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
Q

Tx for pt w/ Brachial Plexopathy:

Tx/Goals 4th Progression:

A
  • 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
Q

Modify, Mix and Progress program based on responses and re-assessment

**FOCUS ON:

A
  • Postural symmetry and awareness
  • Plexus mobility
  • Breathing patterns
  • Tolerance to exercise
  • Lvl of irritability w/ ADLs
89
Q

When would you use Neural Gliding vs. Stretching?

A

MORE irritation, LESS mobility

90
Q

When would you use Neural Stretching vs. Gliding?

A

LESS irritable pts

91
Q

Neural Gliding

A
  • 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
Q

Neural Gliding Key Points:

A
  • 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
Q

Neural Stretching

*LESS irritable pts

A
  • 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
Q

Basic Nerve Gliding or Flossing→ Median N. Based (Median & Lateral Cord)

A

see pics + Instructions

handshake one

95
Q

Basic Nerve Stretching→ Median N. based (Median & Lateral Cord)

A

see pics + Instructions

96
Q

Soft Tissue Tech’s to Enhance Neural Mobilization:

Trans-axillary Pec minor lift w/ Stretch

A

see pics + Instructions

97
Q

Trans-axillary lift w/ nerve glide/stretch

A

see pics + Instructions

98
Q

Scalene Mobilization

A

see pics + Instructions

99
Q

Key Considerations for Neural/Soft Tissue/Jt Mob Techniques

A
  • 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
Q

Brachial Plexopathy HEP Ideas

A
  • 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

MSPT II (20 decks)

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