PT Initial Evaluation: Thoracic Outlet Syndrome

Pamantasan ng Lungsod ng Maynila

(University of the City of Manila)

Gen. Luna, Intramuros, Manila

Physical Therapy Initial Evaluation

General Information:

Pt. Name: E.J.

Age: 28

Sex: Female

Address: Jupiter St., Makati City

Civil Status: Single

Handedness: Right

Occupation: Garment’s Artist

Religion: Roman Catholic

Referring Unit: Phil. Heart Center OPD Service

Referring Doctor: Dr. Adelantar

Date of Referral: March 31, 2007

Rehab Unit: Phil Heart Center PMRD

Rehab Doctor: Dr. Agbayani

Date of IE: April 4, 2007

Informant/Reliability: Patient/Good

Dx: Thoracic Outlet Syndrome

HPI:

Pts condition started 1 mo PTIE when pt experienced tingling sensation c shooting pain of P/S (7/10) at the ® volar aspect of her arm and forearm Tingling persisted day and night but shooting pain occurred during shoulder abduction, flexion, elbow extension and wrist flexion of ® UE. Pt took mefenamic acid prn which temporarily decreased the pain from P/S 7 to (3/10). Pt was able to tolerate the numbness and shooting pain but was already experiencing difficulty c holding a pen and writing.

2 wks PTIE, tingling sensation still persisted and the shooting pain worsened to P/S (10/10) running from her ® axilla down to the palmar aspect of her fingers. Pain occurred during the previously mentioned motions and c neck lateral flexion to the ® and ® finger flexion. Pt also noted dull pain c P/S (7/10) at her nape and ® upper trapezius area. Pt already experiences sleeping difficulty 2° worsening of Sx at night. Pt massages nape, ® upper back and ® UE c oil which temporarily decreases pain of 5 P/S increments. Upon waking up, pt experiences inability to close her ® hand actively and return of minimal hand closure occurs p mins of attempting to squeeze her squeeze ball.

1 wk PTIE, pt sought medical advice at PHC, underwent x-ray of her cervical spine (see ancillary procedures) and was diagnosed to have TOS. Pt was advised to take Neurontin (see drug Hx) for pain relief and to seek PT Mx.

At present, pt still experiences tingling and shooting pain c P/S (7/10) at previously mentioned motions and dull pain at nape and ® upper trapezius of P/s (5/10). PT had to stop working 2° inability to hold and manipulate a pen. Pt will now start pt tx at PHC.]

Drug Hx:

Meds	Dosage	Frequency	Year	Indication
Neurontin	100 mg	bid	March 2007- present	Neuropathic pain
Mefenamic Acid	500 mg	prn	March 2007	Pain relief
Lanoxin	25 mg	od	2004-present	Cardiac glycoside
Vascor	5 mg	od	2004-present	Calcium channel blocker
Aspilet	325 mg	tid	March 2007- present	Anti-coagulant
Coumadin	5 mg/ tab MWF: ½ tab TThSS: ¼ tab	od	2004-present	Anti-coagulant (warfarin sodium)

Ancillary Procedures:

Procedure	Date	Results
X-ray of cervical spine	April 4, 2007	N vertebral structures, normal disc spaces

PMHx:

(+) mitral valve replacement 2° RHD (March, 2006)

(-) trauma to neck, head and spine

(-) Htn

(-) DM

(-) lung dse

(-) allergies

FMHx:

Father Mother

Htn (+) (-)

DM (+) (-)

CVA (-) (-)

Heart Disease (-) (-)

Rheumatoid Arthritis (-) (+)

Cancer (+) prostate CA (-)

PSEHx:

◦ Type B personality

◦ Non-smoker

◦ Non-alcoholic beverage drinker

◦ Hobbies: visual arts and graphic designing

◦ Financially stable

◦ Lives c his aunt and has her as her personal care giver

◦ Stopped from work for 2 wks already

S:

C/c: ‘ Ayos lang naman yung tingling pero yung sakit at kawalan ko ng kakayanan isara ang kanang kamay ko ang problema… hindi na kasi ako makapagtrabaho”

PT Translation: Pt complains of pain and inability to close her ® hand making her unable to work

Pt. Goal: To be able to hold and manipulate a pen properly s pain even c the persistence of the tingling for her to return to work

O:

VS:

	A	during	P
BP	120/70 mmHg	120/70 mmHg	110/70 mmHg
PR	72bpm	74bpm	68bpm
RR	15cpm	17cpm	16cpm
T	Afebrile to touch

OI:

Ambulates independently s assistive device

(+) ectomorph

(+) alert, coherent, cooperative

(+) postural deviation – see postural analysis

(+) Scar at (L) parasternal area 2° MVR

(-) gait deviation

(-) atrophy on (B) UE/LE

(-) deformities on (B) UE/LE

Palpation:

Normothermic on all exposed body parts

(+) Grade 2 tenderness at nape and ® upper trapezius

(+) mm spasm at nape and ® upper trapezius

(+) nodules and taut bands on ® upper trapezius

(+) pectoralis and scalene mm tightness

(+) mm guarding during lateral neck flexion to the ®

(-) edema on all 4’s

(-) subluxations

(-) crepitations

Tone assessment:

Normotonic on (L) UE and (B) LE.

Superficial Sensation

STD Used: Pinch for pain and light finger stroke for light touch

Result was taken via dermatomal testing.

Findings: Decreased sensation as to pain and light touch at C5, C6, C8 and T1 dermatomes.

Significance: Precaution for thermal agents.

MSR:

(R) (L)

Legend:

0 - areflexia

+ - hyporeflexia

++ - normoreflexia

+++ - hypereflexia

++++ - clonus

Findings: Normoreflexive at all tested areas

Significance: Baseline purposes. There may be progression in affectation of structures placed pressure by the TOS which in turn may affect DTR’s.

ROM:

Major joints of the body were grossly assessed and are WNL actively and passively done pain-free and has N end-feel except:

Joint Motion	Normal ROM	AROM	PROM	Difference A/P	End-feel
Neck side flexion to the ®	0-45°	0-30°	0-40°	15°/5°	Empty
Neck extension	0-45°	0-35°	0-45°	10°/0	Firm
® 2nd -5th MCP flexion	0-90°	~0-50°	0-90°	40°/0	Firm
® 2nd -5th PIP flexion	0-100°	~0-45°	0-100°	55°/0	Firm
® 2nd -5th DIP flexion	0-90°	~0-45°	0-90°	45°/0	Firm

Note: Motions at ® UE which produces Sx (shoulder abduction, flexion, elbow extension and wrist flexion) has full ROM, (B) actively and passively but pain is present during ROM A:

Findings:

– neck side flexion is limited 2° production of SX to ® UE as well as ® 2^nd-5^th finger flexion which also produces pain

– limited neck extension is 2° tight scalene mm

MMT:

All major mm groups of the body were grossly graded 5/5 taken via myotomal distribution.

Note: mm grade A: were taken c in pain tolerable ranges.

Special test:

(+) ULTT-4 (BIkele’s Sign) at ®

Finding: (+) Reproduction of radicular pain when pt extended the elbow from 90° abduction of shoulder c elbow fully flexed.

Significance: Ulnar nerve and C8-T1 nerve roots were stretched showing its affectation

(+) ULTT-1 at ®

Finding: (+) Reproduction of radicular pain

Significance: Possible affectation of median nerve, AIN and/or nerve root C5,C6,C7

(+) Reverse Spurling test

Finding: Stretch pain occurred at (L) side of neck when neck neck was side flexed to ® and compressed.

Significance: (+) tightness of neck mm

(-) ULTT 2-3 at ®

Finding: no reproduction of radicular pain

Significance: no affectation of musculocutaneous, axillary and radial nerve

(-) Spurling test and maximum compression test

Findings: no reproduction of Sx occurred

Significance: R/O cervical nerve root affectation

Functional Analysis:

Grip:

1. Grip Strength via dynamometer in lbs

Trials	(L)	®	Difference
1st	32	14	18
2nd	31	19	13
3rd	30	16	14
			14.67

Note: Pt stated that grip strength difference was 2° pain she feels on exertion of force while grip strength A:

Significance: 14.67 lbs difference between grip strength of (L) and ® hand signify weakness of ® hand

2. Pinch Grip Strength via pinchometer in lbs

Trials	(L)	®	Difference
1st	3	2	1
2nd	2.5	1	1.5
3rd	2.5	1.5	1
			1.67

Note: Pt stated that pinch grip strength difference was 2° pain she feels on exertion of force while pinch grip strength A:

Significance: 1.67 lbs difference between pinch grip strength of (L) and ® thumb signify weakness of ® thumb

Postural Analysis:

All landmarks are present and level viewed anterior-posterior-lateral except for the ff:

Anterior/Posterior View:

– Protracted Shoulders

Lateral view:

– Forward head posture

– Increased thoracic kyphosis

Gait Analysis:

(-) gait deviation

ADL Analysis:

Pt. Is independent on all aspects of ADLs such as bed mobility, transfers, dressing and ambulation but experiences:

– Maximal difficulty c occupational aspects (difficulty holding and manipulating a pen)

– Moderate difficulty c feeding and self-care

Note: Pt’s inability to use ® hand for self-care is compensated by pt’s (L) hand. She sometimes pinches objects c her ® hand for self-care and feeding activities.

Significance: Goal setting for PT Mx.

A:

PT Impression: Pt will have increased difficulty in performing ADLs requiring use of ® UE unless the pressure on Sx affected by TOS will be resolved.

Rehab potential: Good as to pain relief but fair rehab potential because pt already has altered sensation and difficulty c ADLs.

Goal: to enable pt to work using his (R) UE s pain and difficulty

Problem List:

1. ADL difficulties:

– Maximal difficulty c occupational aspects (difficulty holding and manipulating a pen.

– Moderate difficulty c feeding and self-care

2. Shooting pain c P/S (7/10) at ® UE and dull pain of P/S (5/10) at nape and 9r0 upper trapezius.

3. Pectoralis and scalene mm tightness

4. Grade 2 tenderness and mm spasm at ® upper tapezius and nape

5. Nodule and taut bands at 9r0 upper trapezius

6. Decreased AROM of neck side flexion to ®, neck extension and ® finger flexion

7. Weak ® pinch and grip strength.

LTG: In 1 month tx session, pt will:

1. Experience elimination of shooting pain and tingling at ® UE to enable her to do her ADLs c ease and painfree.

2. Demonstrate proper body mechanics and posture.

STG: In 2 weeks tx session, pt will:

1. Experience decrease of shooting pain ® UE and dull pain at nape and ® upper trapezius of 3-5 P/S increments.
2. Have elimination of pectoralis and scalene mm tughtness
3. Have elimination of grade 2 tenderness and mm spasm at ® upper trapezius and nape
4. Have elimination of nodule and taut bands at ® upper trapezius
5. Have improvement in AROM of neck side flexion to ®, neck extension and ® finger flexion.
6. Have improvement in grip and pinch grip strength for ® UE.

P:

Modalities:

1. HMP-TENS on ® upper trapezius x 20’ for pain relief.
2. US on (R) upper trapeziux, continuous mode, bighead x 1MHz x 1.5 w/cm² x 5’ prior to exercise.

Massage:

1. MFR on ® upper trapezius to eliminate taut bands and nodules.

Exercises:

1. Manual Stretching of upper trapezius, pectoralis and scalene mm x 10 SH x 7 reps x 1 set (c precaution)
2. ROM exercise for neck x 10 reps x 1 set, all motions.
3. (?) Calliet exercise x 7 SH x 10 reps x 1 set.

Others:

1. Teach pt self stretching of trapezius, scalene and pectoralis mm
2. Teach pt importance of proper body posture and proper body mechanics in relation to condition.

Home Instructions:

1. Tell pt to continue self stretching at home that were taught in clinic.
2. Advice pt to observe proper body mechanics and correct posture.

Maria Socorro C. Britanico

Dominic S. Adolfo

BSPT Batch 2008