neck pain, tingling???

Hi there,

I have a male patient around 4yrs, works in IT industry, c/o neck stiffness & pain, numbness on the post. arm & tingling sensation in the left hand. His sypmptoms increases @ EOD, feels better in AM. X-ray shows degn. changes in lower Cx.

O/E - tight para spinal muscles & upper trap's. Cx- F¡Ô, E- 1/2 pain @ C5-6. SF - pulling along trap's & scm. Rot- EOR¡õ, L=R. Palpation - AP¡õfrom C3, C4 produces numbness, C6 - T1 produces tingling++ sensation from Tx to the hand, T3-T5 ¡õproduces tingling +++ in the hand.
Right now, have treated him for 8 sessions with Cx- Tx ¡õmobs & intermittent Cx traction. His neck pain had decreased but the on & off tingling sensation & numbness hasn't changed much.

I couldn't think of how Tx ¡õ can produce radiating tingling sensation to the hand? If anyone could suggest possible reasons or share their opinions it would be very helpful. looking forward 2 ur reply
cheers

jermi

[alophysio]

Hi

I'm thinking fascial connections. Possibly also dysfunction there affecting structures higher. Also, muscles that start in the thoracic spine go into the C/S so compression can occur from these muscles on joints in the C/S.

[Physiobase]

I agree with alophysio. Note mobilising a "stiff" upper Tx segment is likely to be moving cervical segments at the same time (into extension). Also the dural connection up from around T4-T8 will be affected during your mobilisation.

One cuold also condier the symptoms of thoracic outlet syndrome and the vascular symptoms from this type of presentation. This includes paresthesia in an ulnar distriction and even weakness in the 4th and 5th digits.

Are there any other signs or symptoms, e.g. systemic considerations. Is he a smoker. Have you got a plain chest xray? A complete physical exam is exremely impt at this stage

Check out the T4 syndrome that was published as a case study in the Chartered Physiotherapy Journal awhile back.

It was described as bilateral tingling in the hands when PA T4 and the symptoms often wakes patient up at night with tingling.

I have seen a couple of these T4 syndrome patients. Noted that some have bilateral tingling while others are unilateral. Their T4 is hypo ++ and symptomatic+. I have learnt to be conservative with them. I used to manip T4 but found that their symptoms worsen. I have found Grade II T4 PA or less in 4-6 sesisons seems to work well with these patients.

$0.02

Hi,
I'm still a student but was just wondering if the patient's work station has been assessed. What's his sitting posture like, has he a chin poke, etc...
I had a similar patient on one of my placcements and postural/ work station corrections really helped. Computer at eye level, adjustable desk/chair height, swivel cahir to not have to rotate body, etc.
Mark.
P.S. I realise that my opinion may be wrong due to limited experience but hope it helps.

[alophysio]

Hi MFSA21.

Your opinion is great and absolutely correct.

Even though a change of environment may help, it doesn't answer the original question of why...that's all.

In the management of the patient, workstation assessment would be required simply becuase we see these people for 1/2hr x1-3 times per week and they are spending 40+ hours in the same sort of position...

[MrPhysio+]

Hi
All responses to date are on target. T4 syndrome is certainly relevant, as is the work posture. As most people tend to slump after prolonged sitting at work stations or driving, a chin poke thoracic kyphotic posture with cervical extension develops. Over time, the musculature holds this position, and the body senses the slump as the least tension point. When such a patient tries to sit up, some muscle groups feed back that tension has increased, and other muscular groups are deficient in their ability to sustain the posture (poor endurance), resulting to a return to the slump.
I find that a progressive exercise to build the rhomboid strength and endurance, whilst stretching the pectorals, and at the same time realigning the cervical curves, is very successful.

Each week over 7 weeks, the patient increases one of three parameters, leading to rhomboid shortening and increased endurance, etc, plus reinforces a new postural habit. In the first 7 - 10 days the patient may experience an increase in symptoms of headache and muscle soreness, but this will pass. They need to be warned, and persevere through bthe changes, as this feeds back the changes.

In sitting or standing, the patient looks straight ahead (to do this in front of a mirror for the first week),and elevates the arms to 90 degres of sh. abduction, and 90 degrees of elbow flexion, so that the arms are parallel with the floor. advise the patient to retract the shoulders, keeping the arms parallel with the floor, and not to jut the chin forward, hold the contraction for 3 seconds without the elbows dropping, and repeat three times, three times daily. The second week hold for 4 seconds, three times, three times daily. Once 5 second hold is reached, the next progression is to repeat four times in the fourth week for 5 seconds, three times per day. With this progression, by week 7, the patient is holding the retracted position for 5 seconds, repeating 5 times per session, 5 times per day. Yes, I give them a handout with instructions and a drawing!

The above exercise is actually very simple, and addresses many problems related to the cervical and thoracic spine, which cause upper limb dysfunction and headaches.
Let me know your thoughts.
MrPhysio

[alophysio]

Hi.

With T4 syndrome, have people considered External Oblique has fascicles that go to rib 5.

If this person is a "chest-gripper", then locking down up to T5 will mean T4 will have to move lots to get any movement happening...

If this is so, assess their pattern of breathing and EO status...

With respect to Mr Physio's exercises, I would only add that the patient should attempt to maintain good spinal curves as the positions described could lead to hyper extension of the T/S...

Thanks