Tingling Numbness in both upper and lower limbs

[guru_utkarsh]

Hey.. i just got this patient... The patient has tingling sensation in his upper and lower limbs... at times the tingling is in right Upper limb and lower limb and at times on to the left side.. The patient has had this complaint since the last six years and a few times has had breathlessness and choking feeling...

MRI REPORT-Spondylotic ridges at C5-6 and C6-7 indenting the thecal sac
-Diffuse disc bulge, left foraminal protrusion at C6-7 level causing left
neural foraminal narrowing
-Diffuse disc bulge with small left paracentra protrusion at C5-6 level

Kindly help me... There is no pain on movement or any other complaint...

[sharileedahl]

What are your assessment findings? Particularly from neurological tests?
As for "no pain"...it sounds like a neurological issue and not a mechanical one so wouldn't expect pain necessarily.
Have there been any other medical review of this client (i.e. outside of an MRI, has the client's doctor come up with any reasonable diagnosis; has the client been sent for any further investigations??)

[guru_utkarsh]

hey... well the patient has lack of full range of motion.. rotations to either side are restricted more than flexion and extension... also the axial loading of cervical spine did not alter symptoms... whereas distraction did relieve some numbness though only momentarily... the treating physicians have no diagnosis.. really wanna help this guy.. he's in so much trouble..

[alophysio]

hi,

a number of things.

1. What is causing the disc degeneration in the lower C/S? Is it work, posture, accident, thoracic dysfunction, pelvic dysfunction?

2. Have you cleared all the joints involved? it sounds like you have focused on the C/S.

3. breathing difficulties, rotational restrictions, pain in upper AND lower limbs at the same time - sounds very thorax-y to me.

4. try feeling his ribs. If some "stick out" more than others, hold them "in" (medially) and see if it changes. The change in symptoms sounds like muscular dysfunction/spasm in reaction to other things

5. Does this patient have any visceral issues - stomach upset, constipation, irritable bowel, etc? If so, then i would almost bet my house on Thorax dysfunction.

Good luck!

[Physioindeed]

Hi all.
This is just a thought as I have a patient with tingling and numbness in Hands and legs and also sudden "fits" of breathing problems.
Apart from having Movement disfunktions and postural and habitual and psychological problems this lady has Diabetes Mellitus, which at least some of her neurological problems can be acredited to.
not saying that this has something to do with your patient, just something to think of.
let us know, how you get on!
regards
Annette

[alophysio]

hi -thanks for that.

When your patient has the DM controlled, do her symptoms improve?

Also, how did they determine the neurological signs were from the DM??

Thanks

[guru_utkarsh]

Hey.. thanks for all the discussions...

- The patient suffers from constipation atleast 10 days out of 30 days in a month.. on an irregular basis...

- Patient suffered from intestinal TB 13 years back and did complete the whole dosage and treatment..

- Patients breathing becomes better on pressing the sternum..

- Left lower ribs 11th 12thsticks out and on pressing the patients breathing improved... at least he felt better..

Now how do i proceed??? need ur valuable suggestions...

[alophysio]

Hi,

So it looks to be a thorax problem. Funny how some history things that don't sound significant suddenly are...

Ok, it is very difficult to explain what to do with the patient. However, i am going to assume you have a brain and you obviously must be smart because you are a physio! . Therefore...

*Joints*
1. Assess the thoracic spine facet joints.
2. Assess the ribs joints anteriorly and posteriorly
3. Assess the C/S and L/S facet joints.

*Muscles*
1. Assess ALL the muscles that attach to the thorax/ribs/L/S and C/S.
2. Assess the thorax in relation to breathing and the pattern of breathing - look for the quality of breathing
3. Do certain muscles feel overactive or tight?
4. Do certain muscles feel underactive or flaccid?
5. Is there any asymmetry?

*Motor Control / Neural*
1. How is segmental motion during F/E/Rot/LF?
2. How do the patterns of muscle activation look?
3. How do they change when you change certain joints (like the lower ribs or sternum)
4. Does strength changes occur on isometric muscle testing without rib/sternum holding and with?

*Visceral system*
1. If you are not familiar with osteopathic visceral manipulation type stuff, don't worry.

*rationale*
1. irregular constipation - you often see this a lot when the sympathetic system is dysfunctional secondary to thoracic dysfunction. Go back and see how close the sympathetic tract is to the CV joints.

2. I don't know what intestinal TB is - sorry

3. Breathing better on sternum pressing - not sure what direction you did but assuming AP. By doing this, you have change fascial and articular relationships allowing a different movement pattern to occur. You need to reason out ALL the changes that have been made - was it articular or muscular? Was it pec major or pec minor? Was it at a certain level or it doesn't matter where you push. Don't forget that the obliques can be as high as rib 5 and go to the pelvis...

4. Left lower ribs "sticking out" indicates a dysfunction. It might be articular or myofascial (muscular). What is QL, erector spinae, multifidus, etc doing to those ribs? Are you able to get the patient to think of something (a cue) to activate the deep stabilisers at that level - try something like..."can you feel me sticking my finger in here (press on rib 11 CT joint)...can you think about pushing my finger out of this rib?" - to try get multifidus or something nearby - make it up, you won't hurt your patient by trying different cues.

Good luck. Experiment safely. Remember that this patient has had this a long time. The very fact that you pressed here or there and made them feel better is already alot more than a lot of other people have done (i am guessing of course!). Therefore, be up front, tell them that you need to explore a bit to find the best thing to help them and they should be patient.

Good luck!

[Physioindeed]

Originally Posted by alophysio

When your patient has the DM controlled, do her symptoms improve?

Also, how did they determine the neurological signs were from the DM??

Your first question is exactly what I was trying to find out. However as I mentioned there are a lot of other problems, one of which is that she doesn't want to measure her Sugarlevels herself and therefor only get's a check up every three month. It is therefor difficult to find out if attacs and symptoms are related, as I am unsure how controlled her DM really is.
the other is a language problem which ment i could only dip into the history on the surface.

The neurological examinations are still continuing with that patient.
That some of the neurological symptoms originate from the DM was an assumption on my behalf due to following facts
80 percent of all DM show at least slight polyneuropathic changes.
the mainly distal symptom areas mimic a glove or sock distribution.
nightly paraesthesien, calf cramps
trophisch skin changes
as all these seemed to fit to the patient I thought it save to assume...

I only saw this patient very shortly as a substitue for a collegue.
however I will mention this discussion to her to maybe also pay some more attention to the Tx.

Thanks
Annette

[Physioindeed]

Originally Posted by alophysio

Hi,

1. irregular constipation - you often see this a lot when the sympathetic system is dysfunctional secondary to thoracic dysfunction. Go back and see how close the sympathetic tract is to the CV joints.

I was wondering how you would find that out?
thanks Annette

[alophysio]

Hi,

How you find out if constipation related to thoracic dysfunction??

When you treat the thoracic dysfunction, the constipation goes away. Not very fancy but effective!

I had a friend who couldn't eat a full meal for 2 years because of stomach cramping. 3 treatments to his spine (mainly manipulations to whole spine actually - that is how locked up he was) and he has been eating normally since. They were actually going to do exploratory operations etc. His mother pleaded with me (and him) to see him - we agreed to 3 sessions and he was grateful.

Many other stories like that.

If you closely question your patients, they will tell you things like that but at the time they don't think it is relevant...

[sharileedahl]

Thanks alphysio and Physioindeed for the interesting posts.

guru_utkarsh - Please keep us up on the results of further testing (if any).

Alophysio - I can honestly say I would not even think of treating related to thoracic dysfunction for the above client mainly because I would be wondering if there is some missing information (medical testing). I have been interested in the role of the sympathetic / parasympathetic N.S. in symptoms related to thoracic dysfunction for many years. Can you suggest any specific reading????

[alophysio]

Hi sharileedahl,

Most of the information is derived (and i use that word deliberately) from learning how to treat thoracic dysfunction.

I can honestly say that LJ Lee is the world's best physio in thoracic dysfunction, especially motor control. There is so little literature out there, she wrote the rehab section of The Thorax with Diane Lee and invented the Seated Arm Lift (SAL) and the Prone Arm Lift (PAL) load transfer tests.

If you can take any of her courses, do so - over and over. Every word she uses is almost deliberate and you can learn a lot more from just listening to what she says and how.

So anyway, i went on these courses and learnt how close the CV joints are to the sympathetic chain then looked up text books on how the autonomic system affects the viscera which inevitably leads to visceral manipulation - of which i wil take further courses.

LJ Lee and Diane Lee are Canadians so you should be able to find a course nearby!

As for this patient, there was no medical diagnosis. Breathlessness, choking feeling, altered sensation etc. All sounds thorax-y to me...but you just have to see lots of them.

The best way to pick these patients is to listen for the phrase "no one seems to know what is going on".

You might have read me say to many people "it will sound right" or "it will make sense". It is because i believe unconsciously you know if something is right or not...that nagging doubt etc is your brain telling you information is consistent. When you tell them what is going on, they don't necessarily understand it but their body can feel it and it feels "right". In fact, patients often tell you they thought they were going crazy because no one believes them that there is a problem...

Anyway, sorry about the long post - i hope it helps. I don't mind discussion on such topics - you can only learn from other people's experiences - whether for good or bad!

Cheers - nice question!

[IceMan]

Originally Posted by alophysio

I can honestly say that LJ Lee is the world's best physio in thoracic dysfunction, especially motor control. There is so little literature out there, she wrote the rehab section of The Thorax with Diane Lee and invented the Seated Arm Lift (SAL) and the Prone Arm Lift (PAL) load transfer tests.

If you can take any of her courses, do so - over and over. Every word she uses is almost deliberate and you can learn a lot more from just listening to what she says and how.

So anyway, i went on these courses and learnt how close the CV joints are to the sympathetic chain then looked up text books on how the autonomic system affects the viscera which inevitably leads to visceral manipulation - of which i wil take further courses.

LJ Lee and Diane Lee are Canadians so you should be able to find a course nearby!

Thanks for the info. I've found Diane Lee's website. It has some info on her clinic and courses and some excellent articles and videos to be found under the "courses" link. Worth a look.

[sharileedahl]

Originally Posted by alophysio

Hi sharileedahl,

So anyway, i went on these courses and learnt how close the CV joints are to the sympathetic chain then looked up text books on how the autonomic system affects the viscera which inevitably leads to visceral manipulation - of which i wil take further courses.

LJ Lee and Diane Lee are Canadians so you should be able to find a course nearby!

Thanks for that. I remember as a new grad having a client that I thought had a lot of sympathetic type symptoms that went along with a locked up and acutely painful Tsp after an MVA. I remember going through my anatomy texts over and over again trying to make sense of it because I couldn't find anything else in writing to support what I was thinking. Eight years later I sometimes wonder if I'm any further ahead in totally understanding what I was seeing then!!!
I listened to LJ talk at one of our national conferences here and it was a good start in understanding thoracic dysfunction but it really was presented as mechanical / biomechanical dysfunction. I'll have to find one of her courses to see if I can gain a better understading of the impact on the symp NS. Thanks.

[alophysio]

Cool. In addition to Diane Lee's site, there is LJ Lee's site as well... Linda-Joy Lee Physiotherapist Corporation - Physiotherapy Education and Resource Company - Vancouver, BC.

Diane Lee and LJ Lee work together. They have common courses but they also run courses on their own so it pays to check both schedules.

Enjoy the learning experience. BTW, if it is specific autonomic nervous system things you want to learn, you will have to specifically ask them.

Good luck!

[linbin]

i wonder whether there is any upper cervical hypermobility,osteophytic compression of spinal cord at the level of atlantoaxial junction or occipitoatlantal area