clinical case report competition...myofascial and gsm techniques were preformed each treatment,...
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P: 604.873.4467F: 604.873.6211
Registered Massage Therapists’ of British Columbia
Clinical Case Report Competition
West Coast College of Massage Therapy Victoria Part-Time
April 2014
Third Place Winner
Kelsey RenwickThe effects of massage therapy and
decreasing thoracic outlet syndrome symptoms
RMTBC 2014
MASSAGE THERAPY AND THORACIC OUTLET SYNDROME
Conflict of Interest
The author and patient were previously acquainted before the start of the case study. Although
previously acquainted, there was no conflict of interest and a therapeutic relationship was
developed throughout the course of the case study. The patient committed to the study and was
informed of procedures prior to commencing, and was aware her identity would be kept
confidential.
Acknowledgments
I would like to thank my case advisor Dean Robertson for his advice and ideas as well as the rest
of the supervisors for their input and motivation. I would also like to thank my patient, who
volunteered her time, effort, and positive attitude. Without her this case study would not have
been possible.
MASSAGE THERAPY AND THORACIC OUTLET SYNDROME
Table of Contents
Title Page…………………………………………………………………………………….…....1
Acknowledgments…………………………………………………………………………………2
Conflict of Interest…………………………………………………………………………..……..2
Abstract…………………………………………………………………………...………………..3
Introduction………………………………………………………..................................................6
Methods and Procedures...................................................................................................................8
Client History………………………………………………...............................................8
Assessment……………………………………………………..…………………....…….9
Treatment……………………………………………………...…………………..……...10
Reassessment…..……………………………………………………………....................14
Results…………………………………………………………………………...…….......….….14
Discussion………………………………………………………………….….………...…….….15
Conclusion……………………………………………………..…………….……………….…..16
References…………………………………………………………………..…………...…….....17
Appendix A: Orthopedic Tests……………………….……………………….………….…...….19
Appendix B: Initial and Final Assessment Pictures…………………..……….............................27
Appendix C: Treatment Breakdown………………………….……………...…………………...29
Appendix D: Anatomy Pictures …………………………………………..…………...………....33
Patient Consent Form ………………………………………….....……………………………...34
Clinic Notes……………………………………………………………………..….……...…..…35
MASSAGE THERAPY AND THORACIC OUTLET SYNDROME
Abstract
Objective: The objective of this case study was to determine if massage therapy is an effective
choice when there is a compression of the brachial plexus, causing Thoracic Outlet Syndrome
(TOS) symptoms. The main choice of techniques used was myofascial release, and General
Swedish Massage (GSM) techniques.
Background: TOS is a common disorder, occurring mainly in athletes who play over hand sports,
or workers who do lots of overhead work. The brachial plexus is often compressed due to
constant overhead movements, resulting in numbness and tingling down the arm and into the 4th
and 5th metacarpal joints. The patient being a twenty-year old female, complained of numbness
and tingling bilaterally in both her hands and arms.
Methods: A total of thirteen hands on treatments were conducted over an eight-week period,
focusing on decreasing hyper tonicity bilaterally in the Scalenes and Pectoralis Minor muscles to
relieve neurological symptoms. A postural assessment using a plumb line was used for the initial
and final assessment, cervical spine ranges of motion and a selection of orthopedic tests.
Myofascial and GSM techniques were preformed each treatment, predominantly focusing on the
cervical spine, anterior chest, and forearm musculature.
Results: The patient’s neurological symptoms decreased immensely, and she was able to perform
certain actions (abduction, external rotation and extension) with no feeling of numbness or
tingling at all. Most orthopedic tests that were strongly positive prior to massage intervention
became negative during the final assessment.
MASSAGE THERAPY AND THORACIC OUTLET SYNDROME
Conclusion: Massage therapy was found to be an effective modality in decreasing neurological
symptoms due to a compression of the brachial plexus.
Keywords: Thoracic Outlet Syndrome, compression, brachial plexus, impingement, neurological
symptoms, myofascial release, General Swedish Massage, upper extremity, bilateral
Introduction
Thoracic Outlet Syndrome (TOS) is a compression disorder of the brachial plexus and
potentially the subclavian vasculature (Rattray, 2000). The brachial plexus arises from the
cervical spine, traveling through various musculatures, below the clavicle towards the axilla,
MASSAGE THERAPY AND THORACIC OUTLET SYNDROME
down the arm, and terminating at the phalanges see Figure 10 in appendix D. Compression
occurs because of increased pressure on structures in the thoracic outlet, which consists of
muscles, nerves, bones and vasculature. The lower trunks of the brachial plexus, C8-T1 nerve
roots, are the most commonly affected, which leads to pain and numbness in the posterior neck,
shoulder, medial arm, forearm, and radiates into the ulnarly innervated digits of the hand
(Goodman, 2009). TOS causes neuropraxia, which results in the loss of conduction at the
compression spot, resulting with no axonal degeneration (Rattray, 2000). When a nerve is
compressed most people report paresthesias and pain in the arm (Goodman, 2009).
There are three major locations that are prone to impingement: the intrascalene triangle
(Anterior Scalene, Middle Scalene and the first rib), costoclavicular space (clavicle and first rib),
and the coracopectoral space (under the coracoid process of the scapula and the Pectoralis Minor
muscle) please see Figure 11 in appendix D. The trunks of the brachial plexus pass through the
intrascalene triangle, and impingement occurs if this space is narrowed, leading to potential
neurological or vascular symptoms (Rattray, 2000). Impingement of the Costoclavicular space
leads to the vascular symptoms of TOS. The subclavian artery and vein are more susceptible to
impingement as the space varies in size due to the position of the shoulder and possible
anatomical abnormalities (Rattray, 2000). As the neurovascular bundle passes through the
coracopectoral space it can be compressed during certain movements, such as Glenohumeral joint
(GH) abduction and maximal extension.
There are many contributing factors associated with TOS. Postural variations and stress
are most commonly found to be the cause (Goodman, 2009). Postural variations such as
anteriorly rounded shoulders, and head forward carriage can cause shortening of Scalene, Levator
MASSAGE THERAPY AND THORACIC OUTLET SYNDROME
Scapulae, Subscapularis and Pectoralis Minor muscles, which leads to a decrease of space in the
thoracic outlet please see Figure 9 in appendix D. If there is increased pressure on the shoulder
girdle such as carrying a heavy bag with a strap, which could result in pressure on the thoracic
outlet or potential traction to the brachial plexus (Kisner, 2012). Hypertrophy of the Scalenes can
be caused from over usage of the respiratory muscles due to bronchitis, pneumonia, asthma and
emphysema; paradoxical breathing is often present (Rattray, 2000). Injuries resulting with scar
tissue formation, inflammation, adhesions or fractures to the clavicle can result in a decrease of
motility to the nerves and potential damage to the plexus and surrounding vessels (Kisner, 2009).
Congenital factors associated with compression of the brachial plexus involve, a cervical rib or a
long transverse process of the C7 vertebra (Kisner, 2012). Overhead sports (such as racquet
sports, volleyball etc.) and heavy lifting aggravate and produce symptoms in the upper plexus
(Goodman, 2009).
Nerve compressions can be treated manually or surgically, with massage therapy playing
a key role in the manual aspect. In relation to nerve compression, the use and effectiveness of
massage therapy to help relieve symptoms would be beneficial to the profession as this is a
common disorder that occurs in the population. This case study was conducted to demonstrate
that myofascial release techniques, with integrated GSM techniques, would benefit and over all
decrease the bilateral symptoms of Thoracic Outlet Syndrome.
Methods and Procedures
Client History
The patient of this study is a 20-year-old female student, who has bilateral neurological
symptoms involving compression of her brachial plexus. The neurological symptoms are felt
MASSAGE THERAPY AND THORACIC OUTLET SYNDROME
when the patient externally rotates and extends her GH, or abducts the GH joint; symptoms
increase when wrist is extended. With extension and external rotation the patient feels the
symptoms on the palmer aspect of her second, fourth, and fifth phalanges. Abduction results in
symptoms appearing in the axilla, Triceps, and Biceps Brachii, as well the fourth and fifth
phalanges. The symptoms were described by the patient as a heaviness as well as numbness and
sharp, shooting tingling ranging from a seven to eight out of ten on the pain scale see appendix A.
It was noted that the patient’s sleeping position was having the left hand under the pillow with
the right leg hip hiked, and occasionally would experience neural symptoms at night due to the
fact that the left shoulder was overstretched.
The patient had no previous injuries to her cervical spine (C/S), or her GH joint, but has
had chronic recurring pain and stiffness bilaterally in her cervical spine, mainly the right side. On
palpation it was noted that the Scalene and Sternoclediomastiod (SCM) muscles were hypertoned
and the patient felt that she had limited range of motion of her C/S. The patient has no known
cervical ribs, although presented with a family history of her grandmother having two. The
patient reported that she had headaches rarely, approximately five times a year, mostly stemming
from the sub-occipital muscles and were usually stress induced tension headaches. The patient
visits a Registered Massage Therapist once a month for maintenance treatments on her neck, as
well as recently getting treatment from a Chiropractor twice a week (the patient was instructed to
withhold treatments throughout the duration of this case study, although had eight treatments,
most pertaining to the lumbar spine).
The patient was diagnosed in 1998 with exercise-induced asthma, which is also triggered
with sickness or allergies. The asthma does not occur day to day, and the patient has an inhaler
(Salbutamol) for when needed. Attacks are often experienced at random. She has noticed that she
MASSAGE THERAPY AND THORACIC OUTLET SYNDROME
tends to breathe more from her chest and not so much with her Diaphragm, as she finds it
uncomfortable due to her asthma.
The patient also mentioned she has undiagnosed Raynaud’s Disease, which is cold
weather induced. Her hands experience cyanosis bilaterally, usually occurring in all five
phalanges as well as the entire hands. Sometimes the patient experiences this in her feet as well.
The patient has a family history of cardiovascular problems such as valve replacements and
stints, but she has not been diagnosed with any of these at this time. There has been no history of
smoking.
Assessment
The initial assessment took place on September 12th, 2013. In the postural scan the patient
showed bilateral anterior rotated shoulders with the left shoulder slightly more superior then the
right. Both knees showed hyperextension with a slight valgus angle. It was also observed that
there was approximately 9.5 centimeters of head forward carriage projected from the plumb line
please see Figure 5 and 7 in appendix B. The patient complained of tightness and stiffness in the
C/S, this was assessed using a verbal analogue using the pain scale please see appendix A.
A gonimometer (see appendix A) was used on the initial assessment to measure range of
motion of the GH and C/S please see appendix A for normal ranges. The patient had neural
symptoms in flexion, abduction, internal and external rotation, in the right GH joint and external
rotation and abduction in the left GH joint all amounting to seven-eight out of ten on the neural
pain scale. Minimal ranges were also seen in flexion, abduction, extension and adduction in both
the right and left GH. C/S range of motion showed minimal ranges in all motions, with bilateral
rotations and side flexion having the most limitations. C/S presented with no neural symptoms
but with pain, which was assessed by using the verbal pain scale.
MASSAGE THERAPY AND THORACIC OUTLET SYNDROME
Orthopedic tests were performed to determine what was causing the neural symptoms.
These tests included Adson’s Maneuver, Wrights Hyperabduction, and Allen’s test, which are
common TOS tests. Median, radial, and ulnar Upper Limb Tension tests were performed to
determine which nerve roots were affected. Other orthopedic tests performed included
Costoclavicular Syndrome and Halstead to check for neural symptoms. Capillary Refill and
Roo’s were performed in order to see if the patient had any vascular symptoms as well as any
neural symptoms see appendix A for orthopedic testing results. A series of manual muscle tests
were performed as well to indicate which muscles were weak, or which were associated with the
pain in the C/S.
Over the course of the 13 hands on treatments Adson’s and Allen’s were used
approximately every treatment. After the seventh treatment, all of the Upper Limb Tension tests
were performed pre and post treatment. Progress was seen as early as the third hands on
treatment. Charts of the orthopedic testing results can be found in appendix 1.
Treatments
Thirteen sixty-minute hands on treatments took place twice a week for the first ten
treatments and then progressed to once a week for the last three treatments. There were two, 70
minute assessments that took place initially and for the final fifteenth session. All thirteen
treatments were in the supine position working on the C/S, anterior chest, and bilateral arms.
Treatments two to four, twelve, and thirteen included Pectoralis Minor and Major work.
Treatments five to thirteen included work on bilateral arms and forearms. All treatments were
otherwise the same.
Treatments would start with myofascial release (MFR) techniques to the C/S, including a
sub-occipital release in order to relax the body and C/S musculature. This technique would be
MASSAGE THERAPY AND THORACIC OUTLET SYNDROME
held for approximately one to three minutes depending on when the release was felt. Next, the
Scalene muscles would be palpated and the subject would be instructed to place her hands on her
stomach and take five deep diaphragmatic breaths, pushing the air into her hands, while still
maintaining the hold on the Scalenes, all the while waiting for a release.
GSM techniques were used on the C/S in order to flush out the area, and decrease the
hyper tonicity in the SCM and Scalene musculature. A series of thumb, fingertip, and knuckle
kneading and stroking were applied. A muscle squeeze was applied to the SCM in order for the
musculature to release, therefore gaining better access to the Scalenes. Contract-relax and isolytic
release techniques for the Scalene muscles were introduced in treatments nine to thirteen. The
patient was to actively side flex and rotate to the ipsilateral side as far as they could and then
resist the pressure of the therapist for five seconds, rest for seven seconds, and repeat twice with
the last resting period being held for thirty seconds. This would occur bilaterally. The isolytic
release was done passively and actively for three times each, bilaterally. The patient’s head
would be passively held, and laterally flexed to the opposite side while doing a downward strip of
the Scalene musculature, mainly the anterior Scalene. This would be done in the same manner
only getting the patient to actively do the side flexion motion.
Multiple MFR techniques were applied in order to open up the anterior chest and promote
a posterior rotation of the GH joints. An arm pull traction technique was used, with one hand on
the Pectoralis musculature and the other applying traction at the mid-humerus, creating a
myofascial pull. This would be held for approximately one hundred and twenty seconds or until a
release was felt and would be performed bilaterally. Next, the MFR technique used was called
reshaping, and would be performed on the Pectoralis Minor muscle by inserting both thumbs into
MASSAGE THERAPY AND THORACIC OUTLET SYNDROME
the axilla and then grabbing the rest of the muscle on the anterior chest, applying pressure and
holding. With this technique the sheering moved inferiorly down the muscle and applying a slight
bend in it as well, creating space around the corocoid process, which is the attachment point of
the Pectoralis Minor. Micro-sheering was performed on the Pectoralis Major, by using the
middle and index fingers of both hands and applying a MFR sheer. GSM was used to flush as
well as to break down adhesions found in the Pectoralis musculature and Subclavius mainly using
the muscle stripping techniques.
During the treatments that involved the arms and forearms, MFR techniques were used
such as sheering, cross-hands and v-stroking to break up adhesions and decrease potential
entrapment of the nerves in the forearm. Applying pressure on the tendons and having the patient
actively flex and extend her wrist applied Isolytic release to the common flexor and extensor
tendons. GSM techniques such as knuckle and forearm stroking and kneading were used. Passive
range of motion of wrist, elbow and GH joint and traction to the wrist were applied. This was all
performed bilaterally on both arms.
In six of the treatments the Diaphragm was worked on with MFR techniques. One hand
was placed under her back, in line with where the diaphragm sits, and the other resting inferiorly
to the ribs on top of the diaphragm, and held for three to five minutes, waiting for a release or
movement. Muscle stripping was also used to break down multiple adhesions in the diaphragm.
This was preformed in hopes of taking pressure off the Scalene muscles, as they are a part of the
muscles of inspiration see appendix C for treatment breakdown.
The patient was given a homecare regime, which included hydrotherapy and remedial
exercises to do on a daily basis, in correlation with the massage treatments. Contrast using hot
and cold were to be applied to the forearms and the Scalenes. Starting with heat for three minutes,
MASSAGE THERAPY AND THORACIC OUTLET SYNDROME
and then cold for one minute repeating this for three cycles and making sure to end with cold.
Heat was given to the patient to apply to the Pectoralis muscles once a day, for a maximum of 20
minutes.
The patient was given two stretches after the first treatment, the first was for the
Pectoralis muscles, using a doorway or wall, having the elbow bent at ninety degrees with the
forearm on the door frame, and turning the torso to the opposite side, feeling a stretch in the
anterior chest. The second stretch was for the SCM muscle, stabilizing by holding the chair with
one hand, and then extending the C/S, side bend the head to the opposite shoulder, and then rotate
the head back the midline, and bringing the chin in towards the chest. A Scalene stretch was
added, stabilizing on a chair with the opposite hand, other hand on head, side flexion to that side,
and then bring chin into chest slightly to increase the stretch. All stretches were to be held for
thirty seconds, twice a day with no pain.
The patient was also given the exercise called neural flossing. The arm is to be abducted
and slightly extended, or until neural symptoms are felt, and then the wrist is to be flexed and
extended. The flossing was to be done for a total of thirty seconds, twice a day, and to be done
with no pain. Diaphragmatic breathing was given to the patient to do once a day, for five breaths.
The patient was encouraged to place hands on stomach, ribs and back in order to practice
breathing into those areas.
Reassessment
The final assessment took place on November 7th, 2013. Ranges of motion for the GH and
the C/S were taken again using the Goniometer. All previous orthopedic testing was repeated in
order to find out what the final results were, and if the symptoms had decreased throughout the
thirteen treatments. The patient was also put into the positions and preformed the motions that
MASSAGE THERAPY AND THORACIC OUTLET SYNDROME
previously brought on the neural symptoms, and it was recorded what the outcome was. Overall
the patient was asked if they felt their symptoms had decreased or if they had improved.
Results
The patient’s symptoms had decreased immensely by the end of the thirteen hands on
treatments. The Scalene and Pectoralis muscles had decreased hyper tonicity, and the overall
tissue quality felt more moveable. The TOS symptoms were decreasing as early as the third
treatment as the Adson’s test had been negative in the post treatment of the right side. The Upper
Limb Tension test for the Ulnar nerve decreased during the ninth treatment, and Allen’s started to
see negative results on the tenth treatment. Overall GH and C/S range of motion improved
greatly. C/S ranges were brought to the maximum range, with no pain. Tension in the C/S has
decreased but subject described the C/S as still being “stiff”. GH ranges improved considerably,
all neural symptoms disappeared, only abduction on both sides had a minimal amount (one out of
ten on the pain scale). (See appendix A for full results)
The patient stated that neural symptoms were minimal, and was now able to hold the GH
extension, external rotation, and wrist extension position without discomfort. The patient
remarked that the symptoms on the left side were “almost gone”, where as the right still has
more, but very minimal symptoms. Neural symptoms were no longer felt in axilla or the
phalanges with external rotation and extension but the patient could feel very minimal “fuzzy”
symptoms in the forearm and upper arm. With abduction symptoms were only occurring
minimally in the Biceps Brachaii and Triceps.
The final postural scan showed an improvement, the shoulders were now more posteriorly
rotated, with the chest looking more open. The head forward carriage has decreased by .5 of a
centimeter, resulting in 9 centimeters of head forward carriage please see Figure 6 and 8 in
MASSAGE THERAPY AND THORACIC OUTLET SYNDROME
appendix B. By the tenth treatment, the patient was able to go from two treatments a week, down
to once a week and did not break the pain tension cycle.
Discussion
The results of this study indicate that the use of MFR and GSM techniques are beneficial
in releasing the compression of the brachial plexus in a TOS subject. By using MFR techniques
the patients anteriorly rotated shoulders became more posteriorly rotated, which allowed more
space for the brachial plexus, and thus relieving compression. Notably, a correction of posture
played a role in relieving symptoms and for further improvement it would be advisable for the
patient to do strengthening exercises for the back and continue stretching the anterior chest in
order to prevent a kyphotic posture and future compression.
The patient was compliant following the homecare given specific to the neural symptoms,
which was the neural flossing technique, but was unsuccessful with the other homecare exercises
provided to her. The patient was asked prior to each treatment how the homecare regime was
going and by the eighth interview it was reported that the subject was not keeping up with the
SCM stretch and Pectoralis stretch as much as the neural flossing and Scalene stretches. If the
patient had been more proactive with the homecare, there could have been more room for
potentially better results. The patient was also advised to withhold getting treatments from her
Chiropractor and RMT for the duration of this case study in order to keep the variables as low as
possible. However, the patient continued to see her chiropractor for a total of eight treatments.
In the regards to changing the treatments, spending more time on the Diaphragm, with
MFR and strengthening exercises would have been beneficial to the patient due to her asthma.
Strengthening her diaphragm could potentially aid in decreasing the extra stress put on the
Scalene and Pectoralis muscles as it would encourage the subject to breath into her abdomen and
MASSAGE THERAPY AND THORACIC OUTLET SYNDROME
not consistently into her chest. With a decrease of stress on her Scalenes and Pectoralis Minor
muscle, the hyper tonicity would potentially decrease, causing less compression symptoms. It
would be advisable for the patient to continue getting massage therapy treatment once a week,
and paying attention to strengthening her Diaphragm and continue to maintain the muscles of
respiration.
Conclusion
This case study proved that using MFR and GSM techniques could decrease neurological
symptoms due to compression of the brachial plexus. Performing myofascial techniques
beginning at the C/S and following the nerve path down the arm provided a positive result in
relieving symptoms, decreasing pain and tension in the C/S and anterior chest. The main focus
was to decrease the tension in the Scalenes and Pectoralis Minor muscles and progress was seen
by the fourth treatment, when the patient extended her GH joints, neurological symptoms had
decreased since the first initial assessment. By treatment seven, the patient could extend the GH
joints with no symptoms except with wrist extension, and by the thirteenth treatment neurological
symptoms were minimal to none. It would be advised to explore the idea of further studies on the
impacts and effects of massage therapy on compression syndromes of the brachial plexus.
References Goodman, C. C., & Fuller, K. S. (2009). The Peripheral Nervous System. Pathology:
Implications for the Physical Therapist (3rd ed., pp. 1612-1615). Philadelphia: Saunders.
Hertling, D., & Kessler, R. M. (2006). Shoulder and Shoulder Girdle. Management of Common
Musculoskeletal Disorders: Physical Therapy Principles and Methods (4th ed., pp. 317-
MASSAGE THERAPY AND THORACIC OUTLET SYNDROME
319). Philadelphia: J.B. Lippincott.
Kisner, C., & Colby, L. A. (2012). Peripheral Nerve Disorders and Management. Therapeutic
Exercise: Foundations and Techniques (6th ed., pp. 395-398). Philadelphia: F.A. Davis.
Lowe, S. (2013). Musculoskeletal Anatomy & Kinesiology Lab 2: Manual Muscle Testing
Magee, D. J. (2008). Shoulder. Orthopedic Physical Assessment (5th ed., pp. 320-323). St. Louis,
Mo.: Saunders Elsevier.
Morphopedics. (n.d.). Thoracic Outlet Syndrome -. Retrieved December 22, 2013, from
http://morphopedics.wikidot.com/thoracic-outlet-syndrome
Rattray, F. S., & Ludwig, L. (2000). Thoracic Outlet Syndrome. Clinical Massage Therapy:
Understanding, Assessing and Treating Over 70 Conditions (pp. 825-840). Toronto: Talus Inc..
"Repetitive Strain Injuries (RSI)." Repetitive Strain Injuries (RSI) Carpal Tunnel Syndrome
Symptoms Treatment COEN Baltimore Neurology Maryland COEN Center for Occupational and
Environmental Neurology. N.p., n.d. Web. 22 Dec. 2013. <http://www.coen1.org/repetitive-
strain-injuries.html>.
TOS - Thoracic Outlet Syndrome. (n.d.). TOS - Thoracic Outlet Syndrome. Retrieved December
22, 2013, from http://www.upright-health.com/thoracic-outlet-syndrome.html
MASSAGE THERAPY AND THORACIC OUTLET SYNDROME
Appendix A: Orthopedic Testing
Verbal analogue of the pain scale – “Zero being no pain and ten being the worst pain you’ve felt” Goniometer – A device used to measure angles; visual of how much movement is at a joint. Table 1.0: Cervical Spine Normal Range of Motion (Magee, 2007)
Flexion 45�-50� Extension 50� Right side bend 40� Left side bend 40� Right rotation 90� Left rotation 90�
MASSAGE THERAPY AND THORACIC OUTLET SYNDROME
Table 2.0: Glenohumeral Joint Normal Range of Motion (Magee, 2007) Flexion 160�-180� Extension 50�-60�
Abduction 170�-180� Adduction 50�-75� Internal Rotation 80�-90� External Rotation 60�-110�
Table 3.0: GH Active Range of Motion First Assessment Range of Motion Right GH Left GH Flexion 165� 7/10 neural 170� Extension 50� 45� Abduction 175� 8/10 neural 170� 8/10 neural Adduction 50� 55� Internal Rotation 85� 7/10 neural 85� External Rotation 80� 7/10 neural 80� 7/10 neural Table 4.0 GH Active Range of Motion Final Assessment Range of Motion Right GH Left GH Flexion 170� 180� Extension 60� 50� Abduction 180� 1/10 neural 180� 1/10 neural Adduction 55� 60� Internal Rotation 85� 85� External Rotation 80� 80� Table 5.0: Cervical Spine Active Range of Motion: * Initial and final assessments were preformed with the use of a Goniometer
MASSAGE THERAPY AND THORACIC OUTLET SYNDROME
Manual Muscle Test
Treatment Flexion Extension Right Side flex
Left Side flex
Right Rotation
Left Rotation
Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post 1 Assessment
45�
50�
35�
38�
2/10 70�
3/10 75�
2/10
2 45�
45�
50�
50�
35�
38�
38�
1/10 38�
1/10 70 �
70�
75�
75�
1/10 3 45�
45�
50�
1/10 50�
1/10 35�
38�
38�
40�
75�
75�
75�
75�
4 45�
45�
50�
50�
35�
38�
38�
38�
75�
1/10 75�
1/10
75�
75�
5 45�
45�
50�
1/10 50�
38�
40�
35�
38�
75�
1/10 78�
78�
80¡
6 45�
45� 50� 50� 38� 40� 35� 38� 80� 80� 75� 77�
7 45� 45� 50� 50� 40� 40� 35� 40� 80� 80� 80� 80� 8 45� 45� 50� 50� 38� 40� 40� 40� 80� 80� 80� 80� 9 45� 45� 50� 50� 40� 40� 40� 40� 80� 80� 80� 80� 10 45� 45� 45� 45� 40� 40� 40� 40� 80� 80� 80� 80� 11 45� 45� 45� 1/10 45�
1/10 38� 38� 40� 40� 80� 80� 80� 80�
12 45� 45� 45� 45� 40� 40� 35� 40� 80� 80� 80� 80� 13 50� 50� 50� 50� 40� 40� 40� 40� 80� 80� 80� 80� 14 50� 50� 50� 50� 40� 40� 40� 40� 80� 85� 80� 85� 15 Assessment
50� 50� 40� 40� 85� 85�
MASSAGE THERAPY AND THORACIC OUTLET SYNDROME
Grade 5 – Normal 100% = range of motion against gravity, max resistance Grade 4 – Good 75% = Complete range of motion against gravity, moderate resistance Grade 3 – Fair 50% = Complete range of motion against gravity Grade 2 – Poor 25% = Complete range of motion, gravity eliminated Grade 1 – Poor trace = slight contraction, no joint movement Grade 0 – Zero = no contraction palpable Table 6.0: First Assessment Muscle Side Grade Pain Sternocleidomastoid Right 4 1/10 Left 4 --- Levator Scapulae Right 5 1/10 Left 5 --- Scalenes Right 5 --- Left 5 --- Pectoralis Major Right 5 --- Left 5 --- Pectoralis Minor Right 5 --- Left 5 --- Triceps Right 5 --- Left 5 --- Biceps Right 5 --- Left 5 --- Upper Trapezius Right 5 --- Left 5 --- Rhomboids Right 4 --- Left 4 ---
Table 7.0: Final Assessment Muscle Side Grade Pain
Sternocleidomastoid Right 5 --- Left 5 --- Levator Scapulae Right 5 --- Left 5 --- Scalenes Right 5 --- Left 5 --- Pectoralis Major Right 5 --- Left 5 --- Pectoralis Minor Right 5 --- Left 5 --- Triceps Right 5 --- Left 5 --- Biceps Right 5 --- Left 5 --- Upper Trapezius Right 5 --- Left 5 --- Rhomboids Right 5 --- Left 5 ---
MASSAGE THERAPY AND THORACIC OUTLET SYNDROME
Table 8.0: Wrights Test Side Test Results First Assessment Right Positive - pulse instantly disappeared Left Positive – pulse instantly disappeared Final Assessment Right Negative – pulse still palpable Left Negative – pulse still palpable Table 9.0: Capillary Refill Test Side Test Results First Assessment Right Positive – 5+ seconds for refill to occur Left Positive – 5+ seconds for refill to occur Final Assessment Right 0.98 seconds for refill Left 1.56 seconds for refill Table 10.0: Costoclavicular Syndrome Test Side Test Results First Assessment Right Positive – pulse instantly disappeared Left Positive – pulse instantly disappeared Final Assessment Right Negative – 1/10 neural in middle finger Left Negative – 1/10 neural in middle finger Table 11.0: Halstead Test Side Test Results First Assessment Right Positive – pulse decreased, 7/10 Left Positive – pulse decreased, 7/10 Final Assessment Right Negative Left Negative Table 12.0: Roo’s Test Side Test Results First Assessment Right Positive Left Positive, fatigued faster Final Assessment Right Positive, less symptoms, equal fatigue, same color
in hands Left Positive, less symptoms, equal fatigue, same color
in hands.
MASSAGE THERAPY AND THORACIC OUTLET SYNDROME
Table 13.0: Median Nerve Upper Limb Tension Test Side Test Results
Pre Treatment Post Treatment
First Assessment Right Positive into fingers/hand
Left Positive into fingers/hand
Treatment 8 Right Positive, symptoms decreased
Positive, symptoms decreased
Left Positive, symptoms decreased
Positive, symptoms decreased
Treatment 9 Right Positive into elbow only
Positive into elbow
Left Positive into wrist and elbow
Positive into wrist and elbow
Treatment 10 Right Positive into palm Positive into palm Left Positive into
elbow and fingers Positive into elbow and fingers
Treatment 12 Right Positive into elbow
Positive into elbow
Left Positive into elbow
Positive into elbow
Treatment 13 Right Positive into elbow
Positive into elbow
Left Positive into elbow
Positive into elbow
Final Assessment Right Positive into elbow
Left Positive into elbow
Table 14.0: Radial Nerve Upper Limb Tension Test Treatment Side Test Results
Pre Treatment Post Treatment
First Assessment Right Positive Left Positive Treatment 8 Right Positive, symptoms
decreased Positive, symptoms decreased
Left Positive, symptoms decreased
Positive, symptoms decreased
Treatment 9 Right
Positive into forearm extensors
Positive into forearm extensors
Left Positive into forearm Positive into forearm
MASSAGE THERAPY AND THORACIC OUTLET SYNDROME
extensors extensors Treatment 10 Right Positive into extensors Positive into forearm
extensors Left Positive into extensors Positive into forearm
extensors Treatment 12 Right Positive into extensors Positive into forearm
extensors Left Positive into extensors Positive into forearm
extensors Treatment 13 Right Positive into extensors Positive into forearm
extensors Left Positive into extensors Positive into forearm
extensors Final Assessment Right Positive into extensors Left Positive into extensors Table 15.0: Ulnar Upper Limb Tension Test Treatment Side Test Results:
Pre treatment Post Treatment
First Assessment Right Positive Left Positive Treatment 8 Right Positive Decreased symptoms Left Positive Decreased symptoms Treatment 9 Right Positive, decreased
since last treatment Decreased symptoms
Left Positive, decreased since last treatment
Decreased symptoms
Treatment 10 Right Positive, minimal Negative Left Positive, minimal Negative Treatment 12 Right Negative Negative Left Negative Negative Treatment 13 Right Negative Negative Left Negative Negative Final Assessment Right Negative Left Negative Table 16.0: Phalens Test Side Test Results First Assessment Right Negative Left Negative Final Assessment Right Negative Left Negative Table 17.0: Reverse Phalens Test
MASSAGE THERAPY AND THORACIC OUTLET SYNDROME
Side Test Results First Assessment Right Negative Left Negative Final Assessment Right Negative Left Negative Table 18.0: Tinells Test Side Test Results First Assessment Right Negative Left Negative Final Assessment Right Negative Left Negative Table 19.0: Allen’s Test Treatment number Side Result
Pre Treatment Post Treatment
First Assessment Right Positive Left Positive Treatment 3 Right Positive Positive Left Positive Positive Treatment 4 Right Positive Positive Left Positive Positive Treatment 5 Right Positive Positive Left Positive Positive Treatment 6 Right Positive Positive Left Positive Positive Treatment 7 Right Positive Positive Left Positive Positive Treatment 9 Right Positive Positive Left Positive Positive Treatment 10 Right Positive Positive Left Positive Positive Treatment 11 Right Positive Negative Left Positive Positive Treatment 12 Right Positive Positive Left Negative Negative Treatment 13 Right Positive Negative Left Negative Negative Treatment 14 Right Negative Negative Left Negative Negative Final Assessment Right Negative Left Negative Table 20.0: Adson’s Test
MASSAGE THERAPY AND THORACIC OUTLET SYNDROME
Treatment Number Side Result Pre Treatment
Post Treatment
First Assessment Right Positive – pulse disappeared Left Positive – pulse decreased Treatment 3 Right Positive Positive Left Positive Positive Treatment 4 Right Positive – pulse
decreased Negative
Left Positive – pulse disappeared
Positive – pulse disappeared
Treatment 5 Right Negative Negative Left Negative Negative Treatment 6 Right Negative Negative Left Negative Negative Final Assessment Right Negative Left Negative
Appendix B: Initial and Final Pictures
MASSAGE THERAPY AND THORACIC OUTLET SYNDROME
Figure 2: Initial Anterior View
Figure 1: Final Anterior View
Figure 3: Initial Posterior View Figure 4: Final Posterior View
MASSAGE THERAPY AND THORACIC OUTLET SYNDROME
27
Appendix C: Treatment
Figure 6: Initial Assessment Right View
Figure 5: Final Assessment Right View
Figure 8: Initial Assessment Left View
Figure 7: Final Assessment Left View
MASSAGE THERAPY AND THORACIC OUTLET SYNDROME
28
Table 21.0: Treatment breakdown Treatment Areas Worked Techniques Used
1 Assessment Only 2
September 13th, 2013 Sub occipitals Scalenes SCM Pectoralis Minor and Major Subclavius
Sub occipital release C/S ROM Scalene release Fascial traction Reshaping Cervical diaphragm Subclavius grab Muscle squeeze to SCM Pincher Grip to SCM Trigger point release GSM
3 September 16th, 2013
Suboccipitals Scalenes SCM Pectoralis Minor and Major Subclavius
Subocciptal release C/S ROM Scalene release Fascial traction Reshaping Cervical diaphragm Subclavius grab Muscle squeeze to SCM Pincher Grip to SCM Trigger point release GSM
4 September 19th, 2013
Suboccipitals Scalenes Pectoralis Minor and Major Biceps Deltoids
Subocciptal release C/S and GH ROM Scalene release Fascial traction Reshaping Bear claw Cervical diaphragm Arm pull Trigger point release Scalene stretch MFR sheering GSM
5th September 24th, 2013
Suboccipitals Scalenes Biceps Deltoids Forearm Extensors Forearm Flexors
Subocciptal release C/S and GH ROM Scalene release MFR: Cross hands Sheering Wrist traction Isolytic release to forearm
MASSAGE THERAPY AND THORACIC OUTLET SYNDROME
29
extensors GSM
6th September 26th, 2013
Suboccipitals Scalenes Forearm Extensors Forearm Flexors Diaphragm
Subocciptal release C/S and GH ROM Scalene release MFR: cross hands Shearing Skin rolling to forearms Diaphragm release (to diaphragm Wrist traction Isolytic release to forearm flexors GSM
7th October 1st, 2013
Suboccipitals Scalenes Forearm Extensors Forearm Flexors Diaphragm
Subocciptal release C/S and GH ROM MFR: Cross hands Sheering Skin rolling to forearms Diaphragm release Wrist traction Isolytic release to forearm flexors GSM
8th October 3rd, 2013
Suboccipitals Scalenes Forearm Extensors Forearm Flexors Pectoralis Minor and Major Diaphragm
Subocciptal release C/S and GH ROM Scalene release Arm pull MFR: cross hands Sheering Skin rolling to forearms Diaphragm release Wrist traction Isolytic release to forearm flexors GSM
9th October 8th, 2013
Suboccipitals Scalenes Forearm Extensors Forearm Flexors
Subocciptal release C/S and GH ROM Scalene release MFR: cross hands Shearing Skin rolling Diaphragm release Wrist traction Isolytic release to forearm
MASSAGE THERAPY AND THORACIC OUTLET SYNDROME
30
flexors, extensors and Scalenes Contract relax to Scalenes GSM
10th October 10th, 2013
Suboccipitals Scalenes Forearm Extensors Forearm Flexors Diaphragm
Subocciptal release C/S and GH ROM Arm pull MFR: cross hands Shearing Skin rolling V stroking Diaphragm release Wrist traction Isolytic release to forearm flexors, extensors and Scalenes Contract relax to Scalenes GSM
11th October 15th, 2013
Suboccipitals Scalenes Forearm Extensors Forearm Flexors Diaphragm
Subocciptal release C/S and GH ROM MFR: cross hands Shearing Skin rolling V stroking Diaphragm release Wrist traction Isolytic release to forearm flexors, extensors and Scalenes Contract relax to Scalenes GSM
12th
October 23rd, 2013 Suboccipitals Scalenes Forearm Extensors Forearm Flexors Deltoids Biceps Pectoralis minor and major
Subocciptal release C/S and GH ROM Arm pull Skin rolling V stroking Wrist traction Isolytic release to forearm flexors, extensors and Scalenes Contract relax to Scalenes GSM
13th October 31st, 2013
Suboccipitals Scalenes Forearm Extensors Forearm Flexors
Subocciptal release C/S and GH ROM Fascial traction Reshaping
MASSAGE THERAPY AND THORACIC OUTLET SYNDROME
31
Deltoids Biceps Pectoralis minor and major
Arm pull Wrist traction Isolytic release to forearm flexors, extensors and Scalenes Contract relax to Scalenes Scalene stretch GSM
14th November 6th, 2013
Suboccipitals Scalenes Forearm Extensors Forearm Flexors Deltoids Biceps Pectoralis minor and major
Subocciptal release C/S and GH ROM Fascial traction Reshaping Arm pull Wrist traction Isolytic release to forearm flexors, extensors and Scalenes Contract relax to Scalenes Scalene stretch GSM
15 November 7th, 2013
Assessment Only
MASSAGE THERAPY AND THORACIC OUTLET SYNDROME
32
Appendix D: Anatomy Pictures
Retrieved from: http://morphopedics.wikidot.com/thoracic-outlet-syndrome
Figure 10. Brachial plexus anatomy Retrieved from: http://www.upright-health.com/thoracic-outlet-syndrome.html
Retrieved from: http://www.coen1.org/repetitive-strain-injuries.html
Figure 9. Postural abnormalities in relation to TOS
Figure 11. Brachial plexus compression areas