CASE STUDY 4 CHIR13009

CASE STUDY AND QUESTIONS: To be completed by the 9th August

Week 4: Case 4: Amber
Amber is a 36 year old hairdresser

Presenting Complaint
2 year history of intermittent right arm pain. Over the last 3 months it has progressed
in severity and had become bilateral.

History of Presenting Complaint

The pain would occasionally awaken her at night and was associated with
numbness, tingling and paranesthesia’s. She did not report any color changes,
hyperhidrosis, swelling or trauma. She also denied other symptoms such as joint
pain, dry eyes, dry mouth, alopecia, photophobia.
Her past medical history was negative as was her family history.
System review elicited a chronic problem with constipation, with occasional diarrhea.
This was occasionally associated with low abdominal pain, which improved with
defecation or passing flatus. These symptoms have been present for many years.

Physical Examination
Amber is a well-built woman. Her vital signs were normal and there was no rash.
There was full range of motion of all of her joints, without any swelling, redness, or
warmth. Her lungs were clear, her cardiovascular and neurological examination
were normal (including cranial nerves). Abdominal examination was unremarkable.
Laboratory studies including complete blood cell count, erythrocyte sedimentation
rate and urinalysis were all normal. A chest x-ray and cervical spine films were also
normal. An EMG and nerve conduction velocity testing were normal.

Questions for Case 4

1. What other further pertinent questions should you ask this patient?

- What side of the arm is the pain felt (medial/lateral aspect)

- How many hours per day does she work and does she tend to work in a specific
position?
- Is there anything that relieves the pain or aggravates the pain?
- Is there any weakness or difficulty utilizing the scissors whilst cutting hair?
- Is there a high level of stress associated with the job?
- Have you seen other practitioners in the past in regard to pain?
- On a scale of 1 – 10 how painful is the pain?
CASE STUDY 4 CHIR13009

2. For the above case history alone, what are your differential diagnoses for:
a. Her arm pain?

- Intervertebral disc disease

- Thoracic outlet syndrome
- Carpal tunnel syndrome: numbness, tingling and pain in your thumb and the first
three fingers of your hand
1. Pain and burning that travels up your arm
2. Wrist pain and night that interferes with sleep
3. Weakness in the muscles of the hand

- Peripheral artery disease (PAD, also called peripheral vascular disease, or PVD,
which is a narrowing of arteries due to a buildup of fat cholesterol on the artery walls,
which limits blood flow to the extremities)

b. Her bowel complaints?

- Symptoms of irritable bowel syndrome: include abdominal pain related to or relieved

by having a bowel movement (defecation), change in stool frequency (such as
constipation or diarrhea) or consistency (loose or lumpy and
hard), abdominal expansion (distention), mucus in the stool, and the sensation of
incomplete emptying after defecation. The pain may come in bouts of continuous
dull aching or cramps, usually over the lower abdomen.

3. Do you think all the tests performed in the physical examination above were
necessary? Explain your answer.

- IBS DDx Yes – abdominal exam - physical examination generally does not reveal
anything unusual except sometimes tenderness over the large intestine. Doctors do
a digital rectal examination, in which a gloved finger is inserted in the person's
rectum. Women undergo a pelvic examination
- Doctors usually do more tests, such as ultrasonography  of the abdomen, x-rays of
the intestines, or a colonoscopy, in older people and in people who have symptoms
that are unusual for IBS, such as fever, bloody stools, weight loss, and vomiting.
Doctors may do a test to rule out lactose intolerance  or bacterial overgrowth and
also ask questions to rule out laxative abuse.
Tests rule out cardiovascular and neurological conditions including cranial nerves

4. Using the information in the case history and physical examination, what is the
more likely diagnosis from the list of differential diagnoses mentioned in question
2.

- Carpal tunnel syndrome with IBS

5. Using only the information in the case history and physical examination, give a
clinical impression.

- Amber a 36 year old hairdresser with a history of 2 years of intermittent pain in the
right arm that has recently progressed in severity to be bilateral. The pain would
occasionally awaken her at night and was associated with numbness, tingling and
paranesthesia’s. A working diagnosis of carpal tunnel syndrome is likely in this case.
- Her past medical history was negative as was her family history although a system
CASE STUDY 4 CHIR13009

review elicited a chronic problem with constipation, with occasional diarrhea. This
was occasionally associated with low abdominal pain, which improved with
defecation or passing flatus. These symptoms have been present for many years and
is consistent with a working diagnosis of Irritable Bowel Disease
- A cardiovascular, neurological and orthopedic examination was unremarkable.
Laboratory studies including complete blood cell count, erythrocyte sedimentation
rate and urinalysis were all normal. A chest x-ray and cervical spine films were also
normal. An EMG and nerve conduction velocity testing were normal.
- There maybe occupational stress as a hairdresser but no history of any medical
conditions complicating factors were found.

6. What is the prognosis for this patient?

- Prognosis is good based on cardiovascular, neurological and orthopedic examination

found to be unremarkable. Laboratory studies including complete blood cell count,
erythrocyte sedimentation rate and urinalysis were all normal. A chest x-ray and
cervical spine films were also normal. An EMG and nerve conduction velocity testing
were normal.

7. Discuss how you would manage/treat this patient.

- STM mobilizations, postural rehabilitation exercises eg wall angles

- Chiropractic adjustments and stretches
- Address sleeping posture and ergonomics

8. An x-ray of Amber showed a cervical rib? Do you think this is the cause of
Amber’s symptoms? Do you think a cervical rib would have any impact Amber’s
management plan?

-
 CASE STUDY 4 CHIR13009

http://learningradiology.com/notes/chestnotes/cervicalrib.htm

NAME OF TEST For the likely diagnosis in Case 4 indicate the likely outcome
for the following tests. Indicate whether it is likely to be a
true positive, false positive, true negative, false negative
 CASE STUDY 4 CHIR13009

Rust sign Na Instability

Cervical Axial Yes Disc
Compression
Cervical distraction Yes Facet Capsulitis
test
Cervical sidebend Yes IVF Compression
Compression test
Cervical Rotation Yes IVF (C6 – T1)
Compression test

Cervical Maximal Yes IVF

Compression test
Shoulder Depression Yes TP arm pain radiculopathy
test
Shoulder abduction Yes TP C6 radiculopathy
test (Bakody’s)
Valsalva test Yes disc
LLermittes sign Na
Brachial plexus tension Na
test
Cervicogenic Na
dizzyness
Allen’s test Yes vascular testing
Wright’s test TOS
(hyperabduction)
Adson’s test TOS
Halstead test (reverse TOS
adson’s)
Costoclavicular test TOS
Provocation elevation TOS
test.

QUESTIONS
1. Describe TOS. What is it?
CASE STUDY 4 CHIR13009

Thoracic outlet syndrome is a group of disorders that occur when blood vessels or
nerves in the space between your collarbone and your first rib (thoracic outlet) are
compressed. This can cause pain in your shoulders and neck and numbness in your
fingers

There are a number of types of thoracic outlet syndrome, including:

- Neurogenic (neurological) thoracic outlet syndrome. This most common type of

thoracic outlet syndrome is characterized by compression of the brachial plexus. The
brachial plexus is a network of nerves that come from your spinal cord and control
muscle movements and sensation in your shoulder, arm and hand.

- Vascular thoracic outlet syndrome. This type of thoracic outlet syndrome occurs

when one or more of the veins (venous thoracic outlet syndrome) or arteries (arterial
thoracic outlet syndrome) under the collarbone (clavicle) are compressed.

- Nonspecific-type thoracic outlet syndrome. This type is also called disputed

thoracic outlet syndrome. Some doctors don't believe it exists, while others say it's a
common disorder. People with nonspecific-type thoracic outlet syndrome have
chronic pain in the area of the thoracic outlet that worsens with activity, but a specific
cause of the pain can't be determined.

2. Complete an illness script for TOS.

Thoracic outlet syndrome symptoms can vary, depending on which structures are
compressed. When nerves are compressed, signs and symptoms of neurological
thoracic outlet syndrome include:

 Muscle wasting in the fleshy base of your thumb (Gilliatt-Sumner hand)

 Numbness or tingling in your arm or fingers

 Pain or aches in your neck, shoulder or hand

 Weakening grip

Signs and symptoms of vascular thoracic outlet syndrome can include:

 Discoloration of your hand (bluish color)

 Arm pain and swelling, possibly due to blood clots

 Blood clot in veins or arteries in the upper area of your body

CASE STUDY 4 CHIR13009

 Lack of color (pallor) in one or more of your fingers or your entire hand

 Weak or no pulse in the affected arm

 Cold fingers, hands or arms

 Arm fatigue with activity

 Numbness or tingling in your fingers

 Weakness of arm or neck

 Throbbing lump near your collarbone

3. What structures/tissues are involved in TOS?

Brachial plexus C5- T1

Nerve to subclavius
Lower subscapular nerve
Thoracodorsal nerve
Upper subscapular nerve
Median pectoral nerve
Medial branch cutaneous(sensory)
Medial antebrachial cutaneous (sensory)
4. What are the typical signs and symptoms of TOS?

- Depends upon if they are either neurogenic or vascular in origin

- Neurological thoracic outlet syndrome includes:
 Muscle wasting in the fleshy base of your thumb (Gilliat-Sumner hand)
 Numbness or tingling in your arm or fingers
 Pain or aches in your neck, shoulder or hand
 Weakening grip
- Vascular thoracic outlet syndrome can include:
 Discoloration of your hand (bluish colour)
 Arm pain and swelling, possibly due to blood clots
 Blood clot in veins or arteries in the upper area of your body
 Lack of colour (pallor) in one or more of your fingers or your entire hand
 Weak or no pulse in the affected arm
 Cold fingers, hands or arms
 Arm fatigue with activity
 Numbness or tingling in your fingers
 Weakness of arm or neck
 Throbbing lump near your collarbone

5. What type of ‘sports’ or ‘activities’ predispose to TOS?

CASE STUDY 4 CHIR13009

- Working overhead, compression from heavy clothing, back packs, repetitive

movements like pitching, swimming, pregnancy

6. What is the difference between Raynaud’s syndrome and Raynaud’s

phenomenon?

- Primary Raynaud's (or Raynaud's disease) happens without any other illness behind

it. ... Secondary Raynaud's (Raynaud's syndrome, Raynaud's phenomenon) happens
as a result of another illness. It's often a condition that attacks your body's connective
tissues, like lupus or rheumatoid arthritis.

7. What are the 2 suspected mechanisms of TOS? Describe how each of these
‘mechanisms’ can lead to symptoms?

- Anatomical defects. Inherited defects that are present at birth (congenital) may

include an extra rib located above the first rib (cervical rib) or an abnormally tight
fibrous band connecting your spine to your rib.

- Poor posture. Drooping your shoulders or holding your head in a forward position can
cause compression in the thoracic outlet area.

8. How would you manage TOS (as a chiropractor)?

- Thoracic outlet syndrome that goes untreated for years can cause permanent
neurological damage, so it's important to have your symptoms evaluated and treated
early or take steps to prevent the disorder.
- If you're susceptible to thoracic outlet compression, avoid repetitive movements and
lifting heavy objects. If you're overweight, you can prevent or relieve symptoms
associated with thoracic outlet syndrome by losing weight.
- Even if you don't have symptoms of thoracic outlet syndrome, avoid carrying heavy
bags over your shoulder, because this can increase pressure on the thoracic outlet.
Stretch daily and perform exercises that keep your shoulder muscles strong.
- Daily stretches focusing on the chest, neck and shoulders can help improve shoulder
muscle strength and prevent thoracic outlet syndrome.
- Chiropractic can offer manipulation of fixated joint structures to improve cervical
biomechanics and improve posture, reducing load on joints and improving
proprioception.

9. What peripheral nerve distribution is most common in TOS?+

CASE STUDY 4 CHIR13009

- Median nerve C6-T1

10. What are the causes of Brachial Neuritis?

Brachial neuritis is also referred to as brachial neuropathy or a brachial plexus injury. When
acute brachial neuritis occurs, the damage to the brachial nerves comes on suddenly and
unexpectedly, without being related to any other injury or physical condition. This is also
called Parsonage-Turner syndrome or neuralgic amyotrophy.

Brachial neuritis affects mainly the lower nerves of the brachial plexus, in the arm and hand.
The brachial plexus is a bundle of nerves that travels from the spinal cord to the chest,
shoulder, arms, and hands. It usually affects just one side of the body, but it can involve
other nerves and other parts of the body, as well. Here is a brief overview of the different
types of brachial plexus injuries:

- Acute brachial neuritis. This type of brachial neuritis occurs unexpectedly on its own.
It is characterized by sharp, severe pain in the nerves of the brachial plexus, followed
by weakness or numbness. The cause of acute brachial neuritis is unknown.
- Brachial plexus injury. Some people have pain and loss of function to the brachial
plexus as the result of another type of injury. For example, babies can injure the
brachial plexus when they pass through the birth canal during labour.
- In brachial neuritis, pain, loss of function, and other damage occurs in the brachial
plexus, the bundle of nerves that travels from the spinal cord to the chest, shoulder,
arms, and hands.
- The cause of brachial neuritis is unknown. In some instances, the symptoms of
brachial neuritis seem to be related to another illness or injury. At other times,
however, the pain and weakness associated with the disease occur without any
explanation. 

11. How is Brachial Neuritis generally managed?

- In some cases, acute brachial neuritis will resolve on its own over time. Your
healthcare provider may give you corticosteroids for the pain in the meantime. If the
brachial neuritis is the result of an injury and surgery can be done in a timely fashion,
then surgery might be used to repair the nerves of the brachial plexus region.