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 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?

- Where specifically the arm pain is (to narrow down whether the pain is referred and
radicular and at what level this is originating)
- Any aggravating or relieving positions (e.g. Side sleeping, posture at work)
- How long her days are at work/how many clients she sees (identifying position and
possible fatigue – overuse injuries)(it is a progressive injury)
- Is there any weakness – loss of dexterity, inability or difficulty using the scissors at work
- Has she received any previous treatment (has it worked etc.)
- Out of 10 how much pain is it
- Any medications or accidents and trauma

2. For the above case history alone, what are your differential diagnoses for:
a. Her arm pain?
• Thoracic outlet syndrome (compression of the neurovascular bundle)
• Intervertebral disc
i. Facet syndrome
ii. IVF encroachment
• Peripheral nerve root entrapment (carpal tunnel)
b. Her bowel complaints?
• Stress related
• Diet
• Irritable bowl syndrome

3. Do you think all the tests performed in the physical examination above were necessary?
Explain your answer.
- Orthopedic tests would be required prior to any imaging (ALARA)

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.
- Thoracic outlet syndrome
5. Using only the information in the case history and physical examination, give a clinical
impression.
- Thoracic outlet syndrome causing compression of the median nerve

6. What is the prognosis for this patient?

- Requires adjusting and releasing of the compression of the neurovascular bundle

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

- Adjusting
- Stretching and releasing surround musculoskeletal tissue (soft tissue)
- Change in working positions (postural)
- Change in sleeping position (mattresses etc.)

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?
- Yes the cervical ribs are most likely the cause of her issues (effecting nerves)

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

Rust sign TN
Cervical Axial Compression TP
Cervical distraction test TN
Cervical sidebend TP
Compression test
Cervical Rotation TP
Compression test
Cervical Maximal TP
Compression test
Shoulder Depression test TP
Shoulder abduction test TN
(Bakody’s)
Valsalva test TP
Lhermitte’s sign TN
Brachial plexus tension test TP
Cervicogenic dizziness TN
Allen’s test TP
Wright’s test TP
(hyperabduction)
Adson’s test TP
Halstead test (reverse TP
adson’s)
Costoclavicular test TP
Provocation elevation test.

QUESTIONS
1. Describe TOS. What is it?
a. Compression of the neurovascular bundle (brachial plexus and surrounding blood
flow)
b. Group of disorders that caused by compression of the vessels and or nerves around
brachial plexus
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

3. What structures/tissues are involved in TOS?

 a. brachial plexus and surrounding blood flow

4. What are the typical signs and symptoms of TOS?

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
• 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
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

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

Activities that involve overhead word, back packs, pitching, swimming, pregnancy, tight clothes

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

One happens with an illness causing it and another happened without an illness occurring

7. What are the 2 suspected mechanisms of TOS? Describe how each of these
‘mechanisms can lead to symptoms?
Poor postures = drooping shoulders or holding forward head position causing compression of
thoracic outlet area.

Anatomical changes = congenital (extra rib) or abnormally tight fibrous tissue connecting spine to
rib

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

Offer myofascial treatment to loosen surrounding tissue, management/rehab plans to change
activities that may exacerbate symptoms as well as give manipulation of fixed structures to
improve biomechanics

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

Median nerve C6-T1

10. What are the causes of Brachial Neuritis?

Usually caused damage/injury to the brachial plexus it can also happen unexpectedly on its own

11. How is Brachial Neuritis generally managed?

Acute brachial neuritis can 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.
 Study Guide Questions: 4.4

1. Which of the following is NOT typically a symptom for cerebellar disease?

a. Weakness
b. Ataxia
c. Diplopia
d. Atrophy

2. What type of sensation is carried in the lateral spinothalamic tract?

a. Light touch
b. Vibration
c. Pain
d. Position

3. What is stereognosis?
a. Inability to alternate hand movements
b. Inability to hear out of both ears equally
c. Ability to recognise familiar objects placed in one’s hand
d. Inability to identify symbols drawn on the skin

4. Explain the clinical significance of signs elicited when testing for meningeal
irritation.

a. Nuchal rigidity (inability to flex the neck forward due to rigidity of the neck
muscles)
b. +ve Kernig’s and Brudzinski’s signs. (Orthopaedic tests) – causes
irritation of motor nerve roots passing through inflamed meninges