clinical case report competition...myofascial and gsm techniques were preformed each treatment,...

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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.


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


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.


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,


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


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


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


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.


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


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


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,


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


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


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


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-


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


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�


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


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�


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 ---


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.


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


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


Positive into elbow

Final Assessment Right Positive into elbow


Table 14.0: Radial Nerve Upper Limb Tension Test Treatment Side Test Results


First Assessment Right Positive Left Positive Treatment 8 Right Positive, symptoms

decreased Positive, symptoms decreased

Left Positive, symptoms decreased


Treatment 9 Right

Positive into forearm extensors

Positive into forearm extensors

Left Positive into forearm Positive into forearm


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 Treatment 13 Right 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


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


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


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


Figure 2: Initial Anterior View

Figure 1: Final Anterior View

Figure 3: Initial Posterior View Figure 4: Final Posterior View


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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


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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


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


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


30

flexors, extensors and Scalenes Contract relax to Scalenes GSM



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



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


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


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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

clinical case report competition...myofascial and gsm techniques were preformed each treatment,...

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