ART Literature Review:
by Everett Johnson, DC, ART
A case report of bilateral hand pain, swelling and numbness in an assembly worker.
A case of early detection of thoracic outlet syndrome is presented in a 46 year old female factory worker. Presenting symptoms were similar to those used as a diagnostic criteria for thoracic outlet syndrome, but were not severe. The patient responded well to treatment of Active Release Techniques soft tissue management system long tract nerve release protocols for the brachial plexus at the coracopectoral tunnel. Thoracic outlet syndrome is considered abnormal compression of the nerves or vascular structures from the base of neck to the axilla (1).
Compression of the structures can result in arm, neck or hand pain that may cause numbness, tingling and feelings of the extremity being swollen. It is reported that prevalence of the condition in the population is approximately 1 percent. One author states that the condition is under reported and often misdiagnosed and mismanaged (2). It is important to understand the clinical presentation of the condition and distinguish it from other conditions of the upper extremity for proper treatment.
A forty-six year old female production worker presented to an ART certified soft-tissue management system provider with a complaint of bilateral pain, swelling and intermittent numbness in her hands. Her discomfort increased when doing overhead activities such as doing her hair and when driving. She experienced the majority of her symptoms at night and awoke every morning for the last week with a swollen feeling in her hands that she claimed to have to shake out and it would feel better after a while. She denies any traumatic events over the last year and her current health status is negative for any contributory conditions such as diabetes, thyroid disease, fibromyalgia, or the use of any medications.
She describes her discomfort at its worst as a 7/10 on visual analog scale (VAS) and rates it a 6/10 on VAS at the time of the session. Motions performed at the wrist by the employee did not increase the feelings of swelling or radiate any discomfort into her hands. She could not actively aggravate the condition with any motions or activities when asked.
Palpation of the structures of the arm revealed adhesions of the neurovascular sleeve at the coracopectoral tunnel bilaterally. The employee verbalized exacerbation of the discomfort she felt in her hands when these areas were palpated.
ART nerve entrapment protocol for the neurovascular sleeve at the coracopectoral tunnel was performed on the employee. The employee was lying on her back and the area of the coracopectoral tunnel was exposed by abducting her arm. The structures were palpated and the location verified when she complained of increase in discomfort. ART nerve entrapment protocol was performed bilaterally, along with the ART protocol for freeing the pectoralis minor muscle bilaterally. The right side felt as though it moved better after a few passes of the protocol, where the left still had some decreased motion of the structures involved. During the session the employee said her hands felt light and cold. Immediately following the session the employee said it felt warm and less swollen.
The employee presented for session two stating that her right hand felt a lot better, with little to no discomfort or feelings of swelling. Her left hand was still experiencing discomfort and some feelings of swelling. She also complains of some slight weakness in her grip for the left hand, which she had not mentioned in the previous visit. The same protocols were performed bilaterally, with the right side appearing to be free from adhesions, and the pectoralis minor felt less tight and restrictive. The ART protocol for the carpal ligaments was added to the session to address the weakness in grip strength in her left hand. After performing the protocol she claimed her hand felt warm and good again. Grip strength felt somewhat better when she squeezed the providers hand after the session, compared to before the session. VAS after the second session was reported as 2/10.
During session three with the employee she states that she has not had much discomfort at all in the last week since the last session and her grip is better. She also says her left hand still has slight feelings of swelling. The session revealed again that the right side was much better, and the left was not moving as well as the right neurovascular sleeve at the pectoralis minor. An increase in relative motion of the sleeve and the pectoralis minor was accomplished during this session. She again reports an2/10 on the VAS after the session.
The employee presented for session four, four weeks after the initial session, reporting no discomfort or feelings of swelling or complaints of decreased grip strength. She says she feels really good. Palpation and application of the protocols reveals the neurovascular sleeve is moving well bilaterally with some slight tightness of the pectoralis minor on the left side. She reports a 1/10 on the VAS after the fourth session.
The ART protocols are based on discomfort patterns that are linked to specific anatomic sites to perform the technique. The specificity of the technique allows for relaxation of the muscle and release of adhesions that occur in the fascia, muscles and nerves. Tension is taken on the site of adhesion with either a thumb or fingers. Active and passive motions of the structures in the area are performed to allow passage of the tissue through the area of tension. Typically the tension is held on the structure for 3 seconds after the end range of motion is reached. The tension created combined with the movement of the structure allows for relaxation of the muscle through a stretch allowing adhesions to release in-between the tissues, thus restoring the relative motion between structures.
The anterior rami emerge from the spine to form the brachial plexus. The plexus exits between the anterior and medial scalene muscles and the first rib. The exit point is triangular in shape and termed the scalene triangle. The characteristics of the triangle, including its height and width, can be modified by anatomic variations in the first rib or anomalous muscles related to the scalenes. The most common causes of disturbance in the scalene triangle are elevation of the first rib, or the presence of a cervical rib and a variant muscle called scalene minimus. All of these contribute to reducing the space the brachial plexus has to pass through the scalene triangle, causing entrapment termed “scalene syndrome” (3,4).
As the plexus extends laterally from the first rib, it must pass under the pectoralis minor and the coracoid process of the scapula. With the arm resting at the side, this point causes little to no compression on the brachial plexus. With the arm in abduction and external rotation however, the brachial plexus is stretched and pulled tight against the coracoid process. The head of the humerus also plays a role in stretching of the brachial plexus at this point. With the arm abducted and externally rotated, the brachial plexus passes around the head of the humerus, causing increased stretch to the nerves.
The patient in this case presented with the early signs of what could have eventually progressed to and been diagnosed as thoracic outlet syndrome had she not sought help during the early stages of the condition. Typical treatment options for thoracic outlet syndrome includes physical therapy to strengthen the muscles of the shoulder, improve range of motion and promote posture. Surgical considerations may be taken if compression of the nerves or vessels is caused by the presence of a cervical rib or traumatic deformity (5, 6).
This report demonstrates the use of Active Release Techniques as an effective method for preventing the progression of arm pain, numbness and swelling into a more severe issue, through early recognition and treatment. More reports of this nature would increase public knowledge and appreciation of this type of care as a method of decreasing medical expenditures and disability from complicated cases. Efficacy of ART concerning the successful treatment of TOS should be evaluated further through randomized control trials in future studies.
2. Cooke R. Thoracic outlet syndrome-aspects of diagnosis in the differential diagnosis of hand-arm vibration syndrome. Occ Med. (2003) 53:331-336
3. Liu J et. al. Shoulder-arm pain from cervical bands and scalene muscle anomalies. Journal of Neurological Sciences. (1995) 128, 175-180.
4. Thomas G et al. The middle scalene muscle and its contribution to the thoracic outlet syndrome. The American Journal of Surgery. (1983) 145 (5) 589-592.
5. Axelrod D. Outcomes after surgery for thoracic outlet syndrome. Journal of Vascular Surgery. (2001) 33 (6) 1220-1225.
6. Rayan G. Thoracic outlet syndrome. J Shoulder Elbow Surg. (1998) 7 (4) 440- 451.