arm paraesthesia

Hi,
Just wondering if anyone could give me a hand!
I have a 63yr old male patient whos main problem is a paraesthesia of the R arm in the C6 distribution which came on "'overnight"" in Oct 2005 and has not changed since.
It is aggravated by Cx extension and relieved by flexion and he does not have it in neutral.
He has very mildly limited Cx rotation L and R and otherwise full Cx ROM. His Cx PAMs are unremarkable and do not reproduce or change symptoms.
He has no pain or change in strength in the R arm.
I have tried manual techniques to ''open up'' the C6 foramina which have not changed his symptoms. I have also tried Mckenzie techniques involving passive Cx retraction/manual traction combined with extension which he does not have symptoms with throughout the action but it returns immediately on retesting of ext in sitting.
Im stuck and would like your opinion on:
1) is it realistic to change these symptoms with manual techniques?
2) Any techniques you would suggest?
Look forward to hearing any responses I may get!
Thanks alot

From what you have said, I wonder if he may have a posterior osteophyte causing some irritation, in which manula techniques to the C spine may not provide much in the way of long term relief.. I would look at myofascial trigger areas in the region, esp Infraspinatus, which is reported as provoking paresthesia in the arm, and is innervated by C5/6.
Long term management will probably involve a self management programe of postural re-ed and exercise I would have thought, hope this helps

Im thinking a infraspinatus trigger point would perhaps be more of a secondary issue if the paraesthesia was being directly provoked by cervical extension?

Hi
Have you considered the possibility that this may be related to Carpal Tunnel Syndrome? Perhaps further investigation is required.

This might just be me being very stupid but I am a student physio and i thought that if the movement was flexion that was easing the symptoms then you would prescribe repeated flexion exercises (if the pain was being centralised). I know that this is the derangement dysfunction part of the Mckenzie theory and if I am wrong, would someone be able to explain to me why as I am always looking to further my knowledge base.

Cheers

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paraesthesia of the R arm in the C6 distribution which came on "'overnight"" in Oct 2005 and has not changed since.

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Perhaps this suggests some neck involvement in the lower cervical spine, or perhaps slightly more distally into the axilla region. I also never forget possibilities of DVT in the brachial artery as I have in fact had one of these in the past. This however often presents with associated mottling of the skin in the affected arm.

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It is aggravated by Cx extension and relieved by flexion and he does not have it in neutral.

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OK, so you have more now to implicate the neck. Is this extension in sitting or in supine with the weight removed. i.e. is is affected by loaded joint movement or by the movement itself? This may guide more to soft tissue vs. joint approaches to Rx.

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He has very mildly limited Cx rotation L and R and otherwise full Cx ROM.

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OK, but it is the lower cervical vertebrae that reduce end of range movement. Is he protracted in the neck? Does retraction ease his symptoms when provoked? Try retraction in supine with you holding the head to create an unloading effect.

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He has no pain or change in strength in the R arm.

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To have a true nerve root compromise you must be able to show motor and sensory loss. Normal strength suggests less probability of nerve root involvement.

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I have also tried Mckenzie techniques involving passive Cx retraction/manual traction combined with extension which he does not have symptoms with throughout the action but it returns immediately on retesting of ext in sitting.

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Good work. You are onto something here. Weight bearing is an issue, unstable disc perhaps? An MRI probably will be positive as it is in almost everyone at the lower levels. You could try to inhibit the upper fibres of trapezius with taping techniques to assist the retracted position.

If you know any mulligan techniques (NAGS and SNAGS) you could try this in the retracted position, initially in supine and later with the patient actively retracting while you do MWM's etc in sitting. Best of luck and let us know how things get on. 8o

Hi,

I would try neck extension in lying, and ask patient to go further in extension with every movement.
In the end range ask him to do neck rotation (slightly).
If this will make his condition better, then he should do described exercises many times a day.
If is not better then further progression is needed!

Check this, and let us know what happened...

hi<

i think that in order to acheive good treatment we must preform good assesment.

what about compression\ distraction tests?
what about symptoms history (gradual ,sudden.......)?

what about x-ray ?

i think you must do further evaluation in order to reach to optimal treatment.

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I would try neck extension in lying, and ask patient to go further in extension with every movement.

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I would not do this without support of the head and retraction prior to performing the extension.8o

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'I would not do this without support of the head and retraction prior to performing the extension.'

Off course, standard force progression...

Hi all,

if I can just take the topic left of centre for a moment, what are your personal theories behind McKenzie for cervical spine? Studies report the cervical disc has a fibrous nucleus and so the mobile nucleus model proposed for the lumbar spine appears redundant in this area.

Thanks for your thoughts and replies in advance,

Chunkypuffin:D

IT would be good to find another comparable sign apart to the Ext.
More questions are required, what about PAms with extension you coulf pick up the level >
ADD some Mulligan SNAG when you find the level, it may work.\
if you think the level is c6 you could do combined movements start the treatment in flexion and work up to extension -PPIVMS
Neural tension tests +ve?

Another not very common condition, thoracic outlet syndrome.

I
Did you try anterior mobilisation of C/S

I would do postural retraining, manual and or cervical training and try modalities re settling neural irritibility, eg. acupuncture, laser, Tens
Tens is probably best place to start as he could learn to use one at home and manage his symptoms independently.
Xray and or CT/MRI should also be considered to assist your diagnosis. Marj

If extension is limited then carefully address this also.

Just to clear up a few questions...
Xray was NAD and we dont have access to MRI where im working.
The syptoms literally came on ''overnight"" and i have tried supported extensions with retraction in supine to no avail...the quest continues!

OK. Have you got someone how to show you how to do some NAGS or reverse SNAGS (Mulligan Tehcniques)?

Also did you comment on ULTT's (Upper Limb Tension Tests)? As a side issue is this person a smoker and did the xray show any of the upper rib cage (apical segments of the lung)?
8o

HI,
u have a nice patient. He is suffering since 2-3 mths. Have u treated patient symptomatically ? Probably cervial collar i.e. soft will help ur patient becoz neutral position is painfree. Gradually reduce its dependency from patient so that muscle spasm or ligament stretch has time to get heal.

Hi Nadia
What type of principles of treatment are you train on?
Cyriax, Maitland, Nordic techniques etc,
It could help with the adive other can gice.
Good luck.

Is there local pain in the cervical spine in extension or is it just the paraethesia that comes on. are there any positive tension tests eg slump, radial nerve etc.

have u considered scalene anterior syndrome (extension will compress the brachial plexus) this muscle can also cause referred sensations to the arm

why not be wholistic and check the upper thoracics for restrictions too. take a more global approach don't just focus on the c 6 level.

have u addressed other issues like any changes to sleeping postures or pillows

would love to know if this helps

hi., can anybody help me with the principles of maitland,meknzie,cyriax....................
lookin for some responses.....