An interesting client presented to me with complaints of tingling,
numbness and weakness in her left hand. She was experiencing difficulty
using her hands for work as a medical professional. She experienced
particular difficulty when attempting to use common everyday items such as a
knife and fork, cutting food, using a brush to style her hair, or even when
buttoning her clothing. This 49-year-old mother of two teenagers worked full
time in a medical facility. She had no previous treatment for this complaint
diagnosed as carpal tunnel syndrome. Past medical history positive for oral
surgery and herniated discs at L4-5 and L5-S1. Social history positive for
significant stress. She was not taking any medications.
Physical examination revealed significant postural distortion with forward
head, protracted shoulders, internally rotated more on the left , thoracic
kyphosis, excessive lumbar lordosis, anterior pelvic tilt, bilateral hip and
knee flexion and significant wide base of support. She had to stand with her
feet 13 inches apart to avoid losing her balance. Palpation revealed
multiple trigger points, upper trapezeii, levators, pectoralis, rhomboids,
scalenes, SCM, left anterior diaphragm, left iliopsoas, left extensor and
flexor digitorum, opponens pollicis and supinator. Pain scale range 7-9/10
at all TPs with taut bands of fascial restriction and positive jump sign on
palpation. Range of motion was moderately limited in cervical rotation,
lateral flexion, scapular depression and retraction, thoracic extension,
bilateral shoulder elevation, and wrist extension. She had bilateral hip
flexion contractures. Strength was limited in neck flexion, shoulder
elevation, wrist flexion, finger opposition and hand grip. Special tests
were positive for Tinel sign, (carpal tunnel) Adsons maneuver, Roos test,
(thoracic outlet signs) and reduced sensation L median nerve L lateral palm
and digits 1-3. (median nerve: carpal tunnel, thoracic outlet) Slump test
positive for tingling into L posterior leg. Median nerve stretch test
positive. Fascial listening test indicated abnormal fascial tension from L
iliopsoas, diaphragm, anterior scalene and levator, causing her to weight
shift anteriorly to the left, resulting in her balance deficit. Breathing
rate elevated 20 bpm with shallow breathing pattern and excessive accessory
muscle recruitment. (scalenes, sternocleidomastoid, upper traps and levator.)
Jamar handgrip dynamometer showed a deficit of 30 pounds in her L hand.
(©2006 Primal
Pictures Interactive Functional Anatomy, with permission)
Initial therapy focused on the primary fascial restriction
evident in her pelvis, which caused her posture to deviate
forward to the left from the abnormal tension in the hip
flexors, and diaphragm. Myofascial release interventions
included iliopsoas release, transverse plane releases to L
hip, pelvic floor, respiratory diaphragm, and thoracic
outlet, scalene stretching, and neurofascial stretching.
Positive outcomes on initial visit included measurable
improvement in thoracic and hip extension range and
alignment, and relief of tingling in her left hand. TP
sensitivity reduced to range 3-6/10. She was instructed in
home exercise of proper diaphragmatic breathing, and
stretches for her neck and hips. Next visit included cross
hand stretch to hip flexors, scalenes, upper traps,
pectoralis and levators resulting in significant increase in
overhead arm elevation and retraction. Breathing restriction
was addressed with scalene and pectoral release. Arm
distraction circumduction release and neural tension
stretches focused on lengthening median nerve restrictions.
Home program of exercise of putty grip for strengthening L
hand, L arm neural stretching (Butler) techniques, and
postural correction (Tai Chi style) was provided. She was
able to stand with her feet 6 inches apart without losing
balance.
In only two visits, functional outcomes improved with
fascial interventions. Overall breathing pattern improved:
rate decreased to 14 bpm. (normal) She had improved postural
alignment and standing balance, decreased painful TPs,
increased overhead reach, and stronger grip strength. This
patient was quite surprised when her radicular symptoms
changed markedly after just working on her pelvis and L hip,
especially since her primary complaint was tingling and
weakness in the left hand. Didn't she realize all of our
body parts are connected? How many medical professionals
fail to see the importance of postural alignment, fascial
tension, and biotensegrity in the human body? Typically,
insurance may only allow treatment of individual body parts,
such as the hand and wrist in this patient. Without treating
her pelvis, hip and thorax, her abnormal fascial tension
would only bring her back to the forward position, causing
shortening of the left scalene and pectoralis, resulting in
abnormal pressure on her brachial plexus and more neural
tension problems. Traditional physical therapy would focus
only on her hand/wrist, maybe even the forearm. What would
happen if we ignored her shallow rapid breathing pattern?
She would continue to overuse her accessory respiratory
muscles, creating abnormal restriction in her anterolateral
neck and additional pressure on her brachial plexus, with
radicular symptoms down her arm.
What can we learn from this short case report? Is imperative
to look at the whole person and to recognize the
connectivity of the fascia throughout the entire person.
Abnormal positioning, poor breathing habits, and faulty
movement patterns can contribute to development of abnormal
fascial tension in the body, resulting in limitation of
movement, pressure on sensitive nerves or circulatory
elements, pain and functional impairment. It is important to
consider not only the presenting complaint signs and
symptoms, but also to consider the etiology of such
impairment. How much more can we do to serve our clients by
determining where their dysfunction came from in order to
limit additional injury, and to promote a more positive
functional outcome? Our manual interventions can make a huge
difference in the quality of life for our clients. Maximize
your positive outcomes when you see and work with the whole
person, not just a body part.
For information about the fascia, visit
www.fasciacongress.com for the latest research. Dr. Schmidt
provides individual hands-on consultations and live or home
study courses on therapy that makes a measurable difference.
Visit www.educise.com.
Special thanks to Primal Pictures for their anatomy slides:
www.primalpictures.com
Last revised: November 24, 2015
by Theresa A. Schmidt, DPT, MS, PT, OCS, LMT, CEAS, CHy
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