ENTRAPMENT SYNDROME OF
(NECK, SHOULDER & ELBOW)
Supervisor : Dr dr Karya Triko Biakto Sp.OT (K) Spine
Frontera WR (2015) Essentials of Physical Medicine and Rehabilitation : Musculoskeletal Disorders, Pain Rehabilitation. Elseviers Saunders Publication, Third
Edition
Passias PG (2016) Cervical Myelopathy. Jaypee Brothers Medical Publishers,
Anatomy
• The neck is made up by the
cervical part of the
vertebrae.
Thompson J (2010) Netter’s Concise Orthopaedic Anatomy. Elsevier’s Saunders Publication, Second Edition ISBN: 978-1-4160-5987-5 Pp 60
• Spinal canal
diameter :
normal 17 mm,
(<13mm
considered as
spinal stenosis)
Frontera WR (2015) Essentials of Physical Medicine and Rehabilitation : Musculoskeletal Disorders, Pain Rehabilitation. Elseviers Saunders
Publication, Third Edition
• A complex system of ligaments serves to stabilise and
protect the cervical spine.
Thompson J (2010) Netter’s Concise Orthopaedic Anatomy. Elsevier’s Saunders Publication, Second Edition
• Intervertebral discs are located between the vertebral
bodies of C2-C7 which serve flexibility and absorption or
distribution of load throughout the spine.
Passias PG (2016) Cervical Myelopathy. Jaypee Brothers Medical Publishers, First Edition
Etiologies
Passias PG (2016) Cervical Myelopathy. Jaypee Brothers Medical Publishers, First Edition
Frontera WR (2015) Essentials of Physical Medicine and Rehabilitation : Musculoskeletal Disorders, Pain Rehabilitation. Elseviers Saunders Publication, Third Edition
Pathophysiology
Cervical myelopathy
Ligamentum flavum
hypertrophy
Pathophysiology
Cervical radiculopathy
Mechanical Chemical irritation
decompresion (nucleus pulposus)
(compression,traction)
Intraneural inflammation
(ischemia,edema,fibrosis,demylisation)
Functional changes
Thompson J (2010) Netter’s Concise Orthopaedic Anatomy. Elsevier’s Saunders Publication, Second Edition
Anamnesis
Cervical myelopathy Cervical radiculopathy
• Chief complaint : Clumsiness in • Chief complaint: sharp pain radiating
the hands / gait abnormality to the dermatom that are affected
• may present with insidious onset of
• Onset : subtle and slowly progress neck pain that is worse with vertebral
over a period of years motion
• Disturbance at the • unilateral arm pain radiating down
arm
• upper extremities myelopathic • Suprascapular pain (C5-C6)
hands, difficulties in handwriting,
buttoning shirts and grasping or • Infrascapular pain (C7)
manipulating small objects • Scapular (C8)
• Lower extremities ( wide based, • unilateral dermatomal numbness &
jerky gaits and history of falls) tingling
• numbness/tingling in thumb (C6)
• Bowel and bladder dysfunction • numbness/tingling in middle finger
(advance stage) (C7)
• History of medical, surgical, social • unilateral weakness
and family background • difficulty with overhead activities (C7)
• difficulty with grip strength (C7)
Physical examination
• General examination :
• Inspection (myelopathic hand,
muscle atrophy); Palpation
(Tenderness, pain); Percussion;
Auscultation
• Motoric of head
• ROM : Flexion, extension, side
bending and rotation Myelopathy Hand
“Wasting of the intrinsic muscle
• Limitations of extension and spastifity of the hand”
(painful) indicates stenosis or
root compression
Motoric examination for • Pathological Reflex
upper extremities
• Muscle strength
• Physiological reflex
• Tromner reflex
Hoffman reflex
Unilateral motoric disturbance
• Muscle strength • Tendon reflex
• C5 radiculopathy • C5 radiculopathy
• deltoid and biceps weakness • diminished biceps reflex
• C6 radiculopathy • C6 radiculopathy
• brachioradialis and wrist extension • diminished brachioradialis reflex
weakness
• C7 radiculopathy
• C7 radiculopathy • diminished triceps reflex
• triceps and wrist flexion weakness
• C8 radiculopathy
• weakness to distal phalanx flexion of
middle and index finger (difficulty
with fine motor function)
• Sensoric of the upper extremities
• Decreased touch, temperature and pain sensation
Myelopathy: bilateral (diffuse non dermatomal)
Radiculopathy : unilateral arm pain based on the dermatom
Frontera WR (2015) Essentials of Physical Medicine and Rehabilitation : Musculoskeletal Disorders, Pain Rehabilitation. Elseviers Saunders Publication, Third
Edition
Motoric and sensoric of Cervical roots
Special Test
Cervical Myelopathy Cervical Radiculopathy
• Lhermitte Sign test: extreme • Spurling Test
cervical flexion leads to electric • extension, rotation to affected side,
shock-like sensations that radiate lateral bend, and vertical
down the spine and into the compression
extremities • Pain and paresthesias at the
ipsilateral arm
Frontera WR (2015) Essentials of Physical Medicine and Rehabilitation : Musculoskeletal Disorders, Pain Rehabilitation. Elseviers Saunders Publication, Third
Edition
Motoric and sensoric of Lumbosacral roots
Gait and balance
• Romberg test
• Balancing difficulty present if lesion affect the dorsal column
Diagnostic studies
• Imaging
• Plain radiographs :
disk space
narrowing, end plate
sclerosis,
osteophytes,
decreased disc
height
• Myelography : useful test in cervical radiculopathy before the advent of MRI. May
visualise compression but does not provide information about extradural process
Boos N, et all (2008) Spinal Disorder. Springer-Verlag Berlin Heidelberg New York,
• Bone Scan
• limited to spondylolysis, infection, and metastatic or
primary spinal tumors.
• Non Operative
Thompson J (2010) Netter’s Concise Orthopaedic Anatomy. Elsevier’s Saunders Publication, Second Edition
Complication
• Cervical myelopathy :
• Post operation : pseudoarthrosis, restenosis, spinal instability, post-op
radiculopathy and axial pain.
• Severe disability
• Neurogenic bladder.
• Cervical radiculopathy
• Progressive neurological weakness, residual neck or radicular pain, chronic
pain syndrome, disability and myelopathy (rare)
Entrapment syndrome
of the shoulder
Anatomy Neurovascular of Shoulder
scapular ligament.
What is the “Unhappy or Terrible Triad” in
regard to the shoulder?
A shoulder dislocation along with rotator cuff tear and peripheral nerve injury.
Dislocations should be considered as a clinical spectrum that includes
1) Isolated dislocations,
3) Combined injuries.
DO NOT GET CONFUSED ENTRAPMENT OF NERVE WITH ROTATOR CUFF PROBLEM!!
A) Suprascapular Nerve Compression
The suprascapular nerve courses from nerve roots C5 and C6 and runs
• Weakness of shoulder
• weakness of supraspinatus
• weakness of infraspinatus
• Stop any type of activity which might stress the suprascapular nerve;
introduced.
plexus (C8 and T1) and subclavian vessels between the clavicle and
neurovascular structures in the area just above the first rib and behind
extending from the shoulder, down the ulnar aspect of the arm and
into the medial two fingers. Symptoms tend to be worse at night and
a) inspection
note specific postures, can increase loading on the brachial plexus, rounded shoulders, increased
thoracic kyphosis, downward rotation or depression of the scapula
At skin we may see cyanosis, congestion, pallor, distal ulcerations, signs of microembolic events
(rare), muscle atrophy.
b) palpation
over the supraclavicular area , may reveal tenderness and/or masses and skin temperature.
TOS Special test.
In Adson’s test the patient’s neck is extended and turned towards the
inter scalene space and may cause paraesthesia and obliteration of the
radial pulse.
TOS Special test (cont)
In Wright’s test the arms are abducted and externally rotated; again the
their head and then open and close the fingers rapidly; this may cause
Unfortunately, these tests are neither sensitive nor specific enough to clinch the diagnosis.
What diagnostic tests are helpful in diagnosing TOS?
the shoulder girdle muscles, postural training and instruction in work practices and
ways of preventing shoulder droop and muscle fatigue. Analgesics may be needed
for pain.
when a person frequently bends the elbows (such as when pulling, reaching, or lifting),
Journal Reading
Update on Diagnosis and
Management of
Rheumatoid Arthritis
Supervisor : Dr dr Karya Triko Biakto Sp.OT (K) Spine
• Percentage method:
This method lowers dosage by a relatively stable decrement of 10 to 20 percent, while
accommodating convenience and individual patient response.
- 5 to 10 mg every one to two weeks from an initial dose above 40 mg of prednisone per
day.
- For example, a patient taking 55 mg’s of prednisone per day would lower dosage to 45
mg or 50 mg depending on the individual patients’ profile. The patient would then stay
on that dose for one to two weeks based on their response to the lower amount.
- 5 mg every one to two weeks at prednisone doses between 40 and 20 mg per day.
- 2.5 mg every two to three weeks at prednisone doses between 20 and 10 mg per day.
- 1 mg every two to four weeks at prednisone doses between 10 and 5 mg per day.
- 0.5 mg every two to four weeks at prednisone doses from 5 mg per day and lower. This
can be achieved by alternating daily dose, eg, 5 mg day one, 4 mg day two.
Glucocorticoids
- Week 1. Alternate total daily dosage by 2.5 mg hydrocortisone. For example; Day 1- 65
mg, Day2-62.5, Day 3-65, Day 4-62.5 Day 5-65, Day 6-62.5 Day 7-65.
- Week 2. Stay on the lower dose. Using the hydrocortisone example above, the patient
would stay on 62.5 mg’s for one week to give the body time to adjust.
- Week 3. Return to alternating daily by 2.5 mg as in week one. Using the example above,
the patient would start week three by taking 62.5 mg, and alternate with a 60 mg dose.
- Week 4. Stay on the lower dose to give patients’ body time to adjust. In the example
above patient would stay on 60 mg’s for the entire week.
- A patient taking prednisone would use decrements of 1 or 2 mg on the alternate day
method. For example, a patient taking 25 mg prednisone per day would lower dosage to
24 or 23 mg on alternate days during week one. The patient would remain on the lower
amount during week two.
DMARDs
Relapse
• In the RRR study and the HONOR study, cut-off points for a successful discontinuation of TNF
inhibitors were a baseline DAS28 value of 2.22 and 1.98, respectively, suggesting that ‘deep’
remission may be required to keep the biological-free remission and that residual
inflammation in patients in DAS28 remission could be associated with a higher likelihood to
flare.
• In the HONOR study, another baseline factor affecting adalimumab-free remission was
disease duration, indicating that patients with early RA have better chance to stop TNF
inhibitors.
• Preliminary analyses in the POET study and earlier data from van der Woude et al also
suggest that longer disease duration is associated with higher relapse riskwhile other studies
did not find such association.
• In accordance, observations from the CORRONA registry suggest that rapid response to
DMARDs is associated with better maintenance of remission when the agents are tapered
later on.
Relapse (cont…)
• In the RETRO study, ACPA status clearly indicated higher relapse risk
with lower chances to maintain remission when ACPAs are present.
• Data from other studies, like BeSt and HIT-HARD (High induction
therapy with anti-rheumatic drugs), as well as preliminary data from
the POET study support this concept.
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