Jodi L. Young, Joshua A. Cleland, Darren A. Rivett, Mark A. Jones Kelly is a 27-year-old female who was referred to physical therapy with a 3-month history of neck and left upper extremity pain. Her primary symptoms were in the left anterior shoulder, with radiation to the left lateral elbow described as achy and dull, and her neck pain was located on the left side of her cervical spine in the C5–C6 region with radiation into her left midscapular region during active cervical left rotation and side flexion (Fig. 22.1). The shoulder pain had an insidious onset 3 months ago, and the elbow symptoms also appeared insidiously within the last month. Her neck symptoms were originally only noticeable in the morning when Kelly woke up with reported stiffness, which she noted began about 5 months prior, with a recent progression to neck pain over the last few weeks. The neck stiffness subsided after an hour or two of Kelly moving around and doing her activities of daily living (ADLs), so she had paid little attention to her neck symptoms. However, she did note that the stiffness and neck pain, along with the shoulder pain, seemed to be getting worse over the past 3 weeks, and Kelly said that she had not done anything differently in her normal daily routine at work or home to exacerbate her symptoms. The shoulder and elbow pain were most prevalent when Kelly was using her arm, specifically at work and if doing activities such as cooking, cleaning or folding laundry at home. Kelly worked as an office assistant, so most of her 8-hour work day was spent sitting at a desk, typing, answering the phone, or working on the computer. At times she had to file charts, which required her to use her left arm extensively for a short duration of time. Recreationally, Kelly ran 3–4 days a week anywhere from 1 to 5 miles. Running provoked her shoulder and elbow pain after about a mile, but it would quickly subside with 15 minutes of rest. Of note is that Kelly was left-hand dominant. Kelly’s symptoms started with morning stiffness of the neck, as indicated previously, that subsided within 1–2 hours after waking. She indicated that there was originally not much pain in her neck but instead general stiffness, specifically with left cervical rotation and side flexion. The numeric pain rating scale (NPRS) was used to capture Kelly’s level of pain. She was asked to indicate the intensity of current, best and worst levels of pain over the past 24 hours using an 11-point scale ranging from 0 (‘no pain’) to 10 (‘worst pain imaginable’). The NPRS has been shown to exhibit a minimal clinically important difference of 2 points (Cleland et al., 2008b). Because of the recent worsening of her neck symptoms, she said that she was actually now beginning to have pain rated 4/10 on the NPRS when turning her head to the left while driving. Kelly stated that the pain in her left shoulder and elbow varied depending on her activity level. On weekends, when Kelly was not at work, her shoulder and elbow symptoms were much less noticeable (1/10) and only occurred if she was cooking, cleaning or folding laundry for more than an hour. If she did these activities for short periods of time, such as 30 minutes, there were no symptoms. She indicated that the pain level would reach a 4/10 on the NPRS if she performed these activities for more than an hour. If she stopped doing those activities, her pain would subside within 15–20 minutes. Kelly reported her work is what triggered her symptoms the most, and after 2 hours of sitting at her desk performing her normal work duties, her symptoms in the left shoulder and elbow would reach a 6/10 pain level, and her neck had begun to exhibit pain in the last few weeks reaching a 4/10. If Kelly were to stand up, walk around or rest her arm, the symptoms in her shoulder and elbow would decrease to a 2/10 pain level after approximately 15 minutes. Her neck pain would decrease within only a few minutes of getting up and moving around. We discussed an ergonomic assessment, and Kelly had already undergone this assessment through her employer, and changes had been made to her desk setup a month prior, but her symptoms had not changed. Because Kelly was exhibiting both left upper extremity (UE) and neck symptoms, she was asked to complete two functional outcome measures: the Upper Extremity Functional Index (UEFI) and the Neck Disability Index (NDI). For the UEFI, patients are asked to rate the difficulty of performing 20 functional tasks on a Likert-type scale ranging from 0 (extremely difficult or unable to perform activity) to 4 (no difficulty). A total score out of 80 is calculated by summing each score. The answers provide a score between 0 and 80, with lower scores representing more disability. The reliability of the UEFI has been shown to be 0.95, and the minimal clinically important difference (MCID) has been identified at 9 points (Stratford et al., 2001). The NDI is the most widely used condition-specific disability scale for patients with neck pain and consists of 10 items addressing different aspects of function, each scored from 0 to 5, with a maximum score of 50 points. The score is then doubled and interpreted as a percentage of the patient-perceived disability. Higher scores represent increased levels of disability. The NDI has been demonstrated to be a reliable and valid outcome measure for patients with neck pain (Hains et al., 1989; Riddle and Stratford 1998). The NDI has been shown to exhibit an MCID of 19 points (Cleland et al., 2008b). Kelly scored a 46/50 on the UEFI and a 56% on the NDI at the time of the initial visit. Kelly also completed a modified Fear-Avoidance Beliefs Questionnaire to assess for any possible psychosocial involvement related to her symptoms. Kelly’s overall score on the work and physical activity subscales did not indicate that her symptoms were related to a psychosocial component. Kelly noted that she would continue to perform her work duties regardless of the pain level, trying to make modifications like standing up and walking around as often as possible. She also stated that there was no pattern of worsening pain or symptoms throughout the day; it solely depended on her overall activity level at work or home. She woke up approximately three to four times per night with shoulder symptoms if she slept on her left side. However, Kelly stated that this was not much of a problem for her because she would fall asleep within a few minutes if she repositioned herself on her back or right side. Kelly’s past medical history was unremarkable for any significant illness, injury or hospitalizations, and her family history was also unremarkable. She denied any paresthesia in her upper extremities, reported no significant weakness in her upper or lower extremities and had no history of unexplained weight loss. She did not exhibit dizziness, diplopia, dysarthria, dysphagia, drop attacks, nystagmus, nausea or numbness that may be indicative of cervical arterial dysfunction (Sizer et al., 2007). Lastly, she did not report any dexterity loss or clumsiness during gait, ruling out cervical myelopathy (Cook et al., 2009). Kelly had not been taking any medications until most recently when she was prescribed an anti-inflammatory by her physician for her current issue. However, she stated that she stopped taking it after a week because it did not seem to change any of her symptoms and resulted in gastrointestinal irritation. At this point in time, it appeared that Kelly’s symptoms in both her left shoulder and elbow were primarily originating from her shoulder, but because there seemed to be a recent, unexplained increase in neck and shoulder pain, the cervical spine was still considered the primary source of Kelly’s symptoms. Kelly presented with a slight forward head posture, and when cued to improve her posture, she was able to exhibit neutral posture. She noted that she attempted to remind herself at work to maintain good posture but that she often found herself with an increased forward head posture in order to ‘get closer to the computer to see the screen better’. Her thoracic spine was slightly flexed from the cervicothoracic junction to T2. She had a relatively flat thoracic spine from T3 to T6. Active cervical flexion, right side flexion and rotation were all full and pain-free. Overpressure was performed on all full and pain-free movements, with no provocation of symptoms. Active extension, left side flexion and rotation were all stiff and provoked Kelly’s most recent neck pain. Kelly had full cervical extension but noted feeling considerable stiffness and a pain level of 2/10 at end range. With left side flexion and rotation, Kelly experienced similar symptoms, but she was also restricted by approximately 20 degrees for each motion as measured by a bubble inclinometer (side flexion) and a universal goniometer (rotation). A passive quadrant test on the left side provoked Kelly’s neck symptoms, with radiation into her left midscapular region. With left side flexion and rotation, Kelly noted increased anterior shoulder pain that radiated to the lateral elbow, similar to the symptoms that brought her to physical therapy. Kelly’s right shoulder active range of motion and left shoulder extension and external rotation were full and painless, but she did have restricted left shoulder flexion to 140 degrees, left shoulder abduction to 120 degrees and internal rotation of 45 degrees when assessed at 60 degrees of abduction and functional internal rotation as measured with the hand behind the back, where Kelly was able to reach the L4 level. Each of these motions provoked Kelly’s primary shoulder and elbow pain. When Kelly was cued to improve her posture prior to performing range of motion, her active range of motion improved by approximately 5 degrees with shoulder flexion and abduction, but she continued to have shoulder and elbow pain. Passively, Kelly had 155 degrees of left shoulder flexion, 130 degrees of shoulder abduction and 50 degrees of internal rotation when assessed at 60 degrees of abduction. Her right shoulder passive range of motion in all planes was full and painless, as expected, per the results of active range-of-motion assessment. Overpressure was performed on all full and painless active motions bilaterally, with no reproduction of symptoms. When overpressure was performed on left shoulder flexion and abduction after passive range of motion, Kelly reported provocation of her shoulder and elbow pain at end range. Joint mobility was assessed in the cervical spine, thoracic spine, shoulder and elbow. The elbow joint mobility was normal bilaterally, with no provocation of symptoms during left elbow joint mobility assessment. The sternoclavicular and acromioclavicular joints were assessed and determined to have normal mobility bilaterally. With a caudal and posterior glide of the glenohumeral joint on the left from a position of elevation short of pain, Kelly’s primary shoulder and elbow symptoms were provoked. Along with the provocation of symptoms, there was also stiffness with these glides. Central posterior-anterior glides to the cervical spine exhibited stiffness at the C4–C6 region, along with provocation of Kelly’s neck and shoulder symptoms. Unilateral posterior-anterior glides of the cervical spine in the C4–C6 region on the left side again provoked Kelly’s neck and shoulder symptoms. Mobility of the cervicothoracic junction was hypomobile with central posterior-anterior glides, but there was no provocation of Kelly’s primary symptoms. Thoracic spine mobility assessment revealed asymptomatic stiffness, both central and unilateral from T1–T7.
Neck and Upper Extremity Pain in a Female Office Assistant
Where Does the Problem Lie?
History
Physical Examination
Observation
Cervical Range of Motion
Shoulder/Elbow Range of Motion
Joint Mobility
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Neck and Upper Extremity Pain in a Female Office Assistant
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Fig. 22.1 Kelly’s body chart.
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