PT on the Net Research

Right Side Numbness


Question:

I have a client who has had surgery on her right shoulder, elbow and wrist including a carpal tunnel release, medial release and thoracic sympathectomy and has lost all feeling down her right arm to her fingertips because she has had her nerves cut. So, her shoulder, elbow and wrist go numb when she holds onto weight or squeezes anything slightly. She obviously has some major muscle imbalances because she has been lifting weight in the past with her left side only and not her right side. I am wondering if there is anything I can do to help improve her upper body strength even slightly or what I can do with her upper body at all to help her situation.

Answer:

Well, you've got a live one here, eh?

First, let me tell you, this is not an easy question to answer because I never make recommendations without first completing a comprehensive evaluation of a patient. There are so many things that could be going on with your client that I could write a book about it! I've had a number of patients like this in the past, so I will share some of the things that may be of benefit to you and your client.

Circulation

You mention that "...her shoulder, elbow and wrist go numb when she holds onto weight or squeezes anything slightly." This leaves me to assume that there isn't numbness when she isn't squeezing anything. When you squeeze something, you blanch the blood out of the working tissues, causing venous return. Upon releasing, there is arterial feed, restoring blood flow to the working tissues. If there are fascial restrictions, fibrous bands around arteries, veins or nerves, muscle spasm in the region of the arteriovascular plexus or lymphatic drainage problems (edema), what you are describing will result. I would recommend that you find a certified Rolfer or Heller worker to assess her fascia. If she still has the problem after seeing either such professional, I would recommend she see an expert in manual lymphatic drainage. There are a group of massage therapists certified in what is called "Dr. Vodder's Manual Lymphatic Drainage." They would be very likely to give your client a real professional treatment that would allow you to assess the contribution of lymphatic drainage to her problem.

Another tip in this regard is to take her into a swimming pool and get her in water up to her jaw line. Have her perform dumbbell exercises in the pool and see if her performance improves, meaning she is potentially going to have better strength, endurance and/or a reduction or elimination of her numbness, aside from what is coming from another source. This simple diagnostic test works because the pressure and stimulation of the skin by the water aids in venous and lymphatic return.

Another common cause of circulatory problems and of numbness in the hands is trigger points, particularly in tissues in the region of C5-T6 or even as low as T7. I recommend you study the book Myofascial Pain and Dysfunction by Travell and Simons. In it, you will see all the referral patterns from trigger points with potential referral to the region of her numbness. In addition, trigger points anywhere in the region of the neck or arm with referral patterns into the arm can cause weakness, circulatory changes, temperature changes and a number of seemingly strange phenomena. Scar tissue often develops very severe trigger points as well, and therefore, you should have a skilled clinical massage therapist check any surgical scars for trigger points. A simple diagnostic test I teach my students is to freeze a wax paper cup of water and then peel off the bottom two thirds of the cup. Use it to ice along the surgical scar by massaging the scar till it goes numb. At that point, test your client to see if her symptoms are better or worse. If they are better, which is not uncommon, it is suggestive of a scar tissue pathology, such as trigger points, or bunching of the scar from less than favorable healing. Again, a good Rolfer, or Heller worker or clinical massage therapist is the person to assist you here.

Mechanical blockages in the lower cervical spine or thoracic segments all the way to as low as T7 should be ruled out. A commonly overlooked problem is first rib dysfunction; it may be elevated, depressed, hypomobile or hypermobile. Any CHEK Level III or IV Practitioner could help you with this issue, as they are taught all the necessary testing procedures to handle a client like this. First rib dysfunctions often create numbness and tingling in the distribution of the first thoracic and eighth cervical nerve (radial distribution), which will encompass the little and part of a large portion of the ring finger, depending on their individual anatomy.

Nerve Entrapment

It is very common to see such symptoms with nerve entrapments. A simple tip: Ask the patient if she can draw around the region of numbness or pain with a skin pencil (eyebrow liner). If she can, this means she has edge and aspect with their dysfunction, suggesting a peripheral entrapment. If not, it suggests that the problem is more likely to be centrally located, most likely along the spinal axis or as I suggested above at the first rib or any of the ribs to as low as T7 (although not likely to be below T5).

Nerve Root Tension

A good physical therapist or CHEK Level III of IV will know how to perform an assessment of nerve root tension. Your client could have a compression or entrapment syndrome in either the radial, median or ulnar nerve. I can't even suggest which because your description of the symptoms is very vague. Sorry.

Cervical Disc Bulge

She may well have an undiagnosed disc bulge in her neck. This is very common, particularly since many therapists and doctors claim not to have time to do full evaluations any more! A simple test you can do is to have her sit in a chair and give her a dumbbell to put in her lap. Stand behind her and with the palms of your hands, grasp her skull and elevate her head as though you were going to lift it off her neck. Use about 20 pounds of lift force and hold it for a good 20 seconds to allow decompression of any neurovascular structure. Then, while holding her head in traction, ask her to do some biceps curls or presses or whatever caused her symptoms before. If there is a noticeable improvement, you may well have an undiagnosed cervical disc bulge or some other compressive pathology in the cervical spine, which is the origin of the brachial plexus.

Some little tips, which I prefer you use AFTER clearing the above issues:

  1. You can get special wrist straps with metal hooks for holding onto things from some weight lifting supply stores. In the past, I've used them with my arthritis patients that had no grip strength and was able to put some good muscle on their arms and shoulders where they were previously lacking. Even the use of a wrist strap alone could do it, but be sure that the strap is not below the distal radius and ulna, as this can cause laxity in the wrist ligaments and problems later on.
  2. You can rig up a sheet or narrow weight belt so that it can be put around the shoulder with the arm through it. Attach it to a cable machine and then your client can do pulling and pushing movements by loading the scapulothoracic joint and not directly loading the arm itself. That at least gets some good circulation to the arm and begins building the scapulothoracic joint musculature while you are doing the other things. You can also do a number of different exercises with a Swiss ball such as the Supine Lateral Ball Roll and the Forward Ball Roll. These can be found by searching the PTN Exercise & Flexibility Library. Resisted crawling will also help build her up without hurting most likely. You will have to test her to be sure.
  3. Swimming is often not painful in such cases, and you can have her use a hand paddle on the involved arm to add load as tolerated. If nothing else, it's some good foundation work.
  4. The below listed books and videos could be very helpful in testing, designing and progressing your client when she is ready.

I could go on and on, but not knowing your level of training or understanding of anatomy, kinesiology and biomechanics, I can't determine the value of my effort to assist you. If nothing else, take this message to her doctor or physical therapist and maybe it will trigger them to do a test or mobilization they may have overlooked.