Treatment of Cervicobrachialgia by myofascial therapy PDF

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Summary

The current clinic shows that more and more patients come to health services suffering from pain in the spine, especially in the cervical region...

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Treatment of Cervicobrachialgia by myofascial therapy: on the subject of a case The current clinic shows that more and more patients come to health services suffering from pain in the spine, especially in the cervical region.1 Definition: Pain in the spine, more specifically in the first 7 vertebrae (cervical) is called cervicalgia. Neck pain is defined as pain in the cervical region and is perceived as an unpleasant sensory and emotional experience associated with significant tissue involvement, sometimes accompanied by distant referred pain to the upper limb, head or even vertigo. In neck pain, pain appears in the posterior and posterolateral parts of the neck, which may or may not irradiate the adjacent areas and segments. Prevalence: Despite the prevalence of low back pain as the most frequent problem in the spine, neck pain is also frequently seen in primary care and by other professionals who treat musculoskeletal problems therapeutically. In the United States, the prevalence of cervical pain of nontraumatic origin is 10% .2 This represents an important percentage that needs to be studied and treated. The one-year prevalence of neck pain has been estimated to range from 16.775.1%. Recently, Fernández-de-las-Peñas et al found a prevalence of 19.5% in one year in population 3

1

It occurs more frequently at working ages and less frequently in the Nordic countries due to the continuous use of scarves.4 In recent decades, the incidence of biomechanical or postural phenomena has increased as triggers of the syndrome, and it becomes in a major occupational health problem. More and more people find that their work is related to automated systems, such as the use of computers, and this type of work has a negative impact on the health of the cervical segment. In studies carried out on academic and university personnel, the prevalence reaches 46.7% .5-8 The prevalence throughout life can reach 71%, thus indicating that approximately two-thirds of the population will experience neck pain at some point in time. his life.3 Etiology: The origin of this pain is essentially bone, joint and / or muscular, affecting the perirachidian region, the most frequent etiology being degenerative processes. Although we can also find neck pain of an anxiogenic psychosomatic type.9 For this reason, most cervical pain has its origin in mechanical factors: repetitive movements, absence of pauses in work, static loads and postures maintained with the head and / or arms. Cervical pain can be caused by brachialgia or trigger neuralgia that reproduce in adjacent areas, receiving the name of cervicobrachialgia.10 Cervicobrachialgia: 

Definition:

Cervicobrachialgias have their most frequent origin in compression of a nerve root of the lower cervical spine at the level of the radicular emergence, which may be accompanied by motor, sensory and / or osteotendinous reflex disorders in the territory of the compressed root.11 It is the pain originating in the cervical region that in turn radiates to the upper limb through the segment corresponding to the affected nerve root. The roots most frequently affected are C7 first followed by C6.12 

Etiology of cervicobrachialgia:

Cervicobrachyalgia occurs as a cause of nerve root irritation as a cause of cervical disc herniation, degenerative spinal disorders, inflammation, tumors (neurinoma, pancoast tumor), narrow spinal canal, post-traumatic cervicobrachialgia

(accidents), entrapment of the nerves or vessels that pass through the scalene muscles and clavicle. Other possible causes are neuromuscular diseases, long thoracic nerve injuries causing winged scapula with consequent anterior flexion of the shoulder, accessory spinal nerve palsy, clavicle osteochondromas, glenohumeral instability, herpes zoster infections.13 

Brachial plexus:

The location of this disease occurs in a small area of the neck, but it is full of nerves and blood vessels, surrounded by muscles and bone structures that have undergone major and vital changes in the course of evolution and embryology, therefore it is essential to know the anatomy of the brachial plexus since it is involved in sensory and motor innervation of the upper limb except for a

part

adjacent

to

the

shoulder whose innervation depends on the cervical plexus and the inner part of the arm that depends on the intercostal nerves. What will help us to understand the clinic of the disease which is exposed in the

The brachial plexus extends from the neck to the armpit and is formed by: the upper primary trunk formed by the union of the anterior branches of C5 and C6, then we have the middle primary trunk formed by the anterior branch of C7 and finally the Lower primary trunk formed by the anterior branches of C8 and T1. The posterior and anterior branches of each primary trunk. The secondary trunk or external cord, formed by the anterior branches of the upper and middle primary trunks. The secondary trunk or external cord, formed by the

anterior branch of the lower primary trunk and finally the secondary trunk or posterior cord formed by the union of the posterior branches of the three trunks. We also find the origin of the suprascapular nerve (upper trunk), external pectoral, musculocutaneous and external cutaneous brachial (external or lateral cord), lateral pectoral, internal cutaneous and ulnar brachial (medial cord), median (lateral and medial cords), subscapularis, thoraco-dorsal, radial and circumflex (posterior cord) .14 

Treatment:

Treatment aims to reduce pain and improve the functional capacity of the patient. The conservative:  Physical measures: rest for 2 to 3 weeks, local heat, exercises when the pain begins to subside, rehabilitation.  Anti-inflammatories: any type of non-steroidal anti-inflammatory such as naproxen, diclofenac, ibuprofen. It is recommended to reduce the dose of these in the second week of treatment.  Analgesics.  Muscle relaxants.  Corticosteroids for severe cases or those that do not respond to NSAIDs or in hyperalgic phases.  Selective nerve blocks or epidural injections for severe pain.15 Surgical treatment: In the event that analgesics or corticosteroids fail to control the pain, the possibility of surgical treatment will be considered depending on the pathology. Another treatment used is radiofrequency, which in a patient with radicular neck pain is effective since it acts by blocking the conduction pathways of pain signals. In addition to osteopathy and neurodynamics. The objective of physiotherapy treatment through these tools is to improve neural mobility and circulation at the level of the peripheral nerve vasanervorum in order to reduce the patient's symptoms.16 It is worth mentioning other tools such as electrotherapy, heat magnetotherapy infrared, active exercises, spinal traction and low-power laser.17 The treatment of this study will be based on the use of myofascial induction, so it is also important to know about the fascial system in our body, which is

made up of connective tissue, which surrounds, organizes, separates, joins and supports organs, vessels, nerves, ligaments, tendons, muscles and bones. 2.2.

The fascia:

The fascia is organized in three dimensions, being continuous and providing the tension component to the different structures of the human body. Due to this spatial conformation, any information (visual, somatosensory, auditory) that modifies its balance will have a global impact.18 There are 12 different types of fasciae or connective tissues in the body, each having different concentrations of collagen, elastin and building block.19 And collagen provides support, shape, and stability while elastin provides flexibility. twenty The presence of smooth muscle cells within the fascia, together with the presence of myelinated or unmyelinated sensory and motor nerve fibers and capillaries, has led to the hypothesis that the fascia is an actively adapting organ with importance. functional rather than just a passive structural organ.21 The fascia can contribute by assisting in support, protection, cellular respiration, elimination, metabolism, and fluid and lymphatic flow.22 As a result, physiological and mechanical trauma to the fascia at the cellular level can have an effect in posture, cellular health, and the immune system.23 There is an important physiological interaction between the fascia and the extracellular matrix on one side, and various cells of the body on the other. "Without the oscillatory activity of the parenchymal matrix and cells, [cellular] metabolism is atrophied or absent.22 Starting with the fascia, we will try to re-educate posture, cellular health and the immune system. The treatment will be carried out using myofascial induction techniques. Myofascial induction techniques, using sustained pressure and very gentle stretching, aim to eliminate the restrictions that the fascial system may present and balance the altered body function. The mechanical stimulation applied by means of this type of technique supposedly allows to reorient the collagen fibers, thus improving the quality of movement, in addition to favoring lymphatic drainage and fluid circulation. There are very few published clinical trials on the effects of treatment with myofascial techniques, and their reliability is very low due in part to the poor quality of the research. 24

Barnes25 emphasizes the intention of practicing sustained pressure and traction on the fascial restraint for a minimum of 3-5 minutes to facilitate the piezoelectric effect for the crystal matrix of the fascia. The ground substance in a fascial restriction becomes more solid and less fluid, the piezoelectric effect is stifled, and the flow of energy is impeded. Electrical impulses are generated in collagen by compressive and distraction forces in the musculoskeletal system. These impulses activate a cascade of cellular, biomechanical, neural and extracellular events as the body's adaptation to external stress. In response to internal stress, the components of the extracellular fluid change in polarity and charge, affecting fascial movement. Stimulation of the gel ground substance of the fascia requires this sustained pressure over time in order to effect "fusion" of the colloidal part of the tissue and to stimulate a piezoelectric flow of electrons through the tissue, for thus maximizing the flow of "energy" to the tissue over a longer period of time. Furthermore, with the softening of the extracellular matrix and the release of the fascial restriction, the pressure on the pain-sensitive tissue is relieved and the tissues rehydrate allowing the conduction of photon flux and vibration.26 However, Schleip27 suggests that fascial plasticity may be due to the self-regulating qualities of the patient's nervous system. In this study, I am going to develop a clinical case in a patient with cervicobrachialgia due to my interest in the approach to this pathology through myofascial therapy and the growing need for alternatives to other treatments in this disease. 2.3.

Goals:

The objectives of this study are to evaluate the effect of myofascial therapy in a patient with cervicobrachialgia, improving mobility of the upper limb and shoulder, as well as relieving pain, and obtaining a recovery of altered body function thanks to the restoration of body balance, eliminating painful symptoms. The circulation of antibodies is also improved, increasing the blood supply to the restriction areas through the release of histamine, a correct orientation in the production of fibroblasts, a greater blood supply to the nervous tissue, thus accelerating the healing process.

3.

Methodology:

In this work we have developed a clinical case on a patient diagnosed with cervicobrachialgia. The period of follow-up and intervention of the clinical case has been between February 19, 2014 and April 26, 2014. The study was carried out in accordance with the ethical criteria defined in the Declaration of Helsinki (modified in 2008) on the development of national legislation for research projects and clinical trials (Law 223/2004 of February 6) and confidentiality of the subjects study (Law 15/1999 of December 13). Prior to the start of our study, the patient was asked for the corresponding informed consent (Annex I and II), being informed that he can abandon the study whenever he deems it appropriate. The inclusion criteria of our clinical case were: -

Being diagnosed with cervicobrachialgia.

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Radiating pain in upper limb.

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Limited mobility of the joint complex of the shoulder, elbow or wrist.

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Limitation in your activities of daily living.

The exclusion criteria considered were: -

Being a carrier of a benign condition that presents with cervicobrachyalgia (spondylolisthesis, ankylopoietic spondylitis, fractures), non-benign (tumors) or severe compression of the nerve root, demonstrated by advanced studies or very evident clinically, decompensated mental diseases, history of severe trauma.

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Having received physiotherapeutic treatment prior to two months for another cervical condition.

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Spasmodic torticollis.

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Rheumatic inflammatory diseases.

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Pregnancy.

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Cervical inflammatory processes.

The measurement variables determined were the following:

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Visual Analogue Scale (VAS) 29: this scale allows to measure the intensity of pain described by the patient with maximum reproducibility among the observer / s. It consists of a horizontal line of 10 centimeters, at the ends of which are the extreme expressions of a symptom. On the left is located the 0 that represents the absence of pain and on the right the 10 that represents the maximum pain imaginable by the patient. This will mark on the line the point that indicates the intensity of your pain at the time of the evaluation. (Annex 3)

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TAMPA Kinesiophobia Scale30 (Tampa Scale for Kinesiophobia - TSK): assesses the patient's phobia or fear of performing movements. (Annex 4)

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The Cervical Disability Index or Neck Disability Index31 (NDI): assesses the disability caused by neck pain. (Annex 5)

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Range of motion:range of motion was measured with a goniometer in degrees. The goniometric examination was performed on the neck, shoulder and elbow.

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Muscular strength: the result of the muscle balance was recorded as a numerical score, using the Daniels scale, using variables between (0), which indicates absence of activity, and (5), which corresponds to a “normal” response, the best possible response or the highest assessable response through muscle balance.

PUNCTUATIO N NUMERIC 5

4

3 2 1

0

QUALITATIVE SCORE NORMAL (N) Perform the movement in full range, overcoming gravity and external resistance without symptoms of fatigue. GOOD (B) Complete movement against gravity and external resistance, sometimes appearing fatigue. ACCEPTABLE (A) Only the force of gravity overcomes. DEFICIENT (D) Full motor effect in the absence of the resistance of gravity. VESTIGE (V) There is no motor effect, although there is perfectible contraction, manually or visually. NULL (N) Absence of activity.

4. Clinical Case Assessment 4.1.

Anamnesis:

The patient manifested loss of mobility in the left arm, edema and loss of functionality in the ADLs, as well as pain in the forearm and biceps brachii area, headaches, neck pain and shoulder joint, without associated injury. 4.2.

History of signs and symptoms:

Headaches and neck pain for months, arm pain and loss of mobility, for about 5 or 6 months. Pain treated with non-steroidal anti-inflammatory drugs, muscle relaxants, etc. The headaches were strong but in the last two years they have stopped, at the time of the assessment he reported a decrease in the intensity of the pain but when he moved it (when walking) it hurt again. 4.3.

Pain history:

Pain in the biceps and forearm (epicondyle area), at the time of the assessment was punctual but two weeks before, it radiated from the occiput to the fingers (with a higher incidence in 4th and 5th finger).

4.4.

Background:

30 years ago I worked in a hairdresser and laundry. At the age of 10-12 he had a broken arm (it is not known exactly at what level: awaiting X-ray). After being immobilized for a long

time, he reported hurting himself, but did not visit the doctor, and soon after he noticed the loss of flexion of the forearm. In addition, it has been subjected to

two surgical interventions: right side inguinal hernia and caesarean section. The patient, along with cervical spine rectification, presented scoliosis. Optional diagnosis of the patient:

4.5.

In the optional report, the presence of cervical pain radiating to the left upper limb accompanied by paresthesia was cited, observing a rectification of the cervical spine on the radiograph. After the diagnosis, a Nuclear Magnetic Resonance was performed, in which this rectification of the cervical physiological curvature was observed, the reduction of the cervical discs, indicative of a change in dehydration and a discrete posterior central intervertebral disc protusion C5-C6 that contacts and it displaces the dural sac without contacting the nerve root. The elbow X-ray performed on the patient revealed a degenerative process in both the humerus-radial and humerus-ulnar joints. On the first day after the anamnesis, the patient was assessed at inspection: The patient presented evident protrusion of the head, due to a cervical rectification, which generates greater wear in the area c5-c6-c7, so she presented blockage in this area. Mobility was assessed with a Quick Scan and hypomobility was found in the C5-C6 segments, in addition to high hyperkyphosis, which also indicates hypomobility of the previously named region specifically in the c5-c6 right joint facets. The Jackson test was performed to analyze if there was irritation of the nerve root, obtaining a negative result so that said irritation was not present. The patient was in a sitting position and the physiotherapist was standing behind the patient. With one hand he stabilized the shoulder and the other hand on the top of the patient's head. The maneuver was to rotate, extend and tilt the neck. If symptoms were aroused, especially on the ipsilateral side with irradiation of the arm, they confirm the lesion and the level. In the case of the patient, it was not positive. Assessment of the brachial plexus as it passes through the different gorges: 

Adson's test: it was used to demonstrate the integrity of the subclavian artery and the brachial plexus as it passed through the gorge formed by the anterior scalene, middle scalene and first rib. The test was positive since a decrease in pulse was recorded

radial without reaching its disappearance. Being positive, it showed us the existence of a spasm of the anterior scalene and middle scalene muscle that compresses the subclavian artery as it passes through the scalene gorge. 

Eden test: it was used to evaluate the integrity of the subclavian artery, the subclavian vein and the brachial plexus in the gorge formed by the clavicle and the first rib. During this test, the radial pulse was evaluated, which was decreased, confirming a positive Eden test. When the test is positive, it shows us the existence of a decrease in the space of the costoclavicular gorge that compresses the neurovascular bundle. (It is probably compressed by an anterior rotation injury of the clavicle or superiority injury of the first rib).



Wright's test: it was used to evaluate the su...