Do you wake up in the middle of the night with pins and needles or pain in one or both of your hands? This is a common experience for many. Physiotherapists can assist you getting the restful, pain free sleep you desire.
Numbness, pins and needles, or a burning, prickling sensation (also referred to as paresthesia) are symptoms of sustained pressure on a nerve and usually disappears when that pressure is relieved.1 Most people have experienced temporary pins and needles when they have sat on their foot for too long or fallen asleep with their head resting on their arm. The symptoms can also occur when there is a narrowing of the space through which a nerve or blood vessel travels, causing pressure on the structure.1 Some examples of this include carpal tunnel syndrome (pressure on the median nerve as it passes across the wrist), arthritic changes in the neck (creating pressure on the nerves where they exit the spine) and thoracic outlet syndrome (pressure on the bundle of nerves traveling into the arm from the spine).
The remainder of this article will discuss the causes, diagnosis, and physiotherapy treatment of thoracic outlet syndrome (TOS) specifically.
The thoracic outlet refers to the space created between the first rib, collar bone, and a group of muscles crossing the front of the shoulder. The blood vessels and nerves that supply the arm must pass through the outlet and under or through the muscles before they enter the arm. (See Diagram #1) At any point in this journey, pressure can be placed on the vessels or nerves causing the sensation of pins and needles or pain. Holding the arm overhead, sleeping with an arm under the head or extreme rotation or bending of the neck can narrow the outlet and cause pressure on the structures. TOS is characterized by pain, paresthesia, weakness, and discomfort in the upper limb.1 It is reported that approximately 8% of the population will experience a form of TOS.2
Diagram #1
TOS is classified as vascular (vTOS) or neurological (nTOS) depending on whether the blood vessels (artery or vein) or nerves are compressed. nTOS can be further divided into true neurological TOS which happens when a bone or muscle compresses the nerve, or symptomatic (sTOS) when sleeping positions, work postures or activities, or sporting activities create temporary compression of the structures involved.2 Evidence identifies that over 90% of TOS cases are neurological with the majority of those classified as sTOS in nature.2,3
It is very important that the true cause of the symptoms be identified to determine the best treatment plan. As noted earlier, there are several causes for pins/needles or pain and numbness in the hand or arm. Each of these must be ruled out as each will be addressed differently to successfully reduce or eliminate the symptoms. There is no one test or investigation that will consistently diagnose TOS, so the diagnosis is based on a collection of symptoms.1 To obtain a clear picture of the source of the problem, a thorough exam must be completed and may include:1
Physiotherapists are well trained to complete these assessments and design a treatment plan. They also have the skills and knowledge to identify situations where a referral to a medical doctor may be appropriate. Conservative treatment, including physiotherapy, is the universally accepted first step in treatment for TOS.2,3,4 Surgery may be indicated when conservative treatment is unsuccessful,2,3,4 and may be the first option in the presence of vascular TOS due to the presence of a structural abnormality such as a cervical rib; however, the success and appropriateness of surgical intervention is controversial.
Based on the assessment findings, a physiotherapist will design a rehabilitation program that focuses on reducing symptoms and correcting muscle or postural imbalances and misalignments.
Many individuals experiencing TOS have had symptoms for a long period of time and require assistance to understand TOS, become aware of what aggravates or relieves their symptoms, and strategies to reduce these symptoms allowing them to manage or prevent issues in the future.3 An individualized rehabilitation plan may include:3
If you are experiencing frequent episodes of pins/needles, numbness, and/or pain in your arm, hand, obtaining a physiotherapy assessment is a great place to start your journey to manage your symptoms.
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