Introduction

Definition of notalgia paresthetica (NP)

Notalgia Paresthetica (NP) is a nerve-related disorder that causes an itchy, burning, or tingling sensation in a small area close to the shoulder blade on the upper back. This term derives from the Greek words “notos,” which means back, and algos, meaning pain, thus reflecting its presentation as back pain syndrome. Although sometimes there isn’t a visible rash, it may feel like your skin is irritated due to nerve compression.¹ 

Causes and contributing factors 

This neuropathy is often associated with compression of nerves or inflammation in the back muscles or spine. It may also be caused by poor posture, degenerative changes in the spine, or musculoskeletal factors like spasm or tightness. NP causes compression of nerves is mainly due to entrapment of the nerve of the dorsal rami of thoracic spinal nerves, typically between T2 and T6. Additionally, muscular factors like tightness or spasm in the paraspinal muscles may contribute to NP.² These musculoskeletal problems may exacerbate nerve irritation or compression, magnifying the symptoms linked with NP.

Besides, poor posture, particularly prolonged periods of forward head posture, can be a contributing factor to developing NP. Understanding these factors is critical for the efficient treatment and management of NP. Treatment interventions often focus on spinal health, correcting posture, and muscle balance to prevent symptoms and improve quality of life.³

Role of physical therapy in managing NP

Physical therapy plays a crucial role in the management of NP as it treats the underlying musculoskeletal issues that may be causing nerve irritation. Muscle tightness, postural imbalance, and spinal misalignment can worsen the compression of thoracic nerves, which are often associated with NP. 

Thus, physiotherapy relieves nerve entrapment and minimises symptoms like persistent itching and discomfort by improving posture, promoting spinal mobility, and easing muscle tension. Moreover, physical therapy offers a sustainable, non-invasive treatment approach to managing symptoms, especially when pharmaceutical treatment provides limited relief.⁴

Pathophysiology and clinical presentation

Anatomical background 

Notalgia paresthetica primarily includes the posterior rami of the thoracic spinal nerves, often located between T2 and T6. The upper back’s skin is innervated by these nerves. Hence, chronic irritation, compression due to degenerative changes, or musculoskeletal conditions lead to neuropathic symptoms and altered sensory input.

Symptoms 

The symptoms of NP are pain, tingling, and numbness, and are mostly unilateral, which means they typically affect only one side of the back. The symptoms appear on the medial side or inferior part of the shoulder blade, known as the scapula, on the upper or middle back. The symptomatic area may be linked with a hyperpigmented patch, most likely secondary to chronic rubbing and scratching to relieve the discomfort. The symptoms may usually last for years, and the course of the disease is characterised by phases where they improve and then flare up again.  

Differential diagnosis 

NP can occasionally be mistaken for other disorders, as it produces persistent discomfort and itching in the upper back. Other potential conditions like eczema, spinal nerve problems, and allergic skin reactions must be ruled out.⁷ Therefore, a comprehensive medical history, skin examination, and sometimes imaging tests like MRI are important to carry out differential diagnosis. 

Assessment in physical therapy

A thorough physiotherapy assessment for NP begins with posture analysis, as incorrect posture is a major contributing factor to NP. Nerve compression or muscle tightness brought about by poor spinal alignment, particularly scapular protraction, forward head posture, or thoracic kyphosis, can exacerbate NP symptoms. The therapist observes how the patient maintains the position of their shoulder and spine both during activity and at rest. After observation, spinal and scapular mobility assessment follows, which examines any restriction in thoracic flexion, extension, rotation, alongside scapular stabilisation and motion, as these movements can impact nerve pathways and musculoskeletal function in the affected area.⁵

Muscle imbalances are then evaluated to identify which muscles are tight versus weak, especially in the shoulder girdle, upper back, and surrounding areas. For example, weakness in the mid-back stabilisers and tightness in the pectoral muscles can result in altered biomechanics, triggering NP symptoms. Additionally, neurological assessment is equally important and involves testing for reflexes, changes in sensation, or signs of nerve irritation, mainly tingling, numbness, or burning sensations, usually present in NP. This aids in differentiating NP from other neurological or skin conditions. Furthermore, palpation and pain mapping are critical to finding trigger points.

Stretching techniques

Improving mobility and flexibility in the shoulder and thoracic spine region can significantly relieve the symptoms of NP.⁶

Thoracic spine mobility stretches

Thoracic extension over the foam roller

This extension of the thoracic spine over the foam roller aids in restoring the normal curve of the spine, thereby reducing stiffness in the upper back. The individual lies on the foam roller that is placed horizontally under the thoracic spine and gently extends the back over it; this stretch mobilises the spine and decompresses the spinal pathway. 

Cat-cow stretch

The cat-cow stretch is a gentle yoga movement that promotes dynamic spine mobility, enhances spinal circulation, and relieves muscle tension along the vertebral column. It includes lying on all fours on a mat and alternating between spinal flexion and extension. 

Pectoral and anterior shoulder stretching

Doorway stretch

Mostly beneficial for the anterior shoulder and chest, the doorway stretch is effective for opening the pectoral girdle muscles. The person stands in the middle of the doorway with arms extended overhead and resting on the door frame. Above, the person leans forward, thus stretching the pectoral muscles. This helps counteract rounded and stiff shoulders. This stretch is easy and can be easily carried out at home.⁸

Corner stretch

The corner stretch includes standing in the corner of a room with both arms on the wall and gently leaning against the wall, stretching the anterior shoulder muscles and the chest wall. 

Scapular and upper back stretching

Child’s pose with side stretch

The child’s pose with side stretch is a yoga-based movement in which the individual sits back on the heels, extends the arms forward, and then walks the arms sideways. This pose helps to open the upper back and sides, thereby promoting flexibility and reducing stiffness around the scapula.

Strengthening and stabilisation exercises

Postural strengthening

Scapular retractions

To correct the rounded shoulders often seen in individuals with NP, scapular retractions activate the rhomboids and middle trapezius, which helps correct posture and reduce pain. Scapular retraction can be performed by squeezing the shoulder blades together while keeping the shoulders relaxed, improving posture and reducing strain on thoracic nerves.

Wall angels

Wall angels are an effective exercise when it comes to strengthening shoulder mobility and reinforcing proper posture. The person moves their arms up and down while maintaining contact with the wall and standing against it with their arms bent in a “goalpost” position. This aids in activating scapular stabilisers and correcting upper thoracic posture. 

Core and thoracic stability

Bird-dog

The bird dog exercise targets the back stabilisers and core. Both the opposing leg and arm are simultaneously stretched from a hands-and-knees position. By improving trunk control and spinal stability, this movement reduces the compensatory strain on the thoracic spine.

Plank variations

Planks, both the forearm and side planks, help to build deep core stability. Indirectly supporting nerve health and posture. Planks help to strengthen the lumbar and thoracic spine by keeping the spine neutral and engaging the core. 

Shoulder blade and mid-back muscles

Prone I, Y, T exercises

The rhomboids, lower trapezius, and posterior deltoids are targeted by performing these exercises while lying face down and raising the arms into the “I”, “Y”, and “T” positions. They strengthen key scapular muscles involved in nerve decompression and maintain posture. 

Summary

A planned and structured physiotherapy program helps to relieve the symptoms of NP. Stretching and strengthening exercises not only provide symptomatic relief but also help in long-term therapeutic benefits and protect the body from other musculoskeletal ailments. In complex cases, multidisciplinary healthcare teams can be involved for holistic care and complete recovery.