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Thoracic Outlet Syndrome

Definition

Thoracic Outlet Syndrome (TOS) is pain, numbness, tingling, and/or weakness in the arm and hand due to pressure against the nerves or blood vessels that supply the arm. It is due to tight muscles, ligaments, bands, or bony abnormalities in the thoracic outlet area of the body, which lies just behind the collar bone. Pressure on the nerves is the problem more than 95% of the time, but occasionally the artery or vein is involved.

Common Symptoms

The most frequent complaints are numbness and tingling in the fingers; pain in the neck, shoulder, and arm; headaches in the back of the head; weakness of the arm and dropping things from the hand; worsening of the symptoms when elevating the arm to do such things as comb or blow dry one's hair or drive a car, and coldness and color changes in the hand. The symptoms are often worse at night or when using the arm for work or other activities.

 

Cause

TOS is most often produced by hyperextension neck injuries. Auto accidents that cause whiplash injuries, and repetitive stress in the workplace, are the two most common causes. Some of the occupations that we see causing TOS include, working on assembly lines, keyboards, or 10-key pads, as well as filing or stocking shelves overhead. In some people, symptoms develop spontaneously, without an obvious cause. An extra rib in the neck occurs in less than 1% of the population. People born with this rib, called a cervical rib, are 10 times more likely to develop symptoms of TOS than other people. However, even in people with cervical ribs, it usually requires some type of neck injury to bring on the symptoms.

Diagnosis

Physical examination and history are most helpful. Common findings are tenderness over the scalene muscles, located about one inch to the side of the wind pipe; pressure on this spot causes pain or tingling down the arm; rotating or tilting the head to one side causes pain in the opposite shoulder or arm; and elevating the arms in the "stick-em-up" position reproduces the symptoms of pain, numbness, and tingling in the arm and hand. There is often reduced sensation to very light touch in the involved hand (this can only be detected in people with involvement on one side). Diagnostic tests, such as EMG's or NCV's, may show non-specific abnormalities, but in most people with TOS, these tests are normal. Neck or chest x-rays may show a cervical rib. Loss of the pulse at the wrist when elevating the arm or when turning the neck to the side (Adson's sign), has been thought by some to be an important diagnostic sign. However, we find it unreliable because many normal people also lose their pulse in the same positions, and the majority of people with TOS do not lose their pulse in these positions. Shrinkage of hand muscles (atrophy) occurs in about 1% of people with TOS, and these people will have nerve tests that show a typical pattern of ulnar nerve damage.

Disease Process

Microscopic examination of scalene muscles from the necks of people with TOS demonstrates scar tissue throughout the muscle. Presumably, this was caused by a neck injury stretching these muscle fibers. The tight muscles then press against the nerves to the arm (brachial plexus) producing the hand and arm symptoms. Neck pain and headaches in the back of the head are caused by the tightness in these muscles.

Treatment

Treatment begins with physical therapy and neck stretching exercises cervical and thoracic manipulation. Abdominal breathing, posture correction, and nerve glides, carried out on a daily basis, are a part of the therapy program. Gentle, slow movements and exercises are stressed. Methods like Feldenkrais have helped many people with TOS. Modalities to avoid are those that emphasize strengthening exercises, heavy weights, and painful stretching. It is important to be examined and tested for other causes of these symptoms because other conditions can coexist with TOS, and these should be identified and treated separately. Some of these associated conditions include carpal tunnel syndrome, ulnar nerve entrapment at the elbow, shoulder tendinitis and impingement syndrome, fibromyalgia of the shoulder and neck muscles, and cervical disc disease. Surgery can be performed for TOS, but it should be regarded as a last resort. Non-surgical forms of treatment should always be tried first.

Treatment frequency is usually daily for 3-7 days and then three times a week for 3-6 weeks. After that, realignment of the vertebra must be performed to prevent eventual return of this condition. It can be accomplished in 30-60 days of reduced frequency management. Often once a week treatment is sufficient at that point to restore alignment. Thereafter, this condition can be reasonably avoided with monthly correction of spinal alignment.

After the first few days of treatment, you will be given a sheet of stretching exercises to do at home. This is to help reduce the treatment time and speed healing. It is very important for you to do these daily as prescribed. If you have any questions about them or difficulty or pain on performing them, please tell the doctor right away.

Several days following the initiation of treatment, more aggressive exercise routines will be proscribed for you. You will be taken to the rehabilitation center and instructed on how to use the computer monitored exercise routines specifically designed for this condition. The routines are monitored for completion and graduated in difficulty after certain numbers of routines have been completed. You will be expected to perform these routines after treatment during the initial part of the restorative phase and throughout the rehabilitative phase of your treatment. Our goal is to help you get well and stay well. We know from experience that most mechanical conditions return gradually over a period of months and become more advanced each time. The only way this can be prevented is with exercise. We expect you to be successful.

We offer treatment of these conditions at various levels for all patients. We expect that you will follow this treatment plan through to its logical conclusion of restoration of complete function and rehabilitation. Our management system is designed to help you remember all of your appointments and to be fully compliant with all of our recommendations. At any time, should you decide to discontinue the process, please just let us know so that we don't become a bother.

Results of Treatment

Most people with TOS will improve with manipulation, stretching and physical therapy. In our experience with over 5000 people with TOS, less than 30% had surgery. The improvement rate with surgery varies with the cause of the TOS. Auto injuries have a success rate of 80-85% while repetitive stress at work has a success rate of 60-70%.

Expectations

We understand that you have come here for help. We have spent many years learning the best ways to solve the problems of mechanical back and neck pain. We expect you to comply with our recommendations and follow our treatment schedule completely regardless of the treatment plan you have. We expect you to set all of the recommended appointments at times convenient for you and we expect you to keep all of them. We expect you to respond favorably and know that your 100% compliance is the determining factor. We also expect you to attend our next class on Absolute Spinal Health. The staff can give you a schedule of the next class. Other Information At our class on Absolute Spinal Health, we discuss mechanical conditions of the back, neck and spine and teach you ways to prevent mechanical conditions from occurring. We also offer a wide variety of health information at our web site. www.piclilnic.com All patients are welcome to use our information to improve your life and maintenance your spinal health.

SUPPLEMENTATION: B complex, Inositol and Trace Minerals have proven effective in long-term reduction of symptoms

LIFE STYLE CHANGES:

Long periods of stress should be avoided. Do not sleep or lie on your stomach and avoid activities that hyper extend the neck. Water intake should be increased substantially.

HOME REMEDIES AND RECOMMENDATIONS:

Utilize ice packs on the neck back for 10 minutes at a time and moist heat packs on the muscles of the upper back at 20 minutes at a time, not simultaneously and not more often than once per hour. This should continue until the arm pain or numbness disappears. Hot tubs provide buoyancy and may be used after 5 days of onset for temporary relief.

MAINTENANCE:

Regular spinal adjustments are important to reduce the symptoms of thoracic outlet syndrome. Patients who receive monthly spinal manipulation and therapy report fewer complications. It is important that you follow your chiropractic physician's advice about the frequency of treatment for your particular condition.

Follow our wellness recomendations for absolute health.

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