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Home , Cervical rib, Subclavian nerve, Thoracic outlet, Ulnar nerve entrapment, Upper subscapular nerve

An osteopathic approach to conservative management of thoracic outlet syndromes

RICHARD DOBRUSIN, DO

Thoracic outlet syndromes lateral border of the first . It then passes under (TOS) are a group of disorders in which the and . It enters the there is compression of the axilla by passing between the tendon of the pector- or the or vein or both as alis minor muscle (as it inserts onto the coracoid they pass through the thoracic outlet. Most process of the scapula) and the head of the patients have neurologic symptoms of the humerus. The subclavian vein follows a similar and . These syndromes are course, the principal exception being that it passes generally named according to the site of anterior to the scalenus anticus muscle as it en- compression or the compressing structures. ters the outlet. There are many factors that predispose The brachial plexus is normally made up of con- patients to the development of TOS. The tributing fibers from cervical nerve roots differential diagnosis includes many 5,6,7, and 8 and thoracic nerve root 1. Cervical diseases that can add to or imitate TOS nerve roots 5 and 6 join at the lateral border of symptoms. Diagnosis is based mainly on the the scalenus medius to form the of the findings of the history and physical plexus. The middle trunk is made up of fibers from examination. Most patients respond well to cervical nerve root 7. Cervical nerve root 8 and tho- a conservative care regimen, which should racic nerve root 1 form the lower trunk of the be tailored to the individual patients needs. plexus. These trunks pass behind the clavicle where In most instances, surgery should be each splits into an anterior and posterior division. reserved as a treatment of last resort. The anterior divisions of the upper and middle trunks form the of the plexus. The an- The thoracic outlet syndromes (TOS) are a group terior division of the lower trunk forms the medial of disorders in which the patients symptoms are cord of the plexus. The posterior divisions of all caused by compression of the brachial plexus or three trunks join to form the . These the subclavian artery or vein or both. These syn- cords are named according to their relationship to dromes can be classified as entrapment neuropa- the axillary artery. The cords then go on to form thies and are named according to the site of com- the peripheral of the arm. The sympathetic pression. The true frequency of these disorders is supply to the upper extremities arises from the up- unknown owing to the difficulty in establishing per thoracic area. It travels through the thoracic strict diagnostic criteria. The diagnosis of these syn- outlet and makes up 8% of the brachial plexus. dromes is based largely on the findings of a thor- ough patient history and a physical examination. 1rpes of thoracic outlet syndromes The scalenus anticus syndrome and the cervical rib Anatomic relationships syndrome are similar in that both cause compres- The thoracic outlet is an anatomic space bordered sion in the interscalene triangle. They develop by the first thoracic rib, the clavicle, and the supe- when there is compression of the brachial plexus rior border of the scapula. The neurovascular sup- or subclavian artery or both as they pass between ply to the arm must pass through this space. There the scalenus anticus and the scalenus medius mus- are many congenital variations, but the descrip- cles and over the first thoracic rib. The costoclavi- tion given here is the most common anatomic cular syndrome is caused by compression ()file bra- arrangement. chial plexus or the axillary artery and vein or both The subclavian artery leaves the as they pass between the first thoracic rib snd the and passes above the first rib and between the scale- clavicle. The pectoralis minor syndrome is also nus anticus and scalenus medius muscles. The sub- called the coracoid-pectoralis syndrome or the clavian artery becomes the axillary artery at the hyperabduction syndrome. It is caused bycompres-

1046 • JAOA • Vol 89 • No 8 • August 1989 Clinical Practice • Dobrusin sion of the axillary artery and, the brachial plexus Table 1 between the pectoralis minor tendon (as it inserts Factors That Predispose to Thoracic Outlet Syndromes onto the coracoid process of the scapula) and the humeral head. • Cervical and long transverse processes of C-7 • Abnormal fibrous bands and/or scalenus medius insertions Predisposing factors • Abnormal first thoracic ribs There are many factors that predispose patients • Postural changes Localized and distant areas of somatic dysfunction to TOS (Table 1). The presence of these factors does • • Trauma not necessarily mean that these patients will be • Degenerative changes unresponsive to conservative management. Also, there often is no cause-and-effect relationship be- tween these factors and the syndromes. However, an understanding of these factors will enable the to the neuromuscular strains placed on the body. physician to take a more comprehensive approach Patients with poor posture in general are prone to the problem. to neuromusculoskeletal stresses. They will often Cervical ribs are present in approximately 1% have altered body mechanics due to excessive tho- of the population. 2 When present, they are bilat- racic kyphotic curves with associated increased cer- eral 75% of the time. These ribs may be associated vical . This condition leads to strain of the with soft-tissue fibrous bands that usually insert supporting musculature and compression of the tho- onto the first thoracic rib. Some patients also have racic outlet space. In essence, these patients have long transverse processes of the seventh cervical to work too hard to maintain an erect posture. . These processes can be either unilateral Areas of somatic dysfunction causing compres- or bilateral. Both types of findings are easily demon- sion either through direct or reflex mechanisms are strated on standard cervical spine x-ray films. The usually found in patients with TOS. It is impor- presence of cervical ribs or long transverse proc- tant to be aware that somatic dysfunction of the esses does not preclude the successful use of con- cervical spine can play a key role in TOS. The scale- servative care measures. nus anticus is innervated by branches of cervical Abnormal fibrous bands or muscular insertions nerve roots 4, 5, and 6, while the scalenus medius can be found in the interscalene triangle. Thomas is innervated by cervical nerve roots 3, 4, 5, 6, 7, and associates3 found that 58% of those patients and 8. 1 Areas of somatic dysfunction in these ver- undergoing surgery for TOS had abnormal scale- tebrae can cause facilitation of the nerve roots and nus medius insertions. Twenty-one percent of these excessive tightness in the . This can patients had solitary outlet fibrous bands. These put pressure on the involved neurovascular bun- muscular insertions and fibrous bands cannot be dle directly as well as by pulling up the first rib. seen on standard x-ray films. Palpatory examination of the first rib would re- Abnormal first thoracic ribs may further close veal it to be raised and caught in inspiration. The the interscalene triangle. The first rib can develop first rib would not lower as expected with expira- a bony exostosis that may compress the structures tion. involved by narrowing the costoclavicular space. It is also important to keep in mind that distant Postural changes can greatly affect the course areas of somatic dysfunction, whether symptomatic of TOS. Certain occupations that require prolonged or not, can affect the thoracic outlet. The upper work Ma hyperabducted position (such as the work are often involved. Areas of so- of painters and mechanics) can aggravate the con- matic dysfunction in the upper thoracic vertebrae dition. This condition is often difficult to treat be- can cause facilitation of the sympathetic outflow cause of the problems associated with correcting to the thoracic outlet and to the entire upper ex- the exacerbating posture. Often patients will as- tremity. This increased sympathetic tone is associ- sume a compressive posture while sleeping. This ated with increased muscular tone, vasoconstric- should especially be suspected in patients whose tion, decreased skin resistance, and decreased skin symptoms are worse in the mornings or who are temperature.4 In general, the area becomes more awakened by discomfort. Weight lifters are predis- prone to injury and more likely to be aggravated posed to pectoralis minor syndrome due to the char- by any other predisposing factors that may exist. acteristio-hypertrophic muscular changes and the Even more distant areas of dysfunction can af- use of the hyperabducted position during workouts. fect the thoracic outlet. Essentially, any area of Kyphoscaliosis patients are prone to TOS owing dysfunction can, through mechanical or direct

Clinical Practice • Dobrusin JAOA • Vol 89 • No 8 • August 1989 • 1047 mechanisms, affect the area. For example, condi- tasks. They may also experience peripheral Hair tions that cause unleveling of the sacral base can loss. Very rarely, patients complain of symptoms cause a compensatory lumbar . This con- of severe arterial disease such as ulcerations, gan- dition, in turn, can cause a compensatory thoracic grene, and cyanosis. Also very rarely, these pa- scoliosis, which can add to the disease process. As tients may be subject to digital infarctions result- another example, any lower-extremity injury caus- ing from embolization from a proximal . ing altered gait and posture can have distant ef- Patients with severe symptoms of arterial compro- fects. One could give many more examples. The mise should be evaluated and treated aggressively. importance of total body evaluation and treatment to eliminate as many contributing factors as possi- Differential diagnosis ble cannot be overemphasized. The differential diagnosis of TOS requires ruling Trauma is often involved in TOS. Fractures or out many different disease processes (Table 2). Most soft-tissue injuries can cause compression. The clav- of these can be eliminated by means of a thorough icle is frequently fractured, and it can heal with history and physical examination. Often, certain callous formation or malunion. These can be de- diagnostic tests can be helpful in differentiating tected by x-ray and should be suspected in patients between TOS and other diseases. A complete dis- with the costoclavicular syndrome and a history cussion of all of these processes is beyond the scope of clavicular fractures. Pseudoarthrosis of a clavicu- of this paper, but they are covered briefly. lar fracture can compress the neurovascular struc- The peripheral entrapment neuropathies can be tures against the first rib. difficult to distinguish from TOS. The Localized degenerative changes can be seen in can be entraped at three sites in the arm: It can TOS. These may be a posttraumatic reaction. They be compressed as it passes through the groove on can also be part of a generalized disease such as the dorsum of the medial epicondyle and as it en- one of the connective tissue diseases. Commonly, ters the between the two heads of the osteoarthritic changes of the cervical spine is asso- flexor carpi ulnaris. It can also be entraped at the ciated with these syndromes. These changes can in Guillians canal. The ulnar entrapments make conservative treatment more difficult, but are difficult to distinguish from TOS due to their they certainly do not preclude it. similar distribution of symptoms. These can often be separated by means of a thorough physical ex- Clinical picture amination. The presence of a positive Tinels sign As previously stated, TOS is classically found in (tenderness or reproduction of symptoms by per- middle-aged women, but it can be seen in either cussion over the site of compression) would sug- sex and practically any age group. Ninety percent gest an .5 of TOS patients will have purely neurologic symp- Electromyography and nerve conduction veloc- toms.2 The remaining 10% will have either vascu- ity (EMG-NCV) tests can also be helpful if skill- lar symptoms or a combination of vascular and neu- fully performed and if the symptoms have been pre- rologic symptoms. It is rare for TOS patients to sent for longer than 6 weeks. Compression of the have venous obstruction-type symptoms. as it passes through the carpal tun- Patients often have vague, diffuse arm pain that nel () can cause vague arm may be difficult to distinguish from other upper- symptoms similar to TOS. The presence of a posi- extremity entrapment neuropathies. The pain is often worse at night or worsens with specific pos- tures assumed during the day. Patients may also Table 2 have paresthesias—including feelings of numbness, Differential Diagnosis of Thoracic Outlet Syndromes "pins and needles"—and hyperesthesia. These symp- toms are most commonly found in an ulnar nerve • Entrapment neuropathies • distribution, but they can be diffuse. Weakness with- Space-occupying spinal cord lesions • Spinal stenosis and degenerative disease out atrophy may be observed. • Connective tissue disease Patients who have arterial symptoms may com- • Metastatic malignancies • plain of coldness and cold intolerance of the affected Posttraumatic damage to the bony or soft tissue structures hand. Patients prone to Raynauds phenomenon • Metabolic disorders will experience increased Raynauds symptoms • Infectious diseases • with a superimposed TOS. Patients may also com- Circulatory disorders • Psychologic disorders plain of claudication when they perform certain

1048 • JAOA • Vol 89 • No 8 • August 1989 Clinical Practice • Dobrusin tive Tinels sign or a positive Phalens test would Posttraumatic damage to bony structures can suggest carpal tunnel syndrome. lead to degenerative disease. In clavicular frac- Space-occupying lesions that compress the spi- tures, direct compression from malunion, pseu- nal cord or cervical nerve roots should be consid- doarthrosis, or callous formation can occur s Soft- ered in the TOS workup. Cervical intervertebral tissue damage is often more difficult to diagnose discs can herniate and put pressure on the cervical because of the lack of x-ray findings. Soft-tissue nerve root as it exits the . injuries to this area are responsive to good con- This condition should be suspected when the pa- servative care and rehabilitation. tient has a history of trauma or if the neurologic Metabolic disorders—such as , thyroid symptoms are associated with a fifth cervical nerve disease, osteoporosis, and electrolyte disturbances— root distribution. can cause diffuse neuropathies that can be confused Space-occupying lesions should be strongly sus- with TOS. These should be investigated and treated pected and ruled out if a neurologic deficit is found where medically indicated. on examination of the upper extremity. Loss of deep Infectious diseases are rarely confused with TOS. tendon reflexes does not normally accompany a Osteomyelitis of the spine or extremities should TOS and should raise the physicians suspicion that be suspected when fever, sweats, and an increased another process is involved. 6 A history of increased erythrocyte sedimentation rate or localized signs symptoms with Valsalvas maneuvers (ie, cough- are present. ing, sneezing, bowel movements, etc.) is more in- Circulatory disorders, such as peripheral vascu- dicative of a space-occupying lesion. Spinal cord lar disease, can produce extremity symptoms simi- tumors should also be considered in this group, es- lar to TOS. A cool extremity with decreased pe- pecially in patients with associated lower extrem- ripheral pulses points to this diagnosis. Such a dis- ity symptoms or signs. These lesions can be evalu- order is always a diffuse process and more com- ated with the aid of cervical myelography, mag- monly involves the lower extremities. netic resonance imaging of the cervical spine, com- TOS is often masked as a psychologic disorder. puted tomography (CT) scanning of the cervical TOS can be associated with a fibrositis-type disor- spine, or EMG-NCV studies of the upper extre- der and its associated depression. Reassuring the meties and paraspinal musculature, either singly patient and treating the depression can be an ex- or in combination. tremely important part of making progress in the Spinal stenosis and degenerative disc and joint treatment of TOS. A good physical examination, disease of the spine can cause compression of the including an osteopathic structural evaluation, can cervical nerve roots. Evidence of this is most com- often uncover the problem. monly seen on standard cervical spine x-ray films. The presence of this common finding does not ex- History-taking clude the possibility of successful conservative care History-taking for TOS is similar to that for any of these patients. However, the treatment regimen syndrome. Initial inquiries should include a com- must be altered to compensate for the degenera- plete medical history in addition to current symp- tive changes. All too often when there are degen- toms, their locations, and their duration. It should erative changes, one may assume an automatic be established whether the symptoms are progres- cause-and-effect relationship to the symptoms ex- sive or regressive. Associated events, such as ists. trauma or previous surgery, should be uncovered. Certain connective tissue diseases, such as lu- It is especially important in evaluating TOS to ques- pus and rheumatoid arthritis, can cause changes tion the patient about exacerbating and alleviat- in the bony and soft-tissue structures involved. ing factors. Patients will often report increased Such diseases should be suspected when the signs symptoms brought on by certain arm positions, and symptoms are more diffuse or when labora- sleeping, or work that requires increased blood sup- tory evaluation points toward a more systemic proc- ply to the arm. Information regarding previous treat- ess. ment and diagnostic tests will help the physician Certain metastatic malignancies can cause spi- to avoid unnecessary duplication. nal pain and nerve root compression. These should A complete musculoskeletal history should be be investigated in people with systemic symptoms taken. Other areas of pain, including back and neck such as weight loss, fevers, or sweats. A thorough pain, should be noted. A history of headaches is a history and physical examination should raise sus- reinforcing sign when complaints involve cervical picion that such lesions are present. spine somatic dysfunctional areas. When deemed

Clinical Practice • Dobrusin JAOA • Vol 89 • No 8 • August 1989 • 1049 appropriate, rheumatologic sources should be sus- supraclavicular bruit as the arm is positioned; this, pected, and the physician should look for evidence again, may be a normal finding. of connective tissue diseases. The tests referred to are as follows: • The Adsons test. In this test, the patient is Physical examination placed in a seated position. The arm is extended, The basic neurologic examination should include externally rotated, and adducted while the ex- testing of the extremities for motor, sensory, and aminer palpates the radial pulse. The patient is deep tendon reflexes. Special attention should be then asked to take a deep breath and rotate the given to cervical nerve roots 5, 6, 7, and 8 and tho- head toward the arm being tested. This maneu- racic nerve root 1. Normally in TOS there is no ver raises the first rib and decreases the space apparent neurologic deficit. Loss of deep tendon re- in the interscalene triangle. lbst results are con- flexes should trigger the suspicion that a more proxi- sidered positive when the pulse disappears, the mal compressive process is present. There may be blood pressure drops more than 20 mm Hg, the a sensory loss in an ulnar nerve distribution. symptoms are reproduced, or a supraclavicular Vascular examination should begin with inspec- bruit is created. The test often produces positive tion of the skin. Areas of cyanosis, ulceration, gan- results in scalenus anticus syndrome. Both grene, or digital infarction should be noted. Loss should be tested for comparison (Figs 1 and 2). of hair or apparent thinning of the skin may be • The costoclavicular maneuver is performed with signs of peripheral vascular insufficiency. The ex- the patient placed in an exaggerated military- amination should include the nail beds. The pa- attention position. The are lifted and tient should also be checked for venous distension the are rotated backward. This test com- and peripheral edema. A blood pressure check presses the space between the clavicle and the should include both arms, and any discrepancies first rib. Thst results are often positive in patients between them should be noted. A drop of greater with a costoclavicular syndrome with clavicular than 20 mm Hg in the symptomatic arm is espe- deformities as previously described. The criteria cially significant. The supraclavicular area can be for a positive test are the same as for the Adsons auscultated for bruits with the patients arm in the test. neutral position. With the arm in that position, the • The hyperabduction test is performed with the skin can be palpated for warmth and texture, and patients arm abducted and externally rotated. peripheral pulses can be obtained. Several arterial The radial pulse is palpated, and the criteria for tests can be performed in the evaluation of TOS.7 a positive test are the same as for the Adsons These tests require palpating the radial pulse for test. A bruit may be auscultated anterior to the a decrease in intensity while performing certain pectoralis minor insertion. This test often pro- maneuvers that increase possible compression at duces positive results in a pectoralis minor syn- certain areas. There has been significant contro- drome (Fig 3). versy regarding the validity of these tests for two • The claudication test is performed with both of reasons: The tests often produce false-positive re- the patients arms externally rotated and ab- sults. Also, it is argued that, since the majority ducted. The patient is then asked to rapidly open of TOS symptoms are neurologic, it does not make and close his or her . Results of the test sense to evaluate TOS with arterial tests.2 are considered positive when the symptoms are I have found these tests to be very useful in cer- reproduced or when the symptomatic arm be- tain patients. I consider it significant if the test comes weak or tired. This test can be useful in produces positive results only in the symptomatic diagnosing and treating a TOS when combined arm or if placing the arm in the required position with the rest of the information obtained. reproduces the symptoms. A blood pressure cuff is often useful in quantifying the decrease in arte- Diagnostic tests rial pressure with the arm in the test position. This Certain diagnostic tests can be helpful in the diag- is helpful in patients in whom the pulse is not com- nosis of TOS. These tests are useful in differentiat- pletely obliterated as well as for monitoring future ing TOS from the many other conditions that can progress. present in a similar manner. At present, there is It is also helpful to be able to quantitatively moni- no diagnostic test that has a pathognomonic find- tor blood pressure changes as treatment progresses. ing for TOS. The extent of the diagnostic workup Some physicians will also listen for creation of a should be adapted to the individual patient and to

1050 • JAOA • Vol 89 • No 8 • August 1989 Clinical Practice • Dobrusin Figure 1. Performing an Adsons test while auscultating for a supraclavicular bruit.

Figure 3. Performing a hyperabduction test while auscultating for a supraclavicular bruit.

the physician. Parts of the diagnostic workup can often be postponed pending the results of a conserva- tive care regimen. Any of the following tests may prove useful according to the circumstances. • A basic laboratory workup, including serologic tests and a urinalysis. The physician should de- cide which of these tests is prudent and cost-ef fective, depending on the findings of the patient history and the physical examination. • X-ray films of the cervical spine, including oblique films. These can help rule out degenera- tive disease, cervical ribs, long transverse proc- esses of cervical vertebra 7, osteolytic lesions, frac- tures, and congenital bony variations. Additional x-ray films of the or clavicle may be nec- essary. A standard chest x-ray film should be or- dered if an intrathoracic abnormality is sus- pected. • Magnetic resonance imaging (MRI), CT scanning, Figure 2. Performing an Adsons test while monitoring blood cervical myelograms. If a space-occupying lesion pressure. is suspected, the workup may include one of these

Clinical Practice • Dobrusin JAOA • Vol 89 • No 8 • August 1989 • 1053 modalities. MRI and CT scanning are good non- invasive diagnostic tests in these circumstances. Table 3 Modalities Used in the Treatment of The decision as to which one to order should be Thoracic Outlet Syndromes based on availability as well as the specific test requirements. Myelograms of the cervical spine • Avoidance of aggravating factors and posture are invasive and often difficult to perform. They modification • Weight loss carry the risks of a procedure using a contrast • Osteopathic manipulative treatment medium and a subarachnoid puncture. I reserve • Exercise therapy cervical myelograms for use in a presurgical test • Counseling and stress control • Medication ordered at the surgeons request. • Trigger point therapy • Arteriograms. The usefulness of arteriograms • Physical therapy is extremely questionable in TOS. Arteriograms • Surgery may be helpful in the rare patient who has signs of embolization or severe peripheral vascular dis- ease of the arm. There can be a normal amount of poststenotic dilation as the subclavian artery gery was indicated in 1408 (38.8%) of the patients. passes over the first rib, making the test diffi- Stallworth and associates 13 described a series of cult to interpret. This limitation combined with 1140 patients with TOS; 143 (12%) required surgi- the risks of the procedure produces a poor risk-to- cal therapy. None of these studies included ma- benefit ratio. The use of venograms is rarely in- nipulative treatment as part of the conservative dicated except when venous is sus- care regimen. pected. It is apparent from this evidence that a large • EMG-NCV studies. Whether these studies are in- percentage of patients with TOS can attain satis- dicated in TOS has been the source of much de- factory improvement without surgical intervention. bate.6,8-1° The problem lies in the difficulty in The only patients who may not be candidates for measuring a conduction delay from a point proxi- a conservative care regimen are the extremely rare mal to a point distal to the site of compression. patients who are experiencing severe vascular com- It is difficult to gain access to the proximal nerve promise or distal embolization. The first step in site because of its anatomic position. I have found conservative care of TOS is patient education. An EMG-NCV studies to be useful in diagnosing cer- informed patient is more likely to comply with rec- vical nerve root and metabolic ommendations and be aware of aggravating fac- neuropathies. In addition, because of its distal tors. compression, a TOS should not cause EMG changes in the paraspinal musculature. If para- Avoidance of aggravating factors spinal EMG changes are found, a more proximal Often certain aggravating factors are revealed dur- compression site should be suspected. ing the history and physical examination. Various positions or movements should be identified to the Treatment patient with the suggestion that the patient avoid There has been considerable controversy regard- them. Many patients are unaware of the interrela- ing the appropriate treatment of TOS. The major tionship between their posture and their symptoms. disagreement is between those advocating a con- Patients who are aggravating a TOS by their work servative care regimen and those opting for a sur- habits should be advised on modification of their gical approach (Table 3). McGough and associates11 posture and body mechanics. In certain occupations, treated 1200 patients with TOS and found a need compliance can be difficult. Sometimes a platform for surgical intervention in only 9.4% of them. Of of appropriate height can be used so that the pa- this 9.4%, 80% had complete symptom relief and tient does not have to work with the arms higher 13% had improvement. All patients were treated than the head for prolonged periods. initially with a comprehensive physical therapy pro- Patients whose TOS is exacerbated during sleep gram. may have to use an appliance to bind the arm to Roos12 believes that conservative measures may the side to avoid nighttime compression. Some phy- control or alleviate mild-to-moderate neurologic sicians advocate tying the loosely to the base symptoms, but if the symptoms have reached the of the bed to avoid positioning the arms over the advanced stage, a surgical approach may be neces- head. Weight lifters and athletes often resist chang- sary. In a study of 3630 patients, he believed sur- ing their workout habits. By reviewing their train-

1054 • JAOA • Vol 89 • No 8 • August 1989 Clinical Practice • Dobrusin ing habits with patients, physicians may be able manner means that they rotate and sidebend to to suggest slight modifications that will aid in de- the same direction.16 compression. Large-breasted women may find a bras- lb perform a counterstrain technique, the phy- siere with good underwire support to be extremely sician should place the segment involved in its po- helpful. sition of ease. This should cause the tender point Weight reduction, where indicated, can be the to become less tender to palpation. In general, the crucial step toward recovery. All too often we phy- lower will require more sidebend- sicians advise patients to lose weight without tell- ing to gain tender point relief, whereas the upper ing them how to do so. Groups such as Weight cervical vertebrae will require more rotation. If re- Watchers can give these patients the guidance and lief is not obtained with the initial positioning, a support they need. Good weight-loss diets are avail- certain amount of fine tuning (small adjustments) able from the American Heart Association and may be necessary. Sometimes it is not possible to other organizations. attain 100% relief of point tenderness. Once the position is found, the physician should release the Osteopathic manipulative treatment pressure on the tender point and hold the position Osteopathic manipulative treatment (OMT) makes for 90 seconds. The patient should be encouraged an excellent addition to a conservative care regi- to relax and the physician should be in a com- men." Because of body interrelationships, the en- fortable position. The return to neutral must be tire body should be treated even if the symptoms slow and unassisted by the patient. The physician are localized to the thoracic outlet. Treatment of should then reevaluate the tender point and test dysfunctional areas can decrease muscular tone in for persistence of motion restriction. If the tender the scalene muscles, allow the first rib to become point is no longer tender and the motion restric- more mobile, and open up the interscalene trian- tion has been relieved, the physician proceeds to gle. Treatment of upper thoracic lesions can reflexly further areas of treatment. cause a decreased sympathetic hypertonia in the Counterstrain can also be a useful technique in TOS and in the arm.4 Balancing of the pelvis and the treatment of TOS involving first rib dysfunc- lumbosacral area can decrease strain on the tho- tion. The procedure is similar to the technique just racic and cervical areas through direct and reflex described except that the tender point and posi- effects. tion for relief are different. The tender point is lo- Specific OMT techniques are designed to open cated where the scalenus anticus inserts onto the up the thoracic outlet. Treatment of the cervical first rib. The positioning requires sidebending the spine is of primary importance. Myofascial, cranial, patient toward the dysfunctional rib while shift- counterstrain, muscle energy, and high-velocity/ ing the away (Fig 4). The cervical spine is low-amplitude (thrust) techniques are all useful in then sidebent toward the affected side and rotated removing specific dysfunctions. I primarily use a slightly away. As before, fine tuning the position combination of counterstrain techniques followed may be necessary in order to maximize the tender by gentle high-velocity/low-amplitude techniques. point relief. The physician should hold this posi- Jones15 describes a system of positioning tech- tion for 90 seconds and slowly return the patient niques using the tender point associated with a to neutral. The first rib should become more mo- dysfunction in treatment of that dysfunction (coun- bile and the tender point should be relieved. terstrain technique). 15 Basically, to perform coun- If there is a persistent restriction of motion af- terstrain techniques an area of somatic dysfunction ter the counterstrain technique, a thrust technique (lesion) must be diagnosed and named according may be indicated. The use of thrust techniques can to the position it goes into most easily. For exam- be helpful in inducing mobility to the restricted ple, if the fifth cervical vertebra goes into flexion, segments. Counterstrain techniques often enable right sidebending, and right rotation more easily the practitioner to perform thrust techniques much than it goes into extension, left sidebending, and more gently. left rotation, it is called a "fifth cervical flexion, The use of thrust techniques requires specific left sidebending, left rotation lesion." training, which is given in osteopathic medical Each cervical area of dysfunction has its associ- schools. In general, these techniques require plac- ated tender point, which is usually posterior to the ing the involved segment into its barrier or point articular pillar on the side toward which the ver- of motion restriction. Often, muscular relaxation tebra is rotated. It is important to note that the and joint relaxation are attained immediately. The cervical vertebrae 2 through 7 lesion in a type II choice of which techniques to use depends on pa-

Clinical Practice • Dobrusin JAOA • Vol 89 • No 8 • August 1989 • 1055 creasing patient awareness of the somato-emo- tional interrelationship can be helpful. Stress con- trol centers incorporate a variety of modalities de- signed to help patients relax. Many different medications are prescribed for TOS patients. A complete review of all of these medi- cations is beyond the scope of this paper. Basically, they fall into five categories: anti-inflammatory agents, muscle relaxants, analgesic agents, anti- depressant medications, and sleep-inducing agents. As with any therapy, a risk-to-benefit ratio must be considered in prescribing medication. Physicians should avoid a shotgun-type approach, including a mixture of these agents for a prolonged period. Keeping the dosage simple increases patient com- pliance and decreases side effects. Treatment modalities that incorporate trigger- point therapy can be useful in TOS and in other musculoskeletal disorders. Travell and Simons 18 describe a system of diagnosis and treatment of trig- ger points throughout the body. They use spray and stretch technique and injection therapy in the treat- ment of these points. I have found this a good addi- tion to the conservative care program in patients Figure 4. Applying a counterstrain technique for treating a left- sided eleiated first rib. who are resistant to less invasive measures. Many physical therapy modalities can be used in TOS. These, combined with osteopathic manipu- lative treatment and exercise therapy, provide an tient variabilities as well as practitioner prefer- excellent first-line approach and low risk. The most ences and experience. common physical therapies are heat, cold, ultra- sound, and electrogalvanic stimulation. Transcuta- Exercise therapy and other noninvasive treatment neous electrical nerve stimulation can be useful, modalities but I reserve it for a later choice because the pa- Exercise therapy for TOS is aimed specifically at tient can develop dependence. A major benefit of increasing the strength and flexibility of the ele- a physical therapy program is the ability to directly vators of the shoulder and scapula and the mus- incorporate it into the exercise program. cles of the cervical and thoracic spine. An overall strength- and flexibility-increasing program can be Surgery helpful where indicated. Peet and associates 17 de- Surgery should be considered the treatment of last scribe excellent results obtained with a conserva- resort for the majority of patients with TOS. The tive care program emphasizing strengthening of two basic surgical approaches are the supraclavi- the elevators of the shoulders and scapulas. Their cular and the transaxillary. 19 The surgery then en- patients used hand-held 2-lb weights while perform- tails resection of the first rib or a scalenotomy or ing shrugging and shoulder abduction maneuvers. both. There is considerable controversy among sur- Patients also performed pectoralis and cervical geons as to which approach and procedure is the spine flexibility exercises. Extension exercises were best. Dale 2° reviewed the results of a national sur- performed with the patients in a prone position. vey of complications of transaxillary first rib re- As the patients performing these exercises become section in which 273 postoperative brachial plexus stronger, the weights and number of repetitions injuries were reported. He concluded that the op- can be increased. eration "should be reserved as a last resort." He When patients are under a great deal of stress also advised that scalenectomy be the initial proce- or are depressed, various forms of relaxation ther- dure with first rib resections reserved for failures. apy can be useful. Tense patients tend to raise their When patients fail on an intensive conservative shoulders and tighten the shoulder elevators. In- therapy program, the physician and the patient

1056 • JAOA • Vol 89 • No 8 • August 1989 Clinical Practice • Dobrusin should discuss the risk-to-benefit ratio of a surgi- 15.Jones LH: Strain and Counterstrain. Newark, Ohio, American Acad- emy of Osteopathy, 1981, pp 24-29, 54, 55, 63. cal approach. Surgery results in a certain amount 16.Mitchell FL, Moran PS, Pruzzo HA: An Evaluation and Treatment of immobility. Some surgeons keep the shoulder Manual of Osteopathic Muscle Energy Procedures. Valley Park, Mo, abducted in an "airplane splint" for up to 6 weeks. Mitchell, Moran and Pruzzo Associates. 1979, pp 63-65. 17.Peet RM, Hendriksen JD, Anderson TP, et al: Thoracic outlet syn- This can lead to frozen shoulder and atrophy. Pleuri- dromes: Evaluation of a therapeutic exercise program. Proc Mayo Clin, tis or pneumothorax or both are not uncommon com- 1956;31:281-285. 18.Travell JG, Simons DG: Myofacial Pain and Dysfunction: The Trig- plications, and occasionally a chest tube will be ger Point Manual, Baltimore, Williams Wilkins, 1983; pp 63-65. placed as a preventive measure. Among the more 19.Sanders RJ, Monsour JW, Gerber WF, et al: Scalenectomy versus serious complications are injuries to the brachial first rib resection for treatment of . Surgery 1979;85:109-121. plexus and the subclavian artery. Damage to the 20.Dale WA: Thoracic outlet compression syndrome: Critique in 1982. thoracic duct can cause a lymphocele to form. The Arch Surg 1982;117:1437-1445. risks of anesthesia and possible transfusion ther- apy should also be considered. From the department of osteopathic manipulative medicine, Summary Philadelphia College of Osteopathic Medicine, Philadelphia.

Thoracic outlet syndromes are caused by compres- Reprint requests to Dr Dobrusin, Booker Family Health Cen- sion of the brachial plexus or subclavian artery or ter, 747 E 47th St, Chicago, 60653. both as they pass through the thoracic outlet. The diagnosis of these syndromes requires a thorough patient history and a physical examination. A thor- ough understanding of anatomic relationships and factors that can predispose a patient to TOS are important precedents to treatment. Various modali- ties, including osteopathic manipulative treatment, can be successfully used in the conservative care of patients with TOS. Surgery should remain a treat- ment of last resort.

1.Williams P, Warwick R (eds): Grays Anatomy, ed 36. Philadelphia, WB Saunders Co, 1980, pp 509, 1065-1067. 2.Silver D: Thoracic outlet syndrome. Hosp Physician October 1983, pp 42-53. 3.Thomas GI, Jones TW, Stavney LS, et al: The middle scalene muscle and its contribution to the thoracic outlet syndrome. Am J Surg 1983;145:589-592. 4.Korr IM: Sustained sympathicotonia as a factor in disease, in The Collected Papers of II.M. Korr. Newark, Ohio, American Academy of Oste- opathy, 1976. 5.Lord JW Jr, Rossati LM: Thoracic-outlet syndromes. Clin Symp 1971;23(2):1-32. 6.Dawson DM, Hallet M, Millender LH: Thoracic outlet syndromes, in Dawson DM, Hallett M, Millender LH: Entrapment Neuropathies. Bos- ton, Little Brown Co, 1983, pp 169-183. 7.Hoppenfeld S: Physical Examination of the Spine and Extremities. East Norwalk, Conn, Appleton-Century-Crofts, 1976, pp 119-127. 8.Urschel HC Jr, Razzuk M: Management of the thoracic-outlet syn- drome. N Engl J Med 1972; 286:1140-1143. 9. Jarrett S, Cuzzone J, Pasternak B: Thoracic outlet syndrome: Electro- physiological reappraisal. Arch Neurol 1984;41:960-963. 10.Wilbourn AJ, Lederman RJ: Evidence for conduction delay in tho- racic outlet syndrome is challenged. Letter. N Engl J Med 1984;310:1052- 1053. 11.McGough EC,Pearce MB, Byrne JP: Management of thoracic-outlet syndrome. J Thorac Cardiovasc Surg 1979;77:169-174. 12.Roos DB: The place for scalenectomy and first-rib resection in tho- racic outlet syndrome. Surgery 1982;92:1077-1085. 13.Stallworth JM, Horne JB: Diagnosis and management of thoracic outlet syndrome. Arch Surg 1984;119:1149-1151. 14.Heilig D: Osteopathic manipulative medicine in thoracic outlet syn- drome. Osteopathic Annals, March 1975, pp 70-76.

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