Orlando, Florida 2015

Thoracic Outlet Syndrome

Confusion

• The fact is that doctors that work with musculoskeletal conditions feel thoracic outlet syndrome is, underdiagnosed, (1) some doctors that don’t know how to examine for it say it's overdiagnosed. (2) others say it's misdiagnosed (3) or not diagnosed. (4) Putting it bluntly, the majority of doctors are really confused about thoracic outlet syndrome!

My Story

What is Thoracic Outlet Syndrome?

• It is one of the most underrated, overlooked and misdiagnosed conditions and proves difficult to manage.

• Medical professionals appreciate that it is probably the most important peripheral nerve compression in the upper extremity. (1)

Incidence

• It affects approximately eight percent of the population with women about four times more likely to develop a neurogenic TOS. (206)

History

• TOS was first described by Sir Ashley Cooper, in 1821 (2) and in 1861 Richard Holmes Coote at St. Bartholomew’s Hospital in London performed one of first surgical procedures, the removal (resection) of a cervical rib, for what came to be termed arterial TOS. (3) (4)

Thoracic outlet syndrome has been called many names

• Thoracic outlet syndrome• bilateral thoracic outlet syndrome• thoracic outlet disorder• neurogenic TOS• arterial TOS• arterial thoracic outlet syndrome• cervical rib syndrome• cervicobrachial neuralgia• compressive neuropathy• costoclavicular syndrome• disputed neurogenic thoracic outlet syndrome• effort thrombosis, first rib syndrome• hyperabduction syndrome• inflammation of the brachial plexus• neurogenic pectoralis minor syndrome (NPMS)• neurogenic thoracic outlet syndrome (NTOS)

• neurological thoracic exit syndrome• Paget-Schroetter syndrome• peripheral nerve compression• scalenus anticus syndrome• spontaneous subclavian vein ("effort")

thrombosis• subcoracoid brachial plexus compression• superior thoracic outlet syndrome • symptomatic thoracic outlet syndrome• thoracic outlet compression• venous compression syndrome• venous thoracic outlet syndrome• double crush syndrome• triple crush syndrome

Cause = Compression

• The Mayo Clinic, Cleveland Clinic and the National Institute of Neurological Disorders And Stroke, plus top 10 ranked hospitals for neurology and neurosurgery all tell us that compression is what leads to thoracic outlet syndrome. (7) (8)

Surgery – Poor Outcomes• Chronic lifelong pain • Progressive weakness • Clot formation • Emboli • Stroke• Limb amputation• Failed surgery • Spinal stimulators• Addiction to painkillers• Complications leading to death

PUb Med / 16 Treatment Approaches

• Medication: Analgesic drug therapy, Antidepressants, Anticonvulsants, others• Scalene Injection (Bupivacaine)• Nonsteroidal Anti-Inflammatory's NSAIDS• Painkillers For Symptom Reduction • Scalene Injection (Botox)• Gentle Stretching Of The Scalene's And Pectoralis Minor• Traction • Nerve Gliding• Ultrasound & Muscle Stimulation• Different Bra For Breast Hypertrophy• Breast Reduction - Reduction Mammoplasty• Ergonomic Corrections• Correction Of The Ergonomics Of The Workstation • First Rib Adjustments Alone• General Massage• Exercise Strengthening

Which one by itself reverses compression?

• None of them

What compels many doctors to recommend surgery for TOS?

• Intractable pain (9) • Neurologic deficit (9) – Weakness and decreased sensation• Long term compression • Limb threatening complications• Arterial compression• Completed and successful initial treatment of subclavian vein

thrombosis (9)• Post subclavian vein thrombosis -- vessel reconstruction• Paget Schroetter Syndrome (PSS)• A previous surgery failed leading to another surgery • Surgery that was performed for all the wrong reasons• Failure of a carefully supervised physical therapy program (9)

Surgery Outcomes

• One study found 66 percent of people who had surgery for TOS as part of workers’ compensation cases rated their experience as good to excellent. (10)

• • But what of the other 34 percent who had

poor results? More surgery? A life on painkillers?

TOS - Diagnosis

Cherington and Cherington imply the diagnosis is made by surgeons according to reimbursement pattern for particular surgical procedures. (13) The findings, in the May, 1992 edition of Neurology, indicate patients who do not have private or workers’ compensation insurance are rarely diagnosed with thoracic outlet syndrome and Medicaid patients almost never undergo surgery for TOS. Medicaid does not pay or pays very little for such procedures.

The thoracic outlet is made up of three passageways in which this neurovascular bundle can be compressed:

• The Scalene Triangle• The Costoclavicular

Space• The Subcoracoid Space

Four Subtypes Of Thoracic Outlet Syndrome

• Neurogenic - compression of the nerves in the bundle

• Venous - compression of the vein of the bundle• Arterial - compression of the artery of the

bundle• Disputed - it is disputed there is a thoracic

outlet syndrome like symptom pattern but the exact cause cannot be determined.

Symptoms of Thoracic Outlet Syndrome

• As the compression of the neck, upper back, shoulders and chest lead to narrowing of the thoracic outlet you may initially feel slight numbness and tingling of the finger tips, then more progressive numbness, weakness in the hands when gripping things like opening a jar of food, arms, and you may even start dropping things.

• • In extreme cases you may see wasting of the muscles of the hand and arm,

discoloration of the hand, cold fingers and hands, a lack of color in the hand and even pain and swelling in the arm and hand, possibly due to blood clots.

• • The symptoms can be in one arm or in both. (17) In fact if the symptoms are

in both arms it’s more likely thoracic outlet syndrome making it easier to diagnose.

First – How Is The Body Designed

• How is it engineered to protect itself from impacts?

• How is it designed to recycle energy for maximum efficiency?

• How is it engineered to provide spaces so bones wont bang or grind?

• By what engineering creates the thoracic tunnel for the blood vessels and nerves to pass safely?

How The Mechanism Is Controlled

• How are movement patterns stored in the brain?• How does the nervous system sense and react to

strained positions and movements?• How does the does the nervous system react to

strained positions or movements? • Can these abnormal strained moment patterns be

reprogrammed?• How does the nervous system modulate and

change the tension on the human spring?

The top 5 advancements in musculoskeletal medicine have been:

• Arthroscopic surgery • The use of nails, screws and plates to stabilize

unstable joints that are damaged or degenerated

• Joint replacements • Digital x-rays • 3-D models from CT and MRI studies

These are the models of human movement we are going to examine:

• The inverted pendulum model, which is 340 years-old and still the primary source of information for most doctors.

• Resistance exercise and the lever series model - A vision of exercising the body and human movement propelled with a series of lever-like connections.

• The spring-mass model, that acknowledges the lower half of the body in motion operates as a spring mechanism.

• The integrated spring-mass model, which is an advancement of the spring-mass model theorized by scientists from Harvard that includes the upper body and head.

Inverted Pendulum Model

• In 1685, a renaissance Italian physiologist physicist and mathematician Giovanni Alfonso Borelli’s major achievements focus on explaining human movement or biomechanics. (1)

• Running according to Borelli was perceived to be a different process – as a rebounding or bouncing off compliant or bent legs. (1)

Plyometrics

• At age 26, I expanded on that experience by organizing a course at the National Institute of Physical Culture and Sports Sciences in Moscow in 1988 that featured Yuri Verkhoshansky and many other top Russian sports scientists.

Borelli Giovanni Alfonso 1680 Inverted Pendulum & Lever Model

• De Motu Animalium, Pars prima or On the movement of animals

• In his seventeenth century volume ‘De motu animalium’, Borelli discussed walking as vaulting over stiff legs using a pair of compasses and noted the importance of rebounding on compliant legs in running (97).

• From that early account up to the present, walking and running have been treated as different mechanical paradigms, and the two corresponding models, the inverted pendulum model for walking (5) (98)

Spring-Mass ModelBlickhan 1989; McMahon & Cheng 1990

Harvard University

• The planar spring-mass model is a simple mathematical model of bouncing gaits, such as running, trotting and hopping (105)

Inverted Pendulum vs Spring-MassGeyer H., Seyfarth A., Blickhan R. 2006 (13)

• Recent modeling analysis has shown that Inverted Pendulum applies well to walking

• The basic mechanics of human locomotion with the Inverted Pendulum model are associated with vaulting over stiff legs in walking and rebounding on compliant legs in running.

• However, while rebounding legs well explain the stance dynamics of running, stiff legs cannot reproduce that of walking.

• With a simple bipedal spring-mass model, we show that not stiff but compliant legs are essential to obtain the basic walking mechanics

• We argue that not stiff but compliant legs are fundamental to the walking gait.

• In fact, they concluded the spring-mass model was best for describing the walking gait

• With a simple bipedal spring-mass model, we show that not stiff but compliant legs are essential to obtain the basic walking mechanics; incorporating the double support as an essential part of the walking motion, the model reproduces the characteristic stance dynamics that result in the observed small vertical oscillation of the body and the observed out-of-phase changes in forward kinetic and gravitational potential energies.

Spring-Mass Model vs

Integrated Spring Mass Model

• The Spring-Mass Model embodies that during walking and running, the whole leg were a linear spring. (15)

• The Spring-Mass Model models the legs as springs and the torso as the mass

Spring-Mass Model vs

Integrated Spring Mass Model

• Integrated Spring-Mass Model suggests the legs are the combination of a Progressive Rate Spring and Torsion Spring

• This new model models the legs as Progressive Rate Torsion Springs the body as a Progressive Rate Spring and Torsion Spring.

• The head is the only mass

Spring-Mass Model vs

Integrated Spring Mass Model

• Lever Defined:

A simple machine consisting of a bar that pivots on a fixed support, or fulcrum, and is used to transmit torque. A force applied by pushing down on one end of the lever results in a force pushing up at the other end.

• Spring Defined:

In classic physics, a spring can be seen as a device that stores potential energy, specifically elastic potential energy, by straining the bonds between the atoms of an elastic material.

Inverted Pendulum Model vs Spring-Mass Model

Spring-Mass Model

Types of Springs in the Human Body

• Menisci, Cartilage and Vertebral Discs = Compression Springs

• Spinal Column = Torsion Spring

• Lower limb = Torsion Spring• Foot Arch = Leaf spring• Tendons = Extension Springs• Human body = Torsion

Spring

Spring-Mass

• The head is the mass

Springs and tunnels provide a space for structures to pass safely

• The nerves pass safely between the vertebra of the spine.

• The nerves that pass safely over the rib cage.

• The nerves pass safely under the shoulder girdle.

• The blood vessels pass safely over the rib cage.

• The blood vessels pass safely under the shoulder girdle.

What Are The Only Structures That Can Compress The Human Spring

Muscles…That is why surgeons cut them out

Muscles When Contracted Compress The Thoracic Outlet & Tunnel

1. Anterior scalene2. Middle scalene3. Pectoralis minor4. Anterior cervical5. Subclavius6. Anterior deltoid7. Biceps short head8. Coracobrachialis

What muscles are addressed with surgery

• ONLY THREE

1. Anterior scalene2. Middle scalene3. Pectoralis minor4. Anterior cervical5. Subclavius6. Anterior deltoid7. Biceps short head8. Coracobrachialis

Hooke’s Law Of Physics Applied To Your Human Spring

• Hookes Law of elasticity, discovered by the English scientist Robert Hooke in 1660, states the amount of deformation of the spring is dependent on the weight or force of the load. That means the heavier the load causes more deforming of the spring.

• The tension on the spring or spring stiffness is also a factor. If your spring is strong and has a greater degree of stiffness then it can hold heavier loads during springing. (walking, running and impacts from sports)

Spring Modification, Tweak, Fine Tuning or Regulation

• Spring Compliance• Spring Stiffness

• Muscle Stiffness is not Spring Stiffness

What Determines Human Spring Strength?

• Overall body stiffness• Single joint stiffness (i.e. foot stiffness, limb stiffness,

spine stiffness and head neck stiffness)• Muscle tendon unit stiffness (i.e. medial

gastrocnemius and achilles acting together)• Individual tissue stiffness (i.e. achilles tendon)• Individual fiber stiffness (i.e. single muscle fiber) (58)• Cellular stiffness – Scientists have found that even

cells have stiffness factors

A Weak Spring

• Capable of improving spring compliance thus protecting you from impacts like steps and accidents

• Capable of increasing the spring stiffness potential to improve efficiency of movement

• Capable of a strong spring suspension system, maintaining a wide opening in your thoracic outlet and tunnel and other openings where blood vessels and nerves pass.

Nervous System Learned Behaviors and Reflexes

• The nervous system can adjust the stiffness of the muscles and tendons that support the spring to reduce stiffness to make it more compliant and better able to absorb the forces of impacts of walking and running on different surfaces. However when the spring is more compliant your body needs more energy to move.

• The nervous system can also adjust the tension on the spring to make it stiffer so the spring bounces

your body off the ground with more efficiency and speed. The greater the tension on the spring the less apt it is to protect you from impacts.

• The nervous system can alter the tension on the spring to adjust for the forces of gravity to control balance, posture and equilibrium while lying down, sitting, standing, lifting and other movements.

• The nervous system tightens the tension on the spring when the sensory system signals that it is in a

stressful or injured state.

• The nervous system can help you by programming every day activities of daily life into programmed patterns such as walking, talking, eating, etc

Key Nervous System Function

• #3 The nervous system can alter the tension on the spring to adjust for the forces of gravity to control balance, posture and equilibrium while lying down, sitting, standing, lifting and other movements.

Reflexes

• In many cases tasks you take for granted are hard wired in your nervous system called reflexes. They react faster than learned behavior, which is a good thing because they protect you from harm.

• This is called an involuntary task because you did not volunteer to do it. It happened automatically without your control.

Is posture reflexive or a learned behavior?

• Sir Charles Sherrington’s made some significant scientific breakthroughs and it was his work entitled, The integrative action of the nervous system published in 1906 is regarded as the founding text of modern neuroscience devoted to understanding how reflexes work. He determined that perfect balanced posture is actually controlled by reflexes.

Posture• Your posture allows you to maintain upright alignment of

the floors of your integrated spring mechanism. • It maintains the spaces between your joints and the

openings and tunnels that allow your blood vessels and nerves to pass safely.

• It permits efficient movement patterns through a recycling of the energy through a balanced spring mechanism.

• It allows your joints to be loaded symmetrically which will decrease loads and strains on your ligaments, muscles and tendons, cartilage and bones.

The two main functional goals of postural behavior are:

• Postural Orientation - Postural orientation involves the active control of body alignment (strain free or strained) of the seven floors of your integrated spring with respect to gravity, the surface you are lying, sitting or standing on, and your internal state.

• Postural Equilibrium - The human body is said to be in equilibrium when all forces or tensions are balanced. The body should have no strain when it is in the state of equilibrium.

Sensory Receptors

• Skin Pressure Receptors• Visual Systems (your eyes)• Somatosensory Systems • Vestibular System

The Somatosensory System

• These special receptor cells include muscle spindles (2) Golgi tendon reflex cells (3), joint receptors, (4) skin receptors, (5) visual and balance control or vestibular receptors (6) (7) (8) (9) and receptors that control the flow of blood through your circulatory system and respiratory system or the control of your rib cage spring (9)

•

Muscle Spindle Cells – What is their function?

• Strain on the muscle fibers creates strain on the filaments of the spindle cells. The nerves that attach to the filaments transmit the message of how much strain is on the muscles. This important information is relayed to the brain’s software by the nerves.

The Vestibular System • provides information

related to movement and head position related to your body positions relative to gravity

• is important for development of balance, coordination, eye control, attention, being secure with movement

Vestibular Reflexes• Vestibulo-Ocular Reflex • The vestibulo-ocular reflex generates eye movements that enable

your eyes to remain focused on the target while the head is in motion.

• Vestibulospinal Reflex • The vestibulospinal reflex generates tenses the muscles below the

neck to provide compensatory body movements in order to maintain head and postural stability and thereby prevents falls.

• Vestibulocollic Reflex• The vestibulocollic reflex takes control of the tone of the neck,

trunk and limb muscles to adjust your head so it remains perpendicular to gravity so your eyes are horizontal to earth.

Righting Reflex Or Labyrinthine Righting Reflex

• The most important reflex is called the "righting reflex". When the position of the head or body changes, reflex movements occur that return the head or body to the normal posture of your head perpendicular to gravity and your eyes level with the horizon.

The Cause of Compression!

• The optimum management of TOS requires an understanding of the underlying cause(s) of the neurovascular compression or tension. (1)

• Headaches• Neck pain• Upper Back Pain• Herniated disc in the neck• Thoracic Outlet Syndrome• Cubital Tunnel Compression• Median Nerve Compression Of The

Forearm• Carpal Tunnel Compression• Guyon Tunnel Compression 107• Low back pain• Herniated disc in the low back• Degenerated discs• Degeneration of the knees• Degeneration of the hips

Doctors say the causes of Causes of Thoracic Outlet Syndrome

• In the 2300 studies that came up in the search of the National Institute of Health, US National Library of Medicine, database there a little over a dozen different ways the thoracic outlet and/or tunnel can become compressed.

1. Muscle Super Contractions (Spasms) caused by poor posture, 2. Something grows into the outlet (scar tissue, tumor)3. Conditions you are born with or anomalies (cervical ribs,

elongated bones)4. A Traumatic Shift (rib fracture, clavicle fracture, car accident,

work injury, sports injury)•

Muscle Contraction• Your brain sends an electric signal through nerves that connect to muscles. When the

signal arrives, a chemical, acetylcholine is released into the space between the nerve and muscle. The acetylcholine docks or binds to the receptors of the muscles surface. This causes calcium to enter the muscle cell. This starts the contraction of the muscle.

• • During the contraction, the pressure on the capillaries increases temporarily moving the

blood out of the area. When the contraction releases, the pressure releases blood flows back into the muscle.

• • After a healthy contraction, a little bit of lactic acid is released. This makes the area a little

acidic. Under normal circumstances lactic acid is flushed out of muscles into the bloodstream within 30 minutes after the exercise.

• • At about the same time, an enzyme called acetylcholineesterase breaks up the

acetylcholine to prevent the acetylcholine from constantly triggering the muscle contraction.

Abnormal Muscle Contractions

• A single overloading is like a whiplash, sports injury or work accident.

• A recurring episode of sustained biomechanical overloading is more than 20 repetitions of muscle contraction with no rest.

• A sustained biomechanical overloading would be like holding a 9-pound bowling ball in your arms for 30 minutes or more without rest.

Theory #1

• Compression• Lack of Blood flow• Aerobic to Anaerobic Metabolism• Lactic Acid• PH Below 7• Acetylcholineesterase cannot breakdown

Acetylcholine

Theory #2• This constant state of muscle contraction damages muscle tissue. These

damaged muscles release inflammation.• Intertwined between muscle and tissues are other receptors called

nociceptors. According to the International Association for the Study of Pain, a nociceptor is defined as: “… a high-threshold sensory receptor of the of the nervous system that is capable of detecting stressful, harmful and even toxic stimuli. (3)

• • They are thin nerve fibers in muscles that sense and send information

about harmful mechanical, temperature and chemical stimuli in and around muscles. These nerves send this information to the brain. (7)

• Different tracts of the spinal cord have the ability to transmit nociceptive information to the central nervous system (spinal cord and brain). (9)

2. Something grows into the outlet (growth or tumor) RARE

• When something like a pancoast tumor or other tumor grows into the thoracic outlet or tunnel this is usually in the later stages of the tumor growth. By this time you should already have the diagnosis of the tumor however sometimes it is the symptoms of TOS that get you to the doctor first.

• If you have a pancoast tumor of the lung you are more concerned with survival than the thoracic outlet syndrome.

3. Conditions you are born with or congenital Abnormalities (cervical ribs)

• It is rare for patients with an extra rib to spontaneously develop thoracic outlet syndrome. One researcher reported that over a 28-year period and 1000 surgeries for thoracic outlet syndrome there has been an incidence of less than five percent for extra or deformed first ribs. (46)

Sleeping Posture and Sustained Contraction

Sitting Posture and Sustained Contraction

Pectoralis Minor Contraction &“All of the above” Contraction

The Rules Of Gravity &The Righting Reflex

• Body Lean Right Causes Scalene Contraction On The Left To Tilt The Head Left And TOS On The Left

• Body Lean Left Causes Scalene Contraction On The Right To Tilt The Head Right And TOS On The Right

• Body Lean Back Causes Scalene And Anterior Neck Muscle Contraction For A Neck Lean Forward And TOS On The Left And Right

Neck-Upper Extremity Problems - Workplace Stressors – Causes

• Repetition Strain Injury – Keyboards - You have to hold the arm in a certain position to get your fingers on the keyboard, which strains your pectoralis minor muscle, the coracobrachialis, the long and short head of the biceps as well as the anterior deltoid muscles.

• Mouse Use Duration - One research study found an association between use of a mouse device for more than 20 hours per week and risk of possible carpal tunnel syndrome rather than actual duration of keyboard use. (23)

• Monitor position and visual stressors

A single overloading strain on muscles, tendons, ligaments and bone.

• Motor vehicle accidents resulting in whiplash are the most common causes of neck injuries with approximately 1,000,000 per year in the US. (38)

Diagnosis – History - The Symptoms

10 most common symptoms reported in patients with TOS include

• Numbness, Burning Pain or Tingling In The Upper Limb (98%) • Neck Pain (88%)• Trapezius Pain (92%)• Shoulder and/or Arm Pain (88%)• Collarbone Pain (76%)• Chest Pain (72%)• Headache at the base of the Skull (76%)• Numbness, Burning Pain or Tingling In All Five Fingers (58%)• Numbness, Burning Pain or Tingling In The Fourth & Fifth Fingers Only (26%)• Numbness, Burning Pain or Tingling –Third Fingers (14%)

Common ADLS associated with TOS• They sit for long periods of time at work in static positions with a

bad chair or in an awkward posture.• They are sitting or lying in static positions with awkward postures

when they're at home when on the computer or when watching TV.

• They are leaning back in the bed propped up with the pillows.• They are sitting on a recliner watching television or reading a book• They are driving long distances with the seat back.• They are doing work over head which forces them to hold their

arms up for a long period of time.• They carry heavy luggage, book bags, purses, bags or backpacks, or

all the above.

These are the two causes of a shift in the structures

• Abnormal Muscle Weakness - Weakness in the muscles that suspend the shoulder over the outlet such as the upper trapezius and levator scapula can happen either from fatigue or general weakness.

• Abnormal Muscle Tension - Trigger point super contraction can cause direct or indirect compression of the outlet. Ribs can elevate into the outlet by a super contraction of the scalenes and the shoulder can get pulled or dragged down into the outlet by super contraction of the pectoralis minor, the subclavius muscle, the coracobrachialis, the biceps short head, and the anterior deltoid.

8 Muscles that Compress the Outlet

1. The Anterior Neck Muscles – (Compress the neck into the head)2. The Anterior Scalene muscle – (Compress the neck)3. The Subclavius Muscle – (Compress the shoulder into the outlet)4. The Coracobrachialis – (Compress the shoulder into the outlet)5. The Pec Minor Muscle – (Compress the shoulder into the outlet from

the front)6. The Latissimus Dorsi Muscle – (Compress the shoulder into the outlet

from the back)7. The Biceps Short Head Muscle – (Compress the arm into the shoulder)8. The Anterior Deltoid Muscle (Compress the arm into the shoulder)

Examination

• Manual Muscle Testing • Orthopedic Tests

Orthopedic Tests • Adsons Test – Scalenes and

First Rib Elevation (Adson’s test more specifically address compromise to the plexus through the scalene triangles)

• I take the pulse to feel the blood pulsating against my fingertips. Then I move your arm behind your back and rotate it in adduction extension and external rotation. (see image)

Orthopedic Tests

• Cervical rotation lateral flexion test

• Costal Clavicular Maneuver

• Hyperabduction Maneuver – Wrights Test

• Roos Test (elevated arms stress test)

• Cyriax Release Test

Roos Test (elevated arms stress test)

• With this test I ask you to raise your arms in a position like you are about to do a military press.

• Then I ask you to open and close your hands slowly for 3 minutes.

• If you are unable to keep your arms in this position for 3 minutes or if you have pain, heaviness, or weakness in the arm or numbness or tingling in the hand during the test then some doctors say this is a positive Roos test.

Hyperabduction Maneuver Wrights Test

• In this test I am feeling your pulse to get the rhythm and intensity. Then I ask you to lift your arm over your head and extend it back behind you.

Cyriax Release Test• What you do is sit down in a

chair with your arms pain down elbows bent at 90°. Put some pillows underneath your forearm to elevate your shoulders up so that the shoulder girdle is elevated opening the thoracic outlet tunnel. If the symptoms of nerve, artery or vein compression diminish then this is a positive sign of thoracic outlet syndrome. (13)

•

Diagnostic Tests

• When is diagnostic testing indicated?

• Persistent thoracic outlet syndrome, back or neck pain with radiating pain, numbness or tingling in the arm and no improvement after 2 weeks of conservative therapy? 4 weeks? 6 weeks?

• One doctors recommendation was that diagnostic testing should start at 12 weeks of conservative therapy.

Why would they order these tests the first day without conservative care for 2 – 12 weeks first?

• They don't have faith in their field exam skills.• They just don't know what to look for and think the test will tell them

everything.• They don't have faith in conservative therapy for TOS and are setting you up

for surgery.• They were told by the hospital to do more tests.• You may have a thrombus that could turn into an emboli.• Your arm is blue or purple.• Your arm is grey and you may lose a limb.• They think it is something other than thoracic outlet syndrome.• Your condition has not improved after 2-3 weeks of treatment• You had a car accident or work injury and your lawyer said diagnostic

testing was necessary to prove you had an injury.

What are legitimate reasons for doing diagnostic testing?

• Dx tests are ordered if you are experiencing progressively severe symptoms regardless of what conservative therapy is done after at least 4 weeks of aggressive conservative therapy outlined in chapter 11.

• You have severe pain requiring hospitalization. The doctor may suspect you don't have thoracic outlet syndrome but instead maybe a spinal cord injury secondary to trauma, spinal fracture, some infectious process, spinal stenosis, multiple sclerosis, spinal cord or bone tumors fracture.

• You have some new neurological signs or symptoms: noticeable arm or leg weakness; abnormal reflexes, or a suspected cord compression with any of the following neurologic deficits, e.g., extremity weakness, abnormal gait, asymmetric reflexes.

• They suspect thoracic outlet syndrome and a rotator cuff tear, or labral tear.

• You had an auto accident or work related trauma that could be a fracture or dislocation

Diagnostic Tests that Rule out Thoracic Outlet Syndrome

• X-Rays • Specialized nerve Tests: EMG, NCV and SSEP Tests• Venography• Venous Scintillation Scans (Ct, Mri Or Pet Scans)• Doppler Ultrasonography• Plethysmography• Magnetic Resonance Angiography• Duplex Scanning• CT Angiography• Pulse Oximetry

X-Rays

• A Straight Or Reversal Of The Curve in the Neck (military neck)

• Disc Degeneration and Joint Degeneration In The Neck

• Calcium Deposits In The Rib Joints• Extra Ribs In The Neck (Cervical Ribs)

Nerve Conduction Velocity Test

• Some doctors think that the nerve conduction velocity test is their primary objective test for thoracic outlet, nerve compression. (3)

Venography Also Called Phlebography Or Ascending Phlebography

• Doctors can check to see if you have a compressed vein. If a vein or artery has a clot, doctors can deliver medications through the catheter to dissolve the clot.

• showed appropriate flow in left subclavian artery in adduction of left upper limb.

Pulse Oximetry

• Pulse oximetry monitors the oxygen in your blood.

• I have a pulse oximeter with plethysmogram that I use when doing my examinations of patients.

30 Different Conditions in theDifferential Diagnosis

Neck Trauma• Trauma - Cervical Disc Injury – 6th

nerve root• Trauma - Cervical Disc Injury – 7th

nerve root• Trauma - Cervical Disc Injury – T1

nerve root• Cervical Radiculopathy or Brachial

Plexus Injury Brachial Neuritis (5)• Cervical Spondylosis – • Neck Trauma • Thoracic Disc Injuries

Shoulder Diagnosis

• Clavical Injuries - Acromioclavicular Joint Injury

• Clavical Fracture Malunion• Inflammatory Conditions of the

shoulder (tendonitis arthritis)• Shoulder impingement Syndrome• Rotator Cuff Inflammation

• Intercostal Neuritis (pinched nerve between the ribs)

Extremity Compression

• Compressive Neuropathy - Cubital Tunnel Compression

• Compressive Neuropathy - Carpal Tunnel Syndrome

• Compressive Neuropathy - Guyon's canal

• Compressive Neuropathy - Median Nerve Entrapment

• Compressive Neuropathy - Double Crush (5)

• Compressive Neuropathy - Triple Crush

• Compressive Neuropathy - Quadruple Crush

Vascular Compression

• Vascular Diseases (atherosclerosis)• Paget-Schroetter syndrome AKA

Effort Thrombosis• Tumors and Others

• Pancoast’s Tumor• Spinal Cord Tumor or Neoplasm• Complex Regional Pain Syndrome

(reflex sympathetic dystrophy) (5)• Degenerative Spinal Cord Disease –

MS• Degenerative Spinal Cord Disease -

Syringomyelia• Raynauds Phenomenon• Cervical Ribs and Fibrous Bands (6)

General Musculoskeletal

• Myofascial Pain Syndrome

Neck Trauma

• Trauma - Cervical Disc Injury – 6th nerve root• Trauma - Cervical Disc Injury – 7th nerve root• Trauma - Cervical Disc Injury – T1 nerve root• Cervical Radiculopathy or Brachial Plexus

Injury Brachial Neuritis (5)• Thoracic Disc Injuries• Cervical Spondylosis –

Shoulder Diagnosis

• Clavical Injuries - Acromioclavicular Joint Injury • Clavical Fracture Malunion• Inflammatory Conditions of the shoulder

(tendonitis arthritis)• Shoulder impingement Syndrome• Rotator Cuff Inflammation • Intercostal Neuritis (pinched nerve between

the ribs)

Extremity Compression

• Compressive Neuropathy - Cubital Tunnel Compression

• Compressive Neuropathy - Carpal Tunnel Syndrome• Compressive Neuropathy - Guyon's canal• Compressive Neuropathy - Median Nerve

Entrapment • Compressive Neuropathy - Double Crush (5)• Compressive Neuropathy - Triple Crush• Compressive Neuropathy - Quadruple Crush

Vascular Compression

• Vascular Diseases (atherosclerosis)• Paget-Schroetter syndrome AKA Effort

Thrombosis

Tumors and Others

• Pancoast’s Tumor• Spinal Cord Tumor or Neoplasm• Complex Regional Pain Syndrome (reflex

sympathetic dystrophy) (5)• Degenerative Spinal Cord Disease – MS• Degenerative Spinal Cord Disease - Syringomyelia• Raynauds Phenomenon• Cervical Ribs and Fibrous Bands (6)

What treatment “alone” doesn’t work and why?

• • Gentle Stretching and/or Stretching Exercises• Traction • Ultrasound, Hot Packs & Muscle Stimulation• Structural Massage (myofascial, neuromotor techniques)• Scalene Injection (Bupivacaine)• Scalene Injection (Botox)• Nerve Gliding• Different Bra For Breast Hypertrophy• Breast Reduction - Reduction Mammoplasty• First Rib Adjustments Alone• Nonsteroidal Anti-Inflammatory's NSAIDS• Medication: Analgesic drug therapy, Antidepressants, Anticonvulsants, others• Painkillers For Symptom Reduction • Strengthening with Exercise• Correction Of The Ergonomics Of The Workstation • Ergonomic Corrections

1. Gentle Stretching and/or Stretching Exercises

• Gentle stretching of the neck from side to side in my opinion actually causes of elevation of the ribs even worse

5. Scalene Injection (Bupivacaine, Etidocaine, Lidocaine, and corticosteroids)

• The first flaw in this approach to diagnosis and treatment is that the scalene muscle is not the only muscle that causes the compression of the nerves and blood vessels.

• The second flaw in this approach to diagnosis and treatment is that these injections only affect the muscle itself. The reflex is stored in the brain.

6. Scalene Injections of Botulinum toxin or Botox

• Botulinum toxin can also cause prolonged muscle relaxation through inhibition of acetylcholine release. (12)

• It causes muscle fibers began to get weaker on the 4th day and this continued to the 14th day after being injected. (11)

• It blocks contraction of not only of muscle contraction, but also of contraction of the spindle cell fibers too. (395) Atrophy or weakness will result in the spindle cells which are the strain gauges that gauge the tension on the scalenes for balance and equilibrium.

• Also, after the drug wears off you will end up with severe atrophy of the muscle, which will require months of rehabilitation to build the strength back.

Are Botox injections effective? Here are three studies that say its not.

• 1. One study found that 64% of subjects had a minimum of 50% decrease in pain, numbness and

fatigue for at least month following the injection. (13) We all know that botulism or Botox injections are a neurotoxin being injected into the body. We also know that Botox only provides temporary relief to ONLY muscle with spasms that are injected.

• 2. In a double blind, randomized, controlled trial conducted at the University of British Columbia, Department of Medicine, Division of Physical Medicine and Rehabilitation, British Columbia, Canada, the effect of botulism toxin type injections to the scalene muscles on patience with thoracic outlet syndrome's were studied in six week, three months and six months increments. (14)

– The study concluded that Botox injections to the scalene muscles did not result in clinically or statistically significant improvements in pain, paresthesias, or function in this population of subjects with TOS. (14)

• 3. Additionally, many patients in a study done at Johns Hopkins Hospital in Baltimore report no relief of symptoms from Botox or scalene injections, which may indicate that the pain does not stem from the scalene muscle and may not be TOS. Botox can be an effective treatment for neurogenic TOS.

When is surgery medically necessary?

• Failure Of A Carefully Supervised Physical Therapy Program (8)• Intractable Pain (8) • Neurologic Deficit (8) – Weakness and Decreased Sensation• Long Term Compression • Limb Threatening Complications• Arterial Compression• Completed And Successful Initial Treatment Of Subclavian Vein

Thrombosis (8)• Post Subclavian Vein Thrombosis - Vessel Reconstruction• Surgery was performed for all the wrong reasons.• Paget Schroetter Syndrome (PSS)

Failure Of A Carefully Supervised Physical Therapy Program (8)

• The condition was misdiagnosed from the start.

• The patient was under diagnosed - The patient had thoracic outlet syndrome and an overlapping condition or two that were not treated.

• The treatment approach did not focus on the 5 requirements to effectively reverse thoracic outlet syndrome in the long term.

• The health care professional tried the five requirements but did not have enough experience nor the skill set to do the release of the super contractions.

• You don’t have the resources (insurance) or you ran out of insurance.

Thoracic Outlet Syndrome - Surgery

• Thoracic outlet syndrome surgery involves surgical removal of the scalene muscles and the first rib.

• They may even remove the pectoralis minor if they feel the collarbone and shoulder is compression of your thoracic tunnel.

• Some do the shot gun approach because they feel, when in doubt cut it all out.

• This is the strategy of surgically removing all three muscles and the ribs too. (2)

• The treatment approach must erase the neuromotor pattern in the brain, which controls the constant super contractions of the eight muscles, which can either directly or indirectly compress the thoracic outlet completely.

• The “joint play” must be reestablished in the joints such as the top ribs (costochondreal and sterno claviular joints), the joints of the collarbone ( the sternoclavicular joint and acromioclavicular joints) as well as the joints of the vertebral column must be unlocked.

• All inflammatory chemicals must be flushed out of the area to prevent retriggering of the neuromotor pattern of muscle super contractions.

• The muscles that suspend the shoulder over the thoracic outlet and tunnel must be trained to open and preserve adequate space in the thoracic outlet and tunnel.

• Your activities of daily living must not exacerbate the condition.•

Pectoralis minor surgery

Why The Pectoralis Minor Surgery Is An Inadequate Approach To Decompression

• The Pectoralis Minor isnt the ONLY muscle to compress the shoulder girdle to the chest

• The coracobracialis and biceps short head also attach at the coracoid and drag the shoulder into the outlet

Complications of surgery1. Postoperative Scars 2. Recurrences3. Winging Scapula - Long Thoracic Nerve?4. Postoperative Bleeding - Apical Hematomas5. Pneumothorax6. Artery Injuries7. Upper Limb Ischemia8. Vein Complications9. Brachial Plexus Injuries10. Phrenic Nerve Paralysis11. Scapula Alta12. Death

What are the 5 Key Components to a Successful Conservative Therapy Approach

• • The treatment approach must erase the neuromotor pattern in the brain, which controls

the constant super contractions of the eight muscles, which can either directly or indirectly compress the thoracic outlet completely.

• The “joint play” must be reestablished in the joints such as the top ribs (costochondreal and sterno claviular joints), the joints of the collarbone ( the sternoclavicular joint and acromioclavicular joints) as well as the joints of the vertebral column must be unlocked.

• All inflammatory chemicals must be flushed out of the area to prevent retriggering of the neuromotor pattern of muscle super contractions.

• The muscles that suspend the shoulder over the thoracic outlet and tunnel must be trained to open and preserve adequate space in the thoracic outlet and tunnel.

• Your activities of daily living must not exacerbate the condition.

Paget-Schroetter Syndrome • Effort thrombosis, or Paget-

Schroetter Syndrome, is a outcome of venous thoracic outlet syndrome that got much worse!

• It is when the compressed vein in your chest under your collarbone (axillary-subclavian vein) has a blood clot (thrombosis).

• This is usually associated with strenuous and repetitive activity of the upper extremities.

Paget-Schroetter Syndrome Symptoms

• The primary symptom is arm swelling, frequently accompanied by cyanosis, pain, and occasionally paresthesias. (7)

• Cyanosis is a blue discoloration of the skin and mucous membranes resulting from inadequate oxygenation of the blood.

• Symptoms can be excruciating deep pain the chest,

shoulder and entire upper extremity, accompanied by a feeling of heaviness that occurs especially after activity

The symptoms of subclavian vein effort thrombosis are

• Heavy After Activity• Deep Pain In The Chest• Cyanotic Discoloration• Distended Dilated

Collateral Veins – Urschels Sign

• Edema• Swelling And Discomfort• Redness In The Arms• Cyanosis

Paget-Schroetter Syndrome - Cause• Effort thrombosis usually follows

sporting activities, such as wrestling, playing ball, gymnastics and swimming, which involve vigorous and sustained shoulder and arm movements. (10)

• A majority of patients report a discrete

precipitating event, usually sports-related arm exertion. (10)

• Approximately 60–80% of patients diagnosed with Paget-Schroetter Syndrome report a history of repetitive or vigorous overhead activity.

Diagnose the Vein Obstruction

• Angiography• MRV Venography For

High Sensitivity • Compression

Ultrasonography With Color Doppler

• Contrast Venography• Magnetic Resonance

Venography

Treatment - Surgery• Limb Elevation• Local Catheter Directed Thrombolytic

(drugs are used in medicine to dissolve blood clots)

• Fibrinolytic Agent (clot dissolving drug)• Remove The Extrinsic Compression

(thoracic outlet surgery)• Remove The Intrinsic Stenosis (cut out

part of the vein that is narrowed)• Vein Patch Angioplasty (patch that part

of the vein)• Percutaneous Angioplasty (technique of

mechanically widening narrowed or obstructed arteries)

• Subclavian vein narrowing requires balloon angioplasty

Rehabilitaiton• • Inpatient physical therapy is started

the day after the operation to maintain range of motion, with postoperative rehabilitation then overseen by a physical therapist with expertise in the management of TOS, and no restrictions placed on upper extremity activity beyond 12 weeks after surgery. (4)

• • Full recovery is typically complete

within 3 months of the operation, and a return to previous levels of functional activity can usually be expected. (4)

Pulmonary Embolism• When the clot releases into the lung,

this could be a big problem. Doctors call it a pulmonary embolism. The key signs and symptoms of a pulmonary embolism include dyspnea, chest pain, syncope, low-grade fever, and Racing heart rate. (25) (26)

• • It only happens with 5.6%, which is

rare for Paget–Schroetter syndrome. However, a pulmonary embolism is a serious complication related to this condition that may result in a fatal outcome, reinforcing the importance of a proper diagnosis. (25) (26)

What works• Step 1 - Release the compression of your bodies spring

and the compression on your thoracic outlet and tunnel• • Step 2 - Strengthen your bodies spring suspension

system to suspend the shoulder over the thoracic outlet and tunnel with resistance exercises

• • Step 3 - Spring train the human spring with spring

training drills and plyometric exercises to enhance and maintain the bodies human spring engineering

What makes your deep tissue treatment effective in decompressing the outlet?

• You must know what muscles and where they are.• You have to know how to get the super contraction directly under

your thumb• You must apply the right depth of pressure• You must know how long to hold the point• You must know where the super contraction patterns will be.• You must know the patterns of referred pain• You must know how the symptomatology progresses through the

application• You must know what is good pain and what is bad pain• You need to know when its completely released (MMI)• You need the ideal therapy to change the biochemistry

You need to know how long each treatment will take

Eight Muscles that Either Directly or Indirectly Contribute to Compression of the Outlet

1. Subclavian Muscle – 6 cun2. Supraspinatus Muscle – 4 cun3. Anterior Scalene Muscle - 6 cun4. Middle Scalene Muscle – 6 cun5. Pectoralis Minor Muscle – 6 cun6. Anterior Deltoid Muscle – 4 cun7. Biceps Short Head Muscle – 4 cun8. Coracobrachialis Muscle – 4 cun

Additional Muscles Considered: 9. Latissimus Dorsi Muscles 2 cun10. Suboccipital Muscles – 2 cun

• Total area to cover is 44 cun.

• So if you have a very chronic severely compressed upper body it may take 3 or more minutes per application point.

• If you are that patient it would take an estimate 132 minutes to treat all the muscles that directly or indirectly compress the outlet on one side of the body on the first three visits.

• It would be 264 minutes if the condition is on both right and left sides equally. That means that it could take over 2 hours to cover every inch of every muscle on one side and up to 4 hours if its on both sides.

The Fastest Approach• Patients are treated in slots of three

hours per day where they get 30 minutes of vibrational massage and 2.5 hours of deep tissue per day.

• This amount of deep tissue allows me to pass through all of the effected muscles multiple times per visit speeding up the recovery.

• The treatments are minimum three hours long. This is required for more difficult to reverse cases that come from out of town.

How I Got My Wiggle Back Anthony Field / Wiggles

Deep Tissue Techniques

Neck Muscles

Shoulder Muscles

First Rib Adjustment

Neck Exercises

Neck Exercises

Torso, Chest and Shoulder Stretch

Thank You!