THORACIC OUTLET SYNDROME (TOS)

  

STEVEN D. FEINBERG, M.D.

American Board of Pain Medicine

American Board of Electrodiagnostic Medicine

American Board of Physical Medicine & Rehabilitation

Qualified Medical Evaluator

Stanford Medical School 

1101 Welch Road, Suite C-8

Palo Alto, CA 94304

 

 RACHEL M. FEINBERG

Physical Therapy Student

University of Southern California

 

PETER I. EDGELOW, M.A., P.T.

Physiotherapy Associates

3100 Diablo Avenue

Hayward, CA  94545

 

 In this article on Thoracic Outlet Syndrome, we provide you with the traditional view of treatment but also include a different approach pioneered by physical therapist Mr. Peter I. Edgelow. I personally have been impressed with his treatment regimen but have found that patient’s with non-physiologic or psychosocial issues or those with a sense of entitlement or anger may do poorly with treatment, regardless of the approach, unless those perceptions and attitudes are changed. As always, please feel free to contact me directly with any questions or comments¼.sdf

 INTRODUCTION

The diagnosis and treatment of thoracic outlet syndrome (TOS) has evolved over many years surrounded by controversy and disagreement. In fact, even the existence of this syndrome as a true clinical entity has been questioned. The weight of clinical and scientific evidence though does suggest that certain individuals have symptoms and signs compatible with the diagnosis of thoracic outlet syndrome. In the great majority of these patients, a successful outcome can be achieved with a careful diagnostic workup and a conservative rehabilitation approach. Surgery is occasionally indicated in specific cases or when the rehabilitative approach has failed.

DESCRIPTION & ANATOMY

Thoracic outlet syndrome is a term describing compression of the nerves (brachial plexus) and/or the vessels (subclavian artery and vein) to the upper limb. This compression occurs in the region (thoracic outlet) beneath the clavicle (collar bone) between the neck and the shoulder. The thoracic outlet is bounded by several structures: the anterior and middle scalene muscles, the first rib, the clavicle, and, at a lower point, by the tendon of the pectoralis minor muscle.

The brachial plexus is a branching group of nerves that form from the nerve roots as they leave the spinal cord in the region of the cervical spine (neck). The brachial plexus passes anteriorly and downward, passing behind and underneath the clavicle (collar bone) where it branches into the peripheral nerves which course below and in front of the shoulder, and then down the arm to provide motor (strength) and sensory (feeling) function to the upper extremity.

As the brachial plexus and subclavian vessels pass through the thoracic outlet, there is potential for both static and dynamic compression and/or compromise. Since the thoracic outlet is a closed space, any intrusion or swelling such as from a fractured clavicle, hypertrophied or spasming muscle or tumor can lead to static compression of the structures that pass through that space. Further, in an already “tight” or compromised thoracic outlet, dynamic movements, such as holding the arm overhead and backward (hyperabduction), will put further compression on the enclosed structures and bring on symptoms. Even breathing can add compression to the thoracic outlet. Breathing is normally begun with the diaphragm, but in paradoxical or chest breathing the patient starts by elevating the upper ribs with the scalene muscles and this tightens the thoracic outlet.

SYMPTOMS

The character and pattern of symptoms will vary depending on the degree to which the nerves and/or blood vessels are compromised. The patient may complain of tingling, numbness, weakness and discomfort particularly down the inside of the arm going into the hand. There may also be swelling, paleness and coldness of the arm and hand. Other related symptoms may include headaches in the back of the head and pain in the neck, shoulder and arm. Symptoms can be brought on by overhead activities such as hair combing, or at night when sleeping on one side which can put pressure on the structures within the thoracic outlet. Each of these maneuvers/positions causes a tightening or compression of the thoracic space. Thus the nerves and/or blood vessels may be compromised and produce the associated symptoms.

THE CONTROVERSY

Over the years TOS has taken on a negative connotation because of poor surgical results or because it has often been employed as a “wastebasket” term when the treating clinician is short on a diagnosis and unable to explain the patient’s complaints. This has resulted in much controversy and disagreement among professionals along with confusion and distrust among claims examiners and patients.

TOS is commonly confused with the following clinical entities: cervical nerve root compression from a protruded disc or degenerative spine disease, stretch injuries to the brachial plexus, tumors, a myofascial pain syndrome or peripheral upper extremity nerve entrapment.

Once the diagnosis is made, too many practitioners have been quick to offer a surgical remedy. A surgical approach is at the core of the controversy precisely because it has either been too often recommended to treat clinical entities that are not TOS or else surgery has been inappropriately used in patients with TOS, with poor results in either case.

Thoracic Outlet Syndrome does exist and is usually treatable with a non-invasive physical rehabilitation approach. Surgery should be reserved for the exceptional case.

DIAGNOSIS

At the foundation of appropriate treatment for TOS, or for any pathology for that matter, is careful diagnosis. Diagnostic tests, such as EMG's or NCV's, may show non-specific abnormalities, but are often normal in patients with TOS. Therefore, these tests are used more for differential diagnosis than confirmation of the diagnosis of TOS. There are advocates of newer tests and procedures such as MRI neurography and various nerve blocks, but these techniques have not been widely accepted.

After taking a thorough history, the physician or therapist will do a physical examination and then may perform a variety of thoracic outlet compression maneuvers during the physical examination to reproduce the patient’s symptoms and thus help pin down the diagnosis. Thoracic outlet compression tests must be interpreted carefully, since even asymptomatic individuals can develop arm numbness, tingling, pain, and diminution of the wrist pulse with these maneuvers. It is a challenge to the clinician to determine the significance of findings on examination in light of the entire clinical picture, including consideration of non-organic, psychosocial factors of disability and dysfunction.

TREATMENT

Treatment approaches for thoracic outlet symptoms are directed toward alleviation or reduction of compression of this space. Surgery, if indicated, may involve total or partial removal of the first rib and an occasionally present extra cervical rib. One of the scalene muscles may also be removed if it felt to be entrapping or compressing the neurovascular structures. The risks with TOS surgery are significant and include brachial plexus and nerve injury, hemorrhage, infection, and pulmonary complications. Compared with a nonsurgical approach, patients receiving surgery had greater medical costs and have been found to be three to four times more likely to be work disabled. Therefore, due to often unnecessary surgery with poor results and the above-mentioned risks, surgery is not typically the preferred treatment.

More commonly and appropriately though, first-line treatment is directed towards a physical rehabilitation program, in which physical therapy plays a large role. Initial treatment emphasis is placed on weight loss, postural re-education, and shoulder girdle exercises along with stretching, strengthening, conditioning and the passage of time. Evaluation of activities of daily living and the workplace environment is a must. Physical therapy management of TOS requires accurate evaluation of the peripheral nervous system, posture, and the cervico-scapular muscles. Patients should be instructed in postural correction in sitting, standing and sleeping, stretching exercises, and strengthening exercises of the lower scapular stabilizers beginning in gravity-assisted positions to regain normal movement patterns in the cervico-scapular region. Other techniques include evaluation of joint mobility and muscular imbalance. Patient education, compliance to an exercise program, and behavioral and ergonomic modification at home and work are critical to long-term successful conservative management. Selected patients may benefit from trigger point injections or acupuncture treatments.

Short-term modalities such as heat, cold, massage, ultrasound and electrical stimulation may reduce symptoms temporarily and through pain reduction allow treatment and stretching of the effected tissues. The patient is taught to avoid postures or positions that aggravate symptoms. Patients are told to avoid drooping shoulders, to guard against the arms being above shoulder level and in a sustained position overhead. It is important to not carry heavy objects in the hand of the affected extremity or on the affected shoulder. The patient should avoid sleeping on the affected side. Biofeedback and/or relaxation training can be helpful in relaxing the involved musculature, retraining skilled hand function at the computer and improving postural awareness.

PSYCHOSOCIAL ASPECTS of TOS

Each person responds and reacts differently to discomfort. There are many individuals who for whatever reason are somatically preoccupied and/or may have underlying psychopathology or psychosocial dysfunction which seems to enhance their perception of pain and disability. Some patients become extremely angry and some display a dep sense of entitlement. Surgically removing a structural “abnormality” such as a cervical rib (a normal finding in many asymptomatic people) may be a devastating mistake in a patient whose problem is not a significant TOS, but rather emotional dysfunction, anger, entitlement or somatic preoccupation.

Patient #1 is a young woman in her mid-twenties who had a work injury eighteen months before and had a history consistent with thoracic outlet syndrome for which she had eventually undergone surgery. Six months after her injury, the insurance carrier obtained a psychological evaluation that clearly revealed that given her personality type and her somatic preoccupation, that she would be a poor surgical candidate. A well-respected vascular surgeon, who probably never saw the psychological report, noted her lack of progress with conservative treatment and proceeded within the next six months to operate on her with poor results. After the surgery she was worse and then became symptomatic on the other side. Needless to say, she never returned to work, and further stated that she was not physically or emotionally able to participate in vocational rehabilitation. She had become a chronic pain patient.

Patient #2 was a woman who developed what was reported to be a TOS after a fall on her outstretched arm at work. She underwent TOS surgery and over a period of months consumed increasing amounts of narcotic and sedative medication. She kept her effected arm at her side in a sling. After a suicide gesture, she was admitted to the hospital on an urgent basis to a combined chronic pain/psychiatric unit. She had a supportive husband and three young children. Her history included a dysfunctional childhood and drug/alcohol abuse up to seven years before. She had been clean and sober ever since and attending group meetings regularly. Psychological testing suggested a Borderline Personality Disorder. She was placed on a pain cocktail and weaned off all sedative and narcotic medication. She attended physical rehabilitation and educational groups and with the help of her treatment team left the hospital in two weeks with a fully functioning arm without the need for narcotic or other pain medication. The sad part of this story is that she probably never needed the TOS surgery and further, came very close to either suicide or a prolonged dysfunctional lifestyle.

Patients with non-physiologic pain behavior, psychosocial dysfunction, anger or a sense of entitlement are difficult to treat. Often our best efforts lead to poor results and even more complaints of pain and disability. While difficult to treat, they need to be approached from a model of cognitive restructuring or altering thought processes as discussed by Dr. Perry Blackmon in last month’s CWCE Medically Speaking article. Basically, cognitive restructuring is used to change patterns of negative thoughts and self-defeating attitudes in order to generate more healthy and positive thoughts, emotions and actions. These patients tend to do better in a tightly controlled, behaviorally oriented, functional restoration program of chronic pain management.

 SURGERY for TOS

If the patient is not responding to conservative physical rehabilitation treatment approaches, it is then important to differentiate between the occasional patient who should be considered for surgery and others for whom surgery would be a mistake and a potential disaster.

What patient then is a good candidate for surgery when conservative measures have failed? Surgery should be considered an option in the few select emotionally stable patients with significant neurovascular compression at the thoracic outlet. Even in some individuals with less than optimal results with conservative treatment, surgery is a mistake and will only lead to further problems. Surgery is never a “last resort,” but rather only one tool to be considered for use.

CONCLUSION

Thoracic Outlet Syndrome occurs with compression of the neurovascular bundle as it exits the cervical area, traverses behind the clavicle and progresses towards the upper arm. It is best treated with a rehabilitation approach but certain cases justify surgical intervention. A number of injured workers with TOS, with or without surgery, may appear considerably dysfunctional and disabled.

Our advice to claims examiners and attorneys is simple. Use rehabilitation nurses for difficult cases and find reasonable and knowledgeable physicians who are willing to take the time to provide excellence in diagnosis along with caring, but firm treatment. It is critically important for the physician to assist the patient in understanding that TOS is not life-threatening, is treatable and should not prevent return to some type of gainful employment.

Formal physical therapy should be time-limited with the patient being weaned away from medical intervention and thereafter engaged in a self directed exercise and conditioning program. Medications should be limited to acetaminophen, aspirin, or one of the non-steroidal anti-inflammatory drugs. In an occasional patient, a tricyclic antidepressant may help with pain relief and insomnia.

Injured workers with chronic problems are often difficult to treat, but a rehabilitation approach with early intervention and rapid return to work best serves all parties concerned.

 

Thoracic Outlet Syndrome: A Patient Centered Treatment Approach

by Peter I. Edgelow, M.A., P.T.

 

 

I appreciate the opportunity that is given to me by Dr. Feinberg to share an approach I have developed over the past 10 years to reverse the neurovascular consequence treatment of thoracic outlet syndrome (TOS). This approach has now been used in the treatment of over 800 of the worst patients, and experience indicates that a significant percentage of those patients experienced benefits from the program. Many physicians and nurse case managers have referred these patients to me and to other physical therapists familiar with my approach.

The treatment design involves a radical departure from the normal physical therapy approach for this type of condition. Normally, this patient population receives treatment on a 2 or 3 time a week basis. Treatment procedures involve modalities for pain relief (ultrasound, heat or cold, electrical stimulation) and massage, mobilization and stretching and strengthening exercises. All of these types of therapy had been used with these 800 patients and had proved to be unsuccessful. They either aggravated the problem or helped temporarily but once the therapy was discontinued, the patients reverted to their pre-treatment condition. 

Essentially my program involves training the patient to take control of there own problem. To do this they must first understand it. To help them, a patient booklet has been devised to give them an explanation of why they are in the situation they are in. Secondly, several devices have been put together which allows the patients to do a home exercise program which will assist them in reversing the vicious circle of pain and spasm in which they are caught. Thirdly, the exercises are on videotape to assist the patients in learning to do the program. Fourthly, there is an audiotape that talks them through the breathing and relaxing part of the program. 

The learning curve needed to progress the patient through the program is best accomplished using a once a week format. In order for patients to become appropriately engaged in the problem solving process and in order that necessary modifications to the treatment program be made, once weekly visits are optimal. More frequent sessions did not facilitate faster learning and fewer visits result in loss of patient motivation. By giving the patients the tools to accomplish the treatment at home, they can more precisely apply the right dosage and frequency of treatment. It also gives the therapist an opportunity to test patient compliance. The exercises look easy but they involve a lot of practice to be done correctly. Part of each treatment requires that the patient demonstrate the exercises. If they have not been doing their exercises it is obvious. This need for patient accountability is a necessary step in their gaining control. 

The patients frequently enter therapy with emotional states that can be characterized as skeptical, discouraged and depressed. Therefore, the patients must be continuously assessed as to their readiness to engage in self-treatment. This process involves empowering the patients’ intellects by using visual analogies to help them more clearly understand why they have the problem and why they need to be trained to resolve it. The images of “narrowed tunnels” due to contraction of the scalene muscle, and the analogy of the raising of the rib cage - which can be thought of as the “floor” of the thoracic tunnel - are examples of visual analogies that empower the patient. Use of these analogies logically leads to a solution that requires a change in the patients’ breathing pattern that results in a relaxation of the scalene muscle and a lowering of the rib cage. 

Further, chronic pain impacts negatively on the fluid systems of the involved body parts. This adds another component that needs to be addressed in treatment. A useful analogy to describe this situation is to consider a river flowing into a lake and a river flowing out of the lake, in which the inflow of water equals the outflow. In this state, the volume of the lake is constant, the oxygen content is high, and the pollution content is low. Should there be an obstruction effecting the outflow, then the volume of the lake would increase, the oxygen content would decrease and the pollution would increase. This condition may be likened to a swamp. Since the blood flowing to and from the upper extremity passes through the "tunnel" of the thoracic outlet, the concept of "narrowing of the tunnel" can be a mechanical explanation for the circulation problem.  

Another issue with circulation is to appreciate that all of the fluid systems require movement to maximize their efficiency. The pain of this condition inhibits motion, thereby decreasing the efficiency of the nutritional support. Treatment must address these systems and increase the efficiency of their flow. Therefore, the patient can be guided by seeing the solution to the problem as analogous to "opening the tunnel and draining the swamp." It is important that the patients understand why prior treatments may have been unsuccessful in order for them to have hope that this new approach might work. The traditional paradigm for musculoskeletal injury is that there is a loss of flexibility, coordination, endurance and strength, and the resolution of these issues will correct the problem. However, the neurogenic aspects of TOS make attempts to increase flexibility, coordination, endurance and strength typically result in an increase in pain. 

Treatment based on the concept of “no pain, no gain” results in a worsening of the condition. Of paramount importance in successful treatment is the appreciation that the treatment techniques must not increase the pain. It is through the patients listening to their bodies and the early recognition of an increase in symptoms that might lead to a flare that allows them to begin to gain control. Patients must be trained to pay attention to the tension within their muscular system; for it is this increase in tension which alerts them to the onset of a protective response and the perpetuation of a vicious cycle of pain, narrowing of canals, vascular congestion and pathological reflexes. 

In the physical examination of these patients, there are consistent findings that must be addressed before adequate progress can be attained: 

1.   The patient must become aerobically it.

2.   There is often present asymmetrical weakness of the small muscles that control movement of the thumb. (Flexor and abductor pollicis). This weakness can be reversed by self-traction for 30 seconds (diagram 1) and weakened again by mechanical stress to the neck such as compression.

3.   There is a pattern of chest breathing and an inability for the patient to perform relaxed breathing with the diaphragm.

4.   There is loss of mobility and increased sensitivity of the nervous system, especially the brachial plexus. (The nerves that pass from the neck to the arm.)

5.   There can be coldness of the hand particularly the ring and little finger. 

Treatment must be directed to reversing these 5 issues if they exist. The home program is designed to help the patient accomplish this on his or her own.  

Exercises are 3 in number:  

1.   Self-traction to be performed by the patient every hour for 30 seconds (Diagram 1).

2.   Diaphragmatic breathing with spinal motion and air pillow 4 times a day as well as practicing this while seated, driving car or working at the computer, etc. (diagram 2).

3.   An aerobic walk.  

While working the patient can perform these exercises or they must be done 4 times a day for 40 minutes each time if they are unable to work. 

These patients are incredibly challenging. Repetitive strain injuries can be overcome, but a triad of change is required: 

1.   The patient’s workstation must be improved to minimize stress.

2.   The employer must be made aware of the needs of TOS patients.

3.   The patients themselves must be aware of how their own actions affect their condition and how to best facilitate the healing process.  

TOS problems can best be overcome when all the players in the workers’ compensation system meet their responsibilities.