Treatment of Thoracic Outlet Syndrome

Treatment of Thoracic Outlet Syndrome covers a wide range of manifestations due to compression of nerves and vessels during their passage through the cervico thoracobrachial region. Various forms of TOS are distinguished: vascular forms (arterial or venous) which raise few diagnostic problems [Rx], and “neurological” forms, which are by far the most frequent as they represent more than 95% of all cases of TOS [Rx, Rx]. The “neurological forms” are classified in the “true” neurological form associated with neurological deficits (mostly muscular atrophy), and painful neurological forms (with no objective neurological deficit). These painful forms are very frequent, especially when patients are systematically screened for these symptoms. The existence of these forms of TOS remains controversial in part because muscular and neurological manifestations are strongly interrelated. Clinical experience suggests that the main triggering mechanism is more often a muscular dysfunction in the cervicoscapular region than primitive nerve compression. It is directly responsible for cervicoscapular symptoms (pain and discomfort) and sometimes for referred scapulobrachial and facial pain. In parallel, shortened muscles (mainly scalene muscles) and cervicoscapular muscles imbalance may lead to intermittent nerve compression and/or tension on brachial plexus in the thoracic outlet resulting in proximal pain and producing pain and discomfort in the upper limb. The neurological involvement accounts for most of the distal symptoms, but the controversy concerning the reality of TOS is essentially due to the absence of objective criteria to confirm the diagnosis (no neurological weakness and normal neurophysiological examination). Despite considered as “debatable” for some authors, several arguments support the reality of this syndrome, such as the influence of TOS on the results of treatment of carpal tunnel and cubital tunnel syndromes [Rx,Rx]. This problem is further complicated by the frequent concomitant presence of other neuromuscular diseases of the upper limb, which can be secondary to TOS or, on the contrary, may precede and predispose to the development of TOS [Rx, Rx], in which case TOS is often masked by the concomitant disease. “Neurological” forms of TOS can be subdivided into primary forms in which features of TOS may remain isolated or may be complicated by underlying neuromuscular disorders, and forms secondary to a more distal disease (neuromuscular or joint disease), always responsible for complex clinical features.

Analgesics: Prescription-strength drugs that relieve pain but not inflammation.
Antidepressants: A Drugs that block pain messages from your brain and boost the effects of eorphins .
Medication – Common pain remedies such as aspirin, acetaminophen, ibuprofen and naproxen can offer short-term relief. All are available in low doses without a prescription. Other medications, including muscle relaxants and anti-seizure medications, treat aspects of spinal stenosis, such as muscle spasms and damaged nerves.
Corticosteroid injections – Your doctor will inject a steroid such as prednisone into your back or neck. Steroids make inflammation go down. However, because of side effects, they are used sparingly.
Anesthetics – Used with precision, an injection of a “nerve block” can stop pain for a time.
Muscle Relaxants – These medications provide relief from spinal muscle spasms.
Neuropathic Agents – Drugs(pregabalin & gabapentine) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
Calcium & vitamin D3 – to improve bones health and healing fracture.

Others Treatment Approach

Transaxillary approach – The first rib forms the common denominator for all causes of nerve and artery compression in this region, so that its removal generally improves symptoms. Surgeon makes an incision in the chest to access the first rib, divide the muscles in front of the rib and remove a portion of the first rib to relieve compression, without disturbing the nerves or blood vessels.
Supraclavicular approach – Has been advocated to perform first rib resection and scalenectomy, a safe and effective procedure, characterized by a shorter operative time and having a complication rate lower or comparable to that of transaxillary first rib resection.
This approach repairs compressed blood vessels. The surgeon makes an incision just under the neck to expose the brachial plexus region. Then he looks for signs of trauma or muscles contributing to compression near the first rib. The first rib may be removed if necessary to relieve compression.
Arterial TOS – Decompression can include cervical and/or first rib removal and scalene muscle revision. The subclavian can then be inspected for degeneration, dilation, or an aneurysm. Saphenous vein graft or synthetic prosthesis can then be used if necessary Level of evidence 2B.
Venous TOS – Thrombolytic therapy is the first line of treatment for these patients. Because of the risk of recurrence, many recommend removal of the first rib is necessary even when thrombolytic therapy completely opened the vein. The results of a study show that the infraclavicular approach is a safe and effective treatment for acute VTOS. They had no brachial plexus or phrenic nerve injuries.

Physical Therapy in Thoracic Outlet Syndrome

Conservative management should be the first strategy to treat TOS since this seems to be effective at decreasing symptoms, facilitating return to work and improving function, but yet a few studies have evaluated the optimal exercise program as well as the difference between a conservative management and no treatment.

Stage 1 – The aim of the initial stage is to decrease the patient’s symptoms. This may be achieved by patient education, in which TOS, bad postures, the prognosis and the importance of therapy compliance are explained. Furthermore some patients who sleep with the arms in an overhead, abducted position should get some information about their sleeping posture to avoid waking up at night.

Cyriax release maneuver
Elbows flexed to 90°
Towels create a passive shoulder girdle elevation
Supported spine and the head in neutral
The position is held until peripheral symptoms are produced. The patient is encouraged to allow symptoms to occur as long as can be tolerated up to 30 minutes, observing for a symptom decrescendo as time passes.
The patient’s breathing techniques need to be evaluated as the scalenes and other accessory muscles often compensate to elevate the rib cage during inspiration.
Encouraging diaphragmatic breathing will lessen the workload on already overused or tight scalenes and can possibly reduce symptoms.

Stage 2 – Once the patient has control over his/her symptoms, the patient can move to this stage of treatment. The goal of this stage is to directly address the tissues that create structural limitations of motion and compression. How this should be done is one of the most discussed topics of this pathology. Some examples of methods that are used in the literature are.

Massage
Strengthening of the levator scapulae, sternocleidomastoid, and upper trapezius. This group of muscles open the thoracic outlet by raising the shoulder girdle and opening the costoclavicular space
Stretching of the pectoralis, lower trapezius and scalene muscles

These muscles close the thoracic outlet

Postural correction exercises
Relaxation of shortened muscles Level of evidence 1A
exercises in a daily home exercise program
Shoulder exercises to restore the range of motion and so provide more space for the neurovascular structures.

Exercise

Lift your shoulders backwards and up, flex your upper thoracic spine and move the shoulders forward and down. Then straightened the back and repeat 5 to 10 times.ROM of the upper cervical spine

Exercise

Lower your chin 5 to 10 times against your chest, while you are standing with the back of your head against a wall. The effectiveness of this exercise can be enlarged by pressing the head down by hands.
Activation of the scalene muscles are the most important exercises. These exercises help to normalize the function of the thoracic aperture as well as all the malfunctions of the first rib.

Exercises

Anterior scalene

Press your forehead 5 times against the palm of your hand for a duration of 5 seconds, without creating any movement.
Middle scalene
Press your head sidewards against your palm.
Posterior scalene
Press your head backwards against your palm.

Stretching exercises

Taping – some patients with severe symptoms respond to additional taping, adhesive bandages or braces that elevate or retract the shoulder girdle.
Manipulative treatment to mobilize the first rib
Repositioning/mobilization of the shoulder girdle and pelvis joints cervicothoracic, sternoclavicular, acromioclavicular, and costotransverse joints
Glenohumeral mobilizations in end-range elevation with the elbow supported in extension

Posterior Glenohumeral Glide with Arm Flexion

The patient is supine. The mobilization hand contacts the proximal humerus avoiding coracoid process. The force is directed posterolaterally (direction of thumb).

Anterior Glenohumeral Glide with Arm Scaption

The patient is prone. The mobilization hand contacts the proximal humerus avoiding the acromion process. The force is directed anteromedially.

Inferior Glenohumeral Glide

The patient is prone. The stabilizing hand holds the proximal humerus the humerus distal to the lateral acromion process. The mobilization hand contacts the axillary border of the scapula. Mobilize the scapula in a craniomedial direction along the ribcage.

References

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