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Overcoming Thoracic Outlet Syndrome: A Step-by-Step Guide – Part 2

Updated: Dec 5, 2023


After delving into the causes, anatomy, and diagnostic methods for TOS, we'll now turn our attention to therapeutic approaches for this frequently discomforting ailment. Our discussion will encompass soft tissue and bone-related techniques, and we'll highlight functional exercises typically recommended for patients.


Article Index:

 

Treatment & Prevention of TOS


Addressing Thoracic Outlet Syndrome (TOS) can pose a challenge even for highly experienced practitioners (2). In most cases, TOS is best initially treated with conservative manual therapies and exercise (3; 4). In fact, manual therapy, such as Motion Specific Release (MSR), should be the primary approach when dealing with TOS (14). One crucial factor in effectively treating TOS is the timely implementation of conservative treatment before it develops into a chronic condition (5). Surgery should only be considered if conservative treatment and supportive exercises have proven ineffective (15).


TOS TREATMENT GOALS


Each TOS case should be assessed and treated on an individual, personalized basis. The treatment of TOS needs to achieve several goals.


Reduce Pain: The initial treatment stage should focus on alleviating pain and symptoms and calming the nervous system. This often involves educating patients about avoiding positions that could worsen their condition, such as sleeping with arms abducted in an overhead position.


Improve Posture: Postural correction can significantly contribute to resolving TOS cases (17). Adopting a shoulders up-and-back position can effectively reduce pressure on the neurovascular bundle. In the lower back, avoiding lumbar spine extension can prevent TOS aggravation by reducing extensor muscle over-activation (which causes an upward rotation of the rib cage). Practicing anterior and posterior pelvic tilts alongside diaphragmatic breathing can help relieve tension in the lumbar spine.


Establish Proper Breathing Patterns: Encourage diaphragmatic breathing rather than the dysfunctional upper chest breathing commonly associated with TOS (diaphragmatic breathing helps limit scalene muscle over-activation). Additionally, employing myofascial techniques, such as MSR, on the thoracic spine and diaphragm can be highly beneficial (18).


Enhance Strength and Cardiovascular Conditioning: Studies indicate that 50% to 90% of TOS cases benefit from strength training and cardiovascular conditioning (16).


Restore Normal Nervous System Motion (gliding): This can often be achieved through therapy (neural mobilization) and tailored exercise programs. Research demonstrates that this approach is typically highly effective in treating TOS symptoms.


Osseous Mobilization: The first rib is frequently involved due to the activation of the scalene muscles that elevate the upper ribs. Mobilizing the upper ribs can benefit TOS cases. Furthermore, mobilizing or adjusting the thoracic spine can greatly help in reducing TOS instances.


 

Manual Therapy


The approaches utilized target soft-tissue restrictions, nerve entrapment, and osseous joint constraints. The following videos showcase examples of MSR procedures commonly employed in TOS treatment. The specific techniques implemented are contingent upon the TOS type, impacted regions, and potential co-existing conditions.


Note: These videos are intended solely for demonstrative purposes and should only be employed by certified musculoskeletal practitioners trained in MSR procedures. Do not attempt these techniques independently.


SOFT TISSUE PROCEDURES FOR TOS: These MSR soft-tissue procedures are frequently used to address Thoracic Outlet Syndrome.


MSR Nerve Release - Neck to Shoulder

This video focuses on the application of MSR procedures to release nerves extending from the cervical plexus to the neurovascular sleeve, spanning the neck to the shoulder area.






MSR Ulnar Nerve Release

Ulnar nerve compression frequently occurs in Neurogenic TOS. This video demonstrates the release of the ulnar nerve using Motion Specific Release (MSR) procedures. Patients experiencing ulnar nerve compression often report sensory changes in their fourth and fifth fingers.




MSR - Diaphragmatic Release

Respiratory function is critical, with breathing difficulties often emerging in TOS cases. This video addresses diaphragm restrictions, the primary inspiratory muscle responsible for enlarging the thoracic cavity during inhalation. Due to its extensive myofascial connections, the diaphragm can influence several structures within the thoracic and abdominal regions.


 

Osseous Procedures For TOS


Cervical joint restrictions frequently occur in TOS cases. Implementing joint adjustments or mobilizations is a crucial aspect of effectively treating and resolving Thoracic Outlet Syndrome.


The Power of Chiropractic Adjustments

Chiropractic Adjustments are effective tools in managing chronic back pain. Patients experience better outcomes when they undergo consistent, pre-planned Chiropractic Maintenance Care, as opposed to only seeking treatment during episodes of acute back pain.


MSR Cervical Joint Mobilization

In this video, Dr. Abelson showcases MSR Cervical Joint Mobilization procedures as an alternative to joint manipulation for alleviating neck tension. This gentle, effective method is ideal for patients seeking an alternative to traditional neck manipulation.


5-Point Shoulder Joint Mobilization

The shoulder is more complex than just one joint, comprising five distinct joints. Grasping their inter-relationships is vital for effectively resolving shoulder injuries, including TOS. In this video, Dr. Abelson presents the "5 Point Shoulder Joint Mobilization" protocol using Motion Specific Release techniques.


 

Exercise


The videos below illustrate examples of exercises commonly prescribed to our TOS patients. The precise combination of exercises recommended depends on the TOS type, affected areas, and any potential co-existing conditions specific to each patient.


Correct Your Posture Now – Do Not Wait!

Bad posture is often a significant factor that needs to be addressed in cases of TOS. Poor posture is related to lower self-esteem, decreased energy levels, and lack of alertness. In addition, is can affect lung function, circulation, and digestion, and be a significant source of musculoskeletal pain.


Pain Relief For Problem Headaches

Headaches are a common problem for patients with TOS. In this video, we show you an effective way to reduce the intensity or resolve your headache. This Headache Relief video shows you how to release trigger points at the base of your skull, the Suboccipital region.


Myofascial Release of the Subclavius

The subclavius muscle is often involved in TOS. Releasing the subclavius muscles can be difficult to do with the foam roller. In comparison, a softball is ideal for releasing this muscle.






5-Great Daily Shoulder Mobilization Exercises

Before prescribing these exercises to our TOS patients, we would first have to ensure that they are out of the Acute Stage of this injury. These exercises can be performed throughout the day to obtain the best results and can make a huge positive difference in your posture, especially if you have been sitting for a long period of time.

Ulnar Nerve Flossing Exercises

We would prescribe these exercises if the patient with TOS is also experiencing an ulnar nerve distribution in their arm. The ulnar nerve can be compressed at the wrist, beneath the collarbone, or as it comes out of the spinal cord in the neck. When the ulnar nerve compression occurs at the elbow, it is called "Cubital Tunnel Syndrome."


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Conclusion


Once a TOS diagnosis is established, healthcare providers typically embark on a holistic conservative therapy plan. This integrates manual therapy, targeting soft tissue and bone structures, with a tailored exercise routine. For most TOS patients, surgery isn't necessary. Instead, conservative treatments paired with specific exercises often yield positive results. By tackling the root causes and manifesting symptoms, patients generally observe marked enhancements in their condition.



 

DR. BRIAN ABELSON DC. - The Author


Dr. Abelson's approach in musculoskeletal health care reflects a deep commitment to evidence-based practices and continuous learning. In his work at Kinetic Health in Calgary, Alberta, he focuses on integrating the latest research with a compassionate understanding of each patient's unique needs. As the developer of the Motion Specific Release (MSR) Treatment Systems, he views his role as both a practitioner and an educator, dedicated to sharing knowledge and techniques that can benefit the wider healthcare community. His ongoing efforts in teaching and practice aim to contribute positively to the field of musculoskeletal health, with a constant emphasis on patient-centered care and the collective advancement of treatment methods.

 


Revolutionize Your Practice with Motion Specific Release (MSR)!


MSR, a cutting-edge treatment system, uniquely fuses varied therapeutic perspectives to resolve musculoskeletal conditions effectively.


Attend our courses to equip yourself with innovative soft-tissue and osseous techniques that seamlessly integrate into your clinical practice and empower your patients by relieving their pain and restoring function. Our curriculum marries medical science with creative therapeutic approaches and provides a comprehensive understanding of musculoskeletal diagnosis and treatment methods.


Our system offers a blend of orthopedic and neurological assessments, myofascial interventions, osseous manipulations, acupressure techniques, kinetic chain explorations, and functional exercise plans.


With MSR, your practice will flourish, achieve remarkable clinical outcomes, and see patient referrals skyrocket. Step into the future of treatment with MSR courses and membership!


 

References


  1. Sanders RJ., Thompson RW, Freischlag JA, Donahue DM, Jordan SE, Edgelow PI (Eds). Anatomy of the thoracic outlet and related structures . Thoracic Outlet Syndrome, 1st edition. London : Springer, 2013, pp. 17-24.

  2. Toussaint CP, Ali ZS, Heuer GG, Zager EL. Double crush syndrome. [book auth.] Thompson RW, Freischlag JA, Donahue DM, Jordan SE, Edgelow PI (Eds) Illig KA. Thoracic Outlet Syndrome, 1st edition. London : Springer, 2013, pp. 101-4.

  3. Conservative treatment of thoracic outlet syndrome. Vanti C, Natalini L, Romero A, Tosarelli D, Pillastrini P. Eura. s.l. : Medicophys, 2007, Vols. 43:55-70.

  4. Thoracic Outlet Syndrome Part 2: Conservative Management of Thoracic Outlet. Watson L.A., Pizzari T., Balster S. 2010, Man. Ther., Vols. 15:305–314.

  5. Emery VB, Thompson RW. Pathways of care and treatment options for patients with NTOS. [book auth.] Thompson RW, Freischlag JA, Donahue DM, Jordan SE, Edgelow PI (Eds) Illig KA. Thoracic Outlet Syndrome, 1st edition. London : Springer, 2013, pp. 157-65.

  6. Bilateral variation of subclavius muscle resembling subclavius posticus. Martin RM, Vyas NM, Sedlmayr JC, Wisco JJ., Surg Radiol Anat. 2008, Vols. 30:171-4.

  7. Anatomy of inter-scalene triangle and its role in thoracic outlet compression syndrome. Savgaonkar MG, Chimmalgi M, Kulkarni UK. s.l. : J Anat Soc India, 2006, Vols. 55(2):52-5. .

  8. The forgotten pectoralis minor syndrome, 100 operations for pectoralis minor syndrome accompanied by neurogenic thoracic outlet syndrome. Sanders RJ, Rao NM. s.l. : Ann Vasc Surg, 2010, Vols. 24:701-8.

  9. DM, Donahue. Cervical ribs and NTOS. [book auth.] Thompson RW, Freischlag JA, Donahue DM, Jordan SE, Edgelow PI (Eds) Illig KA. Thoracic Outlet Syndrom, 1st edition. London : Spinger, 2013, pp. 85-8.

  10. Jordon SE. Clinical presentation of patients with NTOS. [book auth.] Thompson RW, Freischlag JA, Donahue DM, Jordan SE, Edgelow PI (Eds) Illig KA. Thoracic Outlet Syndrome, 1st edition. London : Springer, 2013, Vols. 41-8.

  11. RF., Feinberg. Clinical presentation and patient evaluation in VTOS. [book auth.] Thompson RW, Freischlag JA, Donahue DM, Jordan SE, Edgelow PI (Eds) Illig KA. Thoracic Outlet Syndrome, 1st edition. London : Springer, 2013, pp. 345-53.

  12. RW., Thompson. Surgical techniques: pectoralis minor tenotomy for NTOS. [book auth.] Thompson RW, Freischlag JA, Donahue DM, Jordan SE, Edgelow PI (Eds) Illig KA. Thoracic Outlet Syndrome, 1st edition. London : Springer, 2013.

  13. The value of provocative tests in diagnosis of cervical radiculopathy. Ghasemi M, Golabchi K, Mousavi SA, Asadi B, Rezvani M, Shaygannejad V, et al. s.l. : J Res Med Sci., 2013, Vols. 18:S35-8.

  14. Conservative treatment of thoracic outlet syndrome A review of the literature. Vanti, C et al. s.l. : Europa Medicophysica, 2006, Vol. 42.

  15. Surgical treatment of thoracic outlet syndrome in young adults: single centre experience with minimum three-year follow-up. Pietro, Ciampi et al. s.l. : Int Orthop., 2011, Vols. 35(8): 1179–1186.

  16. Thoracic Outlet Syndrome. Huang J.H., Zager E.L. s.l. : Neurosurgery, 2004, Vols. 55:897–903.

  17. Thoracic Outlet Syndrome—A Myofascial Variant: Part 3. Structural and Postural Considerations. Sucher B.M., Heath D.M. s.l. : J. Am. Osteopath. Assoc, 1993, Vols. 93:340–345.

  18. Thoracic outlet syndrome part 2. conservative management of thoracic outlet. Watson LA, Pizzari T, Balster S. Man Ther. 2010, Vols. 15(4):305-14.

  19. Understanding thoracic outlet syndrome. Freischlag J, Orion K. Cairo : Scientifica, 2014, Vols. 2014:1–6.

  20. Imaging of the patient with thoracic outlet syndrome. Raptis CA, Sridhar S, Thompson RW, Fowler KJ, Bhalla S. s.l. : RadioGraphics, 2016, Vols. 36(4):984–1000. .

  21. Diagnosis of thoracic outlet syndrome. Sanders RJ, Hammond SL, Rao NM. s.l. : J Vasc Surg, 2007, Vols. 46(3):601–604.

  22. Thoracic outlet syndrome. Kuhn JE, Lebus GF, Bible JE. s.l. : J Am Acad Orthop Surg, 2015, Vols. 23(4):222–232.

  23. Citisli V. Assessment of diagnosis and treatment of thoracic outlet syndrome, an important reason of pain in upper extremity, based on literature. J Pain Relief. 2015;04(02):1–7.


 

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