• Dr. Brian Abelson DC., Dr Evangelos Mylonas DC.

RESOLVING THORACIC OUTLET SYNDROME (TOS) – PART 2

Updated: Nov 19


Now that you have an understanding of the causes, anatomy and diagnostic process for TOS, it is time to look at how to treat and resolve this often-painful condition.


TREATMENT & PREVENTION OF TOS


Resolving Thoracic Outlet Syndrome (TOS) can be challenging for even the most experienced of practitioners.(2) Most cases of TOS are initially best treated with Conservative Manual Therapies and exercise.(3; 4) In fact, manual therapy such as Motion Specific Release (MSR), should be the first line of treatment when addressing TOS.(14) One of the keys to effectively treating TOS is the early implementation of conservative treatment before TOS becomes a chronic condition.(5) Surgery should only be contemplated after conservative treatment and supporting exercises have proven to be ineffective.(15)


TOS TREATMENT OBJECTIVES


Every case of TOS must be evaluated and treated on an individual, custom basis. The treatment of TOS must achieve several objectives.


Decrease Pain: The focus for the initial stage of treatment is to reduce pain and symptoms, and calm down the nervous system. This will often require educating patients about avoiding certain positions that could aggravate their condition. For example, avoiding sleeping with their arms abducted in an overhead position.


Correct Poor Posture: Postural correction can have a significant positive effect in resolving TOS cases. (17)

  • The shoulders up-and-back position can be effective in reducing pressure on the neurovascular bundle.

  • In the low back, extension of the lumbar spine can exacerbate TOS by over-activating the extensor muscles (causing an upward rotation of the rib cage).

  • Anterior and posterior pelvic tilts combined with diaphragmatic breathing can also be effective in taking tension off of the lumbar spine.

Establish Normal Breathing Patterns: Diaphragmatic breathing should be encouraged, instead of the dysfunctional upper chest breathing that is common with TOS (diaphragmatic breathing helps to limit over-activation of the scalene muscles). In addition using myofascial procedures, such as MSR, on the thoracic spine and diaphragm can provide great benefit. (18)


Increase Strength and Cardiovascular Conditioning: Research has shown that 50% to 90% of TOS cases benefit from strength training and cardiovascular conditioning. (16)


Restore Normal motion (gliding) of the Nervous System: This is often achieved through both therapy (neural mobilization) and custom exercise programs. Research has shown that this approach is often highly effective in treating TOS symptoms.


Osseous Mobilization: The first rib is often involved because activation of the scalene muscles elevates the upper ribs. Mobilization of the upper ribs can be of benefit in addressing cases of TOS. In addition, mobilization or adjustment of the thoracic spine can be of great benefit in reducing cases of TOS.

MANUAL THERAPY DEMONSTRATION VIDEOS FOR TOS


The procedures are used to address soft-tissue restrictions, nerve entrapment and osseous joint restrictions. The following videos show examples of MSR procedures that we often use for treating TOS. The exact procedures we use will vary depending on the type of TOS, areas of involvement, and possible co-existing conditions.


Warning: These videos are provided for demonstration purposes only, and should only be used by certified MSK practitioners who are trained in MSR procedures. Do not attempt these yourself.


SOFT TISSUE PROCEDURES FOR TOS

We often use these MSR soft-tissue procedures to address TOS.


MSR Nerve Release - Neck to Shoulder

In this video we focus upon releasing the nerves from the neck to the shoulder (cervical plexus to the neurovascular sleeve) using MSR procedures.







MSR Ulnar Nerve Release

Ulnar nerve compression is common with Neurogenic TOS. In this video we focus on releasing the ulnar nerve by using Motion Specific Release (MSR) procedures. Patients with ulnar nerve compression often complain of sensory changes in the fourth and fifth fingers.




MSR - Diaphragmatic Release

Respiratory function is incredibly important. Breathing problems are common with cases of TOS. This video addresses restrictions in the diaphragm. The diaphragm is your primary inspiratory muscle. Its main function is to increase the volume of the thoracic cavity during inspiration. However, due to its many myofascial attachments, it can affect multiple structures within the thoracic and abdominal regions.


OSSEOUS PROCEDURES FOR TOS

Joint mobilizations are an important aspect of treating and resolving TOS.


MSR Cervical Joint Mobilization

Cervical joint restrictions are common with cases of TOS. In this video Dr. Abelson demonstrates examples of MSR Cervical Joint Mobilization procedures that we use to release neck tension. This is a gentle and effective way to remove those restrictions, especially for patients who would prefer an alternative to neck manipulation.


5-Point Shoulder Joint Mobilization

When we think of the shoulder, we often think of it as being just one joint. In reality, we must consider five different joints. Understanding the inter‐relationships between the structures in these five joints will play a critical role in being able to successfully resolve any shoulder injury, including TOS. In this video Dr. Abelson demonstrates the Motion Specific Release "5 Point Shoulder Joint Mobilization" protocol.


EXERCISE DEMONSTRATION VIDEOS


The following videos are examples of exercises that we often prescribe to our TOS patients. The exact combination of exercises we prescribe will vary depending on the type of TOS, areas of involvement, and possible co-existing conditions that each patient suffers from.


Myofascial Release of the Suboccipital Muscles

Headaches are a common problem for patients with TOS. In this video we show you a great way to release trigger points at the base of your skull- the suboccipital. The suboccipital muscles are extremely important since they contain very high concentrations of muscle spindle fibres. Muscle spindles are the part of your nervous system that provides postural information to the central nervous system.


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 soft ball 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 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."


CONCLUSION


Once a TOS diagnosis has been reached, your practitioner can begin a systematic program of conservative therapy (such as MSR) along with a customized exercise routine. In most cases of TOS surgery can be avoided, and good results can be achieved with Conservative Treatments, and exercise.

If you suspect that you are suffering from Thoracic Outlet Syndrome, then come see us at Kinetic Health for an effective solution.


RESOLVING THORACIC OUTLET SYNDROME (TOS) - PART 1



Make an appointment with our incredible team at Kinetic Health in NW Calgary. Just scan the QR code with your phones camera and click the link, or call Kinetic Health at 403-241-3772 to make an appointment today!









Bibliography


  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.



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