Physical therapy management, surgical treatment, and patient-reported outcomes measures in a prospective observational cohort of patients with neurogenic thoracic outlet syndrome.

OBJECTIVE: To assess the results of physical therapy management and surgical treatment in a prospective observational cohort of patients with neurogenic thoracic outlet syndrome (NTOS) using patient-reported outcomes measures. METHODS: Of 183 new patient referrals from July 1 to December 31, 2015, 150 (82%) met the established clinical diagnostic criteria for NTOS. All patients underwent an initial 6-week physical therapy trial. Those with symptom improvement continued physical therapy, and the remainder underwent surgery (supraclavicular decompression with or without pectoralis minor tenotomy). Pretreatment factors and 7 patient-reported outcomes measures were compared between the physical therapy and surgery groups using t-tests and χ2 analyses. Follow-up results were assessed by changes in 11-item version of Disability of the Arm, Shoulder, and Hand (QuickDASH) scores and patient-rated outcomes. RESULTS: Of the 150 patients, 20 (13%) declined further treatment or follow-up, 40 (27%) obtained satisfactory improvement with physical therapy alone, and 90 (60%) underwent surgery. Slight differences were found between the physical therapy and surgery groups in the mean ± standard error degree of local tenderness to palpation (1.7 ± 0.1 vs 2.0 ± 0.1; P = .032), the number of positive clinical diagnostic criteria (9.0 ± 0.3 vs 10.1 ± 0.1; P = .001), Cervical-Brachial Symptom Questionnaire scores (68.0 ± 4.1 vs 78.0 ± 2.7; P = .045), and Short-Form 12-item physical quality-of-life scores (35.6 ± 1.5 vs 32.0 ± 0.8; P = .019) but not other pretreatment factors. During follow-up (median, 21.1 months for physical therapy and 12.0 months for surgery), the mean change in QuickDASH scores for physical therapy was -15.6 ± 3.0 (-29.5% ± 5.7%) compared with -29.8 ± 2.4 (-47.9% ± 3.6%) for surgery (P = .001). The patient-rated outcomes for surgery were excellent for 27%, good for 36%, fair for 26%, and poor for 11%, with a strong correlation between the percentage of decline in the QuickDASH score and patient-rated outcomes (P < .0001). CONCLUSIONS: The present study has demonstrated contemporary outcomes for physical therapy and surgery in a well-studied cohort of patients with NTOS, reinforcing that surgery can be effective when physical therapy is insufficient, even with substantial pretreatment disability. Substantial symptom improvement can be expected for ∼90% of patients after surgery for NTOS, with treatment outcomes accurately reflected by changes in QuickDASH scores. Within this cohort, it was difficult to identify specific predictive factors for individuals most likely to benefit from physical therapy alone vs surgery.

Early effectiveness of isolated pectoralis minor tenotomy in selected patients with neurogenic thoracic outlet syndrome.

OBJECTIVE: This study evaluated the early effectiveness of isolated pectoralis minor tenotomy (PMT) in the surgical treatment of selected patients with neurogenic thoracic outlet syndrome (NTOS) compared with supraclavicular decompression (SCD; as scalenectomy, neurolysis, and first rib resection) plus PMT (SCD+PMT). METHODS: Data were obtained for 200 patients undergoing operative treatment for disabling NTOS between 2008 and 2011. Isolated PMT was offered to 57 patients with physical examination findings limited to the subcoracoid space, and SCD+PMT was offered to 143 with scalene triangle and subcoracoid findings. Functional outcomes were assessed before and 3 months after surgery using the Disabilities of the Arm, Shoulder and Hand (DASH) survey and related instruments. RESULTS: There were no significant differences (P > .05) between PMT and SCD+PMT patients with respect to age (overall, 37 ± 1 years), sex (73% women), side affected (52% right, 14% bilateral), or the frequency of various NTOS symptoms, but fewer PMT patients had a bony anomaly (0% vs 18%; P < .01) or a history of injury (35% vs 61%; P < .01). Mean preoperative DASH scores were similar between PMT and SCD+PMT groups (49.9 ± 3.6 vs 50.8 ± 1.6), but previous use of opiate pain medications was higher in PMT patients (47% vs 20%; P = .0004). PMT was conducted as an outpatient procedure, whereas the mean hospital stay after SCD+PMT was 4.8 ± 0.1 days, with two patients (1%) requiring early reoperations for persistent lymph leaks. Mean DASH scores 3 months after surgery were significantly improved after isolated PMT (29.6 ± 4.2; P < .01) and SCD+PMT (41.5 ± 2.2; P < .01), but the mean extent of improvement in DASH scores was not significantly different in PMT (32% ± 9%) vs SCD+PMT (19% ± 5%). There were also no significant differences in the proportion of PMT vs SCD+PMT patients demonstrating improvement in functional outcome measures (75% vs 72%) or in overall use of opiate medications (35% vs 27%). CONCLUSIONS: Isolated PMT is a low-risk outpatient procedure that is effective for the treatment of selected patients with disabling NTOS, with early outcomes similar to SCD+PMT. These findings emphasize the importance of recognizing subcoracoid brachial plexus compression as part of the spectrum of NTOS and support the role of PMT in surgical management.

Supraclavicular decompression for neurogenic thoracic outlet syndrome in adolescent and adult populations.

OBJECTIVE: This study was conducted to better define clinical results and understand factors determining responsiveness to surgical treatment for neurogenic thoracic outlet syndrome (NTOS) in adolescent and adult populations. METHODS: A retrospective review was conducted for 189 patients with disabling NTOS who underwent primary supraclavicular decompression (scalenectomy, brachial plexus neurolysis and first rib resection, with or without pectoralis minor tenotomy) from April 2008 to December 2010. Clinical characteristics were compared between 35 adolescent patients (aged<21 years) and 154 adults (aged>21 years). Functional outcome measures were assessed before surgery and at 3- and 6-month follow-up using a composite NTOS Index combining the Disabilities of the Arm, Shoulder and Hand (DASH) survey, the Cervical-Brachial Symptom Questionnaire (CBSQ), and a 10-point visual analog scale (VAS) for pain. RESULTS: Adolescent and adult patients were not significantly different with respect to sex (overall 72.5% female), side affected (58.7% right, 60.3% dominant limb), bony anomalies (23.3%), previous injury (55.6%), coexisting pain disorders (11.1%), and positive responses to scalene muscle anesthetic blocks (95.6%). Compared with adults, adolescent patients had a significantly (P<.05) lower incidence of depression (11.4% vs 41.6%), motor vehicle injury (5.7% vs 20.1%), previous operations (11.4% vs 29.9%), preoperative use of opiate medications (17.1% vs 44.8%), and symptom duration>2 years (24.2% vs 50.0%). Mean preoperative NTOS Index (scale 0-100) was significantly lower in adolescent vs adult patients (46.5±3.6 vs 58.5±1.7; P=.009), and hospital length of stay was 4.4±0.2 vs 4.9±0.1 days (P=.03), but the rate of postoperative complications was no different (overall, 4.2%). Although both groups exhibited significant improvement in functional outcome measures at 3 and 6 months, adolescent patients had significantly lower NTOS Index (10.4±3.1 vs 39.3±3.3; P<.001) and use of opiate medications (11.4% vs 47.4%; P<.001) compared with adults. CONCLUSIONS: Adolescents undergoing supraclavicular decompression for NTOS had more favorable preoperative characteristics and enhanced 3-month and 6-month functional outcomes than adults. Further study is needed to delineate the age-dependent and independent factors that promote optimal surgical outcomes for NTOS.

Positional compression of the axillary artery causing upper extremity thrombosis and embolism in the elite overhead throwing athlete.

OBJECTIVES: To describe the spectrum of axillary artery pathology seen in high-performance overhead athletes and the outcomes of current treatment. METHODS: A retrospective review of patients that had undergone management of axillary artery lesions in a specialized center for thoracic outlet syndrome (TOS). Treatment outcomes were assessed with respect to arterial pathology and operative management. RESULTS: Nine male athletes were referred for arterial insufficiency in the dominant arm between January 2000 and August 2010, representing 1.6% of 572 patients treated for TOS (19% of 47 patients treated for arterial TOS). Seven were elite baseball pitchers (six professional, one collegiate), and two were professional baseball coaches with practice pitching responsibilities, with a mean age of 30.9 ± 2.9 years. Presenting symptoms included arm fatigue (five), finger numbness (four), cold hypersensitivity/Raynaud's (two), rest pain (one), and cutaneous fingertip embolism (one). Three patients underwent transcatheter thrombolysis prior to referral, including one with angioplasty and stenting. At angiography and surgical exploration 2.5 ± 0.8 weeks after symptom presentation (range, 1-8 weeks), six patients had occlusion of the distal axillary artery opposite the humeral head either at rest (three) or with arm elevation (three), one had axillary artery dissection with positional occlusion, and two had thrombosis of circumflex humeral artery aneurysms. Five patients had embolic arterial occlusions distal to the elbow. Treatment included segmental axillary artery repair with saphenous vein (n = 7; five interposition bypass grafts and two patch angioplasties), ligation/excision of circumflex humeral artery aneurysms (n = 2), and distal artery thrombectomy/thrombolysis (n = 2). Mean postoperative hospital stay was 3.8 ± 0.5 days, and the time until resumption of unrestricted overhead throwing was 10.8 ± 2.7 weeks. At a median follow-up of 15 months (range, 3-123 months), primary-assisted patency was 89%, and secondary patency was 100%. All nine patients had continued careers in professional baseball, although one retired during long-term follow-up. CONCLUSIONS: Repetitive positional compression of the axillary artery can cause a spectrum of pathology in the overhead athlete, including focal intimal hyperplasia, aneurysm formation, segmental dissection, and branch vessel aneurysms. Prompt recognition of these rare lesions is crucial given their propensity toward thrombosis and distal embolism, with positional arteriography necessary for diagnosis. Full functional recovery can usually be anticipated within several months of surgical treatment, consisting of mobilization and segmental reconstruction of the diseased axillary artery or ligation/excision of branch aneurysms, as well as concomitant management of distal thromboembolism.

Development and preliminary reliability testing of an assessment of patient independence in performing a treatment program: standardized scenarios.

BACKGROUND: Physical therapists often assess patient independence through observation; however, it is not known if therapists make these judgments reliably. We have developed a standardized method to assess a patient's ability to perform his or her treatment program independently. OBJECTIVES: To develop a standardized assessment of patient independence in performance of a treatment program and examine the intra- and inter-rater reliability decisions made by two physical therapists. DESIGN: Test-retest. METHODS: An assessment of patient independence in performance was developed. Standardized patient scenarios were used to assess the intra- and inter-tester reliability of two physical therapists. Percentage of agreement (%) and kappa's coefficient (k and k(w)) indexed rater reliability. RESULTS: Intra-rater reliability of therapist 1 was as follows: knowledge: % = 95, k = 0.90; performance: % = 95, k(w) = 0.82. Intra-rater reliability of therapist 2 was as follows: knowledge: % = 85, k = 0.68; performance: % = 94, k(w) = 0.80. Inter-rater reliability for knowledge was % = 91 and k = 0.79 and for performance was % = 91 and k(w) = 0.72. CONCLUSION: Trained therapists displayed substantial to excellent intra-rater reliability and substantial inter-rater reliability in assessing a patient's independence in a treatment program. :