Current Clinical Concepts: Rehabilitation of Thoracic Outlet Syndrome.

Thoracic outlet syndrome (TOS) involves inconsistent symptoms, presenting a challenge for medical providers to diagnose and treat. Thoracic outlet syndrome is defined as a compression injury to the brachial plexus, subclavian artery or vein, or axillary artery or vein occurring between the cervical spine and upper extremity. Three common subcategories are now used for clinical diagnosis: neurogenic, arterial, and venous. Postural position and repetitive motions such as throwing, weightlifting, and manual labor can lead to symptoms. Generally, TOS is considered a diagnosis of exclusion for athletes due to the poor accuracy of clinical testing, including sensitivity and specificity. Thus, determining a definitive diagnosis and reporting injury is difficult. Current literature suggests there is not a gold standard diagnostic test. Rehabilitation has been shown to be a vital component in the recovery process for neurogenic TOS and for arterial TOS and venous TOS in postoperative situations.

FETOS: A Self-Questionnaire for Functional Evaluation in Thoracic Outlet Syndrome.

OBJECTIVE: Thoracic outlet syndrome is caused by the compression of blood vessels and nerves leading to the upper limbs; the level of functional discomfort in activities of daily living can be significant. This discomfort has been evaluated using a variety of nonspecific scales, prompting the development a specific self-questionnaire ("Functional Evaluation in Thoracic Outlet Syndrome). Here, the scale's test-retest reliability, sensitivity to change, and criterion validity were assessed. DESIGN: Between May 2015 and July 2017, a total of 37 patients were assessed during an intensive rehabilitation program. The Functional Evaluation in Thoracic Outlet Syndrome self-questionnaire comprises 16 items rated on a 4-point scale: impossible, major discomfort, moderate discomfort, or no difficulty. A total score is then calculated and the usual level of discomfort is rated on a numerical scale. The questionnaire was completed on day (D)1, D2, and the day of discharge. RESULTS: The questionnaire showed very good test-retest reliability, with an overall correlation coefficient above 0.91. The overall score was highly sensitive to change, with a significant median improvement (-5.89) between D1 and discharge (P < 0.001). Of the 16 items, 9 showed significant scalability in their individual sensitivity to change. The criterion validity was moderate: the coefficient for the correlation with the numerical scale was 0.68 on D1 (P < 0.001), 0.55 on D2 (P < 0.001), and 0.69 at discharge (P < 0.001). CONCLUSIONS: The Functional Evaluation in Thoracic Outlet Syndrome self-questionnaire is a quick, simple way of assessing the impact of thoracic outlet syndrome on activities of daily living. The overall score and most of the items displayed good reproducibility and sensitivity to change.

Efficacy of intensive, hospital-based rehabilitation in cases of thoracic outlet syndrome that failed to respond to private-practice physiotherapy.

BACKGROUND: Rehabilitation is currently the preferred first-line treatment for thoracic outlet syndrome (TOS). When physiotherapy fails, the next treatment option is usually surgery - a complex procedure with potential complications. OBJECTIVE: We sought to establish whether an intensive, multidisciplinary, day-hospital-based rehabilitation programme could reduce the symptoms of TOS after the failure of private-practice physiotherapy and before surgery was considered. METHODS: We performed a retrospective, single-centre study of 63 TOS patients admitted to our day hospital for 3 weeks (15 therapy sessions) between 2003 and 2014. The data were extracted from hospital records or gathered in a phone interview. RESULTS: Immediately after discharge, the observed improvements in hand function were related to lifting a load, reaching a high shelf, sweeping the floor, cleaning windows, and combing hair. Three months after the end of the intensive rehabilitation program, 80% of the patients reported a reduction in their symptoms. Forty-one of the 63 patients were subsequently contacted by phone. The mean time interval between the end of the rehabilitation programme and the phone interview was 4.5 years (median: 3.5 years; range: 1-12 years). Twenty-seven patients (66%) reported a worsening in hand function, and 25% had undergone surgery. Twenty-three patients had kept the same job, 7 had changed jobs after retraining, 4 had stopped working before the programme but were able to return to work afterwards (including one patient in a part-time job), 4 had not returned to work, and 3 received disability benefits. CONCLUSION: An intensive, multidisciplinary, hospital-based rehabilitation programme was associated with improvements in the great majority of patients with TOS - even after private-practice physiotherapy had failed.

Thoracic outlet syndrome (TOS): A case report of a rare complication after Nuss procedure for pectus excavatum.

RATIONALE: The Nuss procedure has become a major alternative operation for patients with pectus excavatum (PE). PATIENT CONCERNS: We report a case of 27-year-old man with PE who developed thoracic outlet syndrome (TOS) after the Nuss procedure. The patient showed clinical symptoms of brachial plexus compression. DIAGNOSES: Further evaluation demonstrated a narrowed space between the first rib and the anterior scalene muscle and compressing the brachial plexus and vessels. INTERVENTIONS: Nerve nourishing medicine and rehabilitation exercising were taken to restore the muscle strength. OUTCOMES: Several months later, the clinical symptoms disappeared. LESSONS: Medicine and rehabilitation exercising may benefit the functional recovery of impaired nerve in TOS in the early stage of TOS.

Compressão da artéria subclávia por pseudoartrose de clavícula: apresentação na quinta década de vida / Late presentation of critical upper limb ischemia caused by pseudarthrosis of the clavicle

A compressão da artéria subclávia no desfiladeiro torácico é um fenômeno amplamente conhecido. Anormalidades ósseas, como a pseudoartrose da clavícula, podem raramente causar compressão arterial a esse nível. A pseudoartrose pode desenvolver-se em decorrência de um trauma, que é a forma mais comum, ou ser congênita. Os autores descrevem o caso de uma paciente de 44 anos com quadro de isquemia crítica de membro superior direito. Apresentava história de fratura não tratada de clavícula direita aos 9 meses de idade que evoluiu com pseudoartrose e compressão extrínseca com oclusão da artéria subclávia. O segmento da clavicula acometido pela pseudoartrose foi ressecado e realizada uma tromboembolectomia tardia das artérias subclávia, braquial e distais, com boa evolução.

Compression of the subclavian artery in the thoracic outlet is a well-known phenomenon. In rare cases, bone abnormalities, such as pseudarthrosis of the clavicle, can cause arterial compression at this level. Pseudarthrosis may develop as a result of trauma, which is the more common form, or it may be congenital. Here, the authors describe the case of a 44-year-old patient with critical ischemia of the right upper limb. She had a history of untreated right clavicle fracture at 9 months of age which had progressed to pseudarthrosis and extrinsic compression of the subclavian artery causing occlusion. The segment of the clavicle involved was resected and late thromboembolectomy of the subclavian, brachial, distal arteries was performed, with good results.

Thoracic outlet syndromes. The so-called "neurogenic types".

Neurogenic thoracic outlet syndrome (TOS) is one of the most controversial pain syndromes of the upper limbs. The controversies revolve around both the diagnosis and treatment of the non-specific or subjective subtypes. Their diagnosis rests on a combination of history, suggestive symptoms and clinical examination. Proximal pain is primarily muscular in origin, while distal symptoms may be the result of intermittent nerve compression and/or myofascial pain syndrome. Stringent clinical criteria are required to confirm the diagnosis of subjective TOS. In reality, multiple factors can be entangled, with TOS being one element within a multifactorial pain disorder; any musculotendinous pathology of the upper limb and any peripheral nerve entrapment require screening for potential concomitant TOS. Surgery is indicated in most cases of true neurogenic TOS, whereas rehabilitation is the standard treatment for subjective TOS.

NTOS symptoms and mobility: a case study on neurogenic thoracic outlet syndrome involving massage therapy.

Neurogenic thoracic outlet syndrome (NTOS) is a neuromuscular condition affecting brachial plexus functionality. NTOS is characterized by paresthesia, pain, muscle fatigue, and restricted mobility in the upper extremity. This study quantified massage therapy's possible contribution to treatment of NTOS. A 24-year-old female with NTOS received eight treatments over 35 days. Treatment included myofascial release, trigger point therapy, cross fiber friction, muscle stripping, and gentle passive stretching. Abduction and lateral rotation at the glenohumeral (GH joint) assessments measured range of motion (ROM). A resisted muscle test evaluated upper extremity strength. The client rated symptoms daily via a visual analog scale (VAS). Findings showed improvement in ROM at the GH joint. VAS ratings revealed a reduction in muscle weakness, pain, numbness, and 'paresthesia'. Results suggest massage may be useful as part of a broad approach to managing NTOS symptoms and improving mobility.

Inserción anómala del músculo subclavio como causa de síndrome de estrecho torácico superior / Anomalous subclavius muscle insertion as a cause of thoracic outlet syndrome

Se presenta una causa inusual de síndrome de estrecho torácico superior secundario a la inserción anómala del músculo subclavio en una mujer de mediana edad con síntomas de cervicobraquialgia y parestesias en la mano derecha. La paciente requirió tratamiento quirúrgico mediante la resección del músculo subclavio, tras la cual sus síntomas remitieron completamente. El presente caso resulta de gran interés por la rareza de la causa de la compresión, pero además resalta la importancia de considerar el síndrome de estrecho torácico superior en el diagnóstico diferencial del dolor cervical y cervicobraquial(AU)

An unusual cause of the thoracic outlet syndrome secondary to an anomalous subclavius muscle insertion that was diagnosed in a middle-aged woman who had neck and upper limb pain with parenthesis in her right hand is presented. The patient was successfully treated by surgical muscle resection. The importance of this case is the uncommon cause of the compression. We would like to emphasize the relevance of considering the thoracic outlet syndrome for the differential diagnosis of cervical and cervicobrachial pain(AU)

A medical-ergonomic program for symptomatic keyboard/mouse users.

OBJECTIVE: To describe the range of ergonomic stressors and effective interventions in otherwise healthy patients diagnosed with upper extremity disorders associated with occupational keyboard/mouse use. METHODS: From patients treated in our Medical-Ergonomic Program, we report demographic data, symptoms, signs, diagnoses and associated ergonomic stressors and response to medical/ergonomic interventions. RESULTS: Fifty-six patients had a mean age (range) of 40 (23-61) years with 20 patients younger than 35 years. The most prevalent diagnoses were myofascial pain syndrome (MPS) of shoulder/neck associated with poor posture, MPS of forearm extensors followed by thoracic outlet syndrome and carpal tunnel syndrome. Common ergonomic stressors were typing/mousing technique, keyboard height, inadequate seating, and lack of breaks. Improvement occurred in 89% following medical/ergonomic intervention. CONCLUSION: Ergonomic education/intervention must be combined with the medical treatment of work-related upper extremity disorders associated with keyboard/mouse use.

A hand surgeon's further experience with thoracic outlet compression syndrome.

Because hand surgeons frequently see patients with arm and hand pain, numbness, and tingling, it is important for them to recognize the possibility of the presence of thoracic outlet compression syndrome (TOCS). Approximately 40% to 50% of patients with this condition have associated peripheral nerve compression symptoms. Only about 10% of patients with suspected TOCS might show some objective evidence during physical examination and other examination modalities. For this reason, TOCS is one of the most overlooked, misdiagnosed, and underrated conditions. During the past 20 years (1989-2009) our surgical experience with combined-approach surgery for TOCS, involving transaxillary first rib resection followed by immediate transcervical anterior and middle scalenectomy, has been gratifying. During this period, more than 750 patients had this combined procedure. Between the end of 1989 and 2002 (13 years), 532 patients (many of whom were from out of state) had this kind of intervention. At the end of 2002, we surveyed our patients for the outcome of their surgery. Unfortunately, we were able to locate only 358 patients, and only 102 patients returned a mailed questionnaire. About 95 patients reported improvement of their symptoms. Since the beginning of 2003, more than 230 patients have had the same procedure. It is our impression that the outcome of the surgery in this last group of patients is at least as good as (if not better than) the earlier reported outcome in the first group of patients. The combined surgical approach to TOCS with transaxillary first rib resection and transcervical scalenectomy is the most complete procedure for total decompression of the thoracic outlet, with a much better rate of improvement of symptoms and a lower rate of recurrences. The surgical techniques of these two procedures are described.

Thoracic outlet syndrome part 2: conservative management of thoracic outlet.

Thoracic outlet syndrome (TOS) is a symptom complex attributed to compression of the nerves and vessels as they exit the thoracic outlet. Classified into several sub-types, conservative management is generally recommended as the first stage treatment in favor of surgical intervention. In cases where postural deviations contribute substantially to compression of the thoracic outlet, the rehabilitation approach outlined in this masterclass will provide the clinician with appropriate management strategies to help decompress the outlet. The main component of the rehabilitation program is the graded restoration of scapula control, movement, and positioning at rest and through movement. Adjunctive strategies include restoration of humeral head control, isolated strengthening of weak shoulder muscles, taping, and other manual therapy techniques. The rehabilitation outlined in this paper also serves as a model for the management of any shoulder condition where scapula dysfunction is a major contributing factor.

Case reports: unusual cause of shoulder pain in a collegiate baseball player.

The objective of reporting this case was to introduce a unique cause of shoulder pain in a high-level Division I NCAA collegiate baseball player. Various neurovascular causes of shoulder pain have been described in the overhead athlete, including quadrilateral space syndrome, thoracic outlet syndrome, effort thrombosis, and suprascapular nerve entrapment. All of these syndromes are uncommon and frequently are missed as a result of their rarity and the need for specialized tests to confirm the diagnosis. This pitcher presented with nonspecific posterior shoulder pain that was so severe he could not throw more than 50 feet. Eventually, intermittent axillary artery compression with the arm in abduction resulting from hypertrophy of the pectoralis minor and scalene muscles was documented by performing arteriography with the arm in 120 degrees abduction. MRI-MR angiographic evaluation revealed no anatomic abnormalities. The patient was treated successfully with a nonoperative rehabilitation program and after 6 months was able to successfully compete at the same level without pain.

Comprehensive surgical management of the competitive athlete with effort thrombosis of the subclavian vein (Paget-Schroetter syndrome).

OBJECTIVES: The results of treatment for subclavian vein effort thrombosis were assessed in a series of competitive athletes. METHODS: A retrospective review was conducted of high-performance athletes who underwent multidisciplinary management for venous thoracic outlet syndrome in a specialized referral center. The overall time required to return to athletic activity was assessed with respect to the timing and methods of diagnosis, initial treatment, operative management, and postoperative care. RESULTS: Between January 1997 and January 2007, 32 competitive athletes (29 male and 3 female) were treated for venous thoracic outlet syndrome, of which 31% were in high school, 47% were in college, and 22% were professional. The median age was 20.3 years (range, 16-26 years). Venous duplex ultrasound examination in 21 patients had a diagnostic sensitivity of 71%, and the mean interval between symptoms and definitive venographic diagnosis was 20.2 +/- 5.6 days (range, 1-120 days). Catheter-directed subclavian vein thrombolysis was performed in 26 (81%), with balloon angioplasty in 12 and stent placement in one. Paraclavicular thoracic outlet decompression was performed with circumferential external venolysis alone (56%) or direct axillary-subclavian vein reconstruction (44%), using saphenous vein panel graft bypass (n = 8), reversed saphenous vein graft bypass (n = 3), and saphenous vein patch angioplasty (n = 3). In 19 patients (59%), simultaneous creation of a temporary (12 weeks) adjunctive radiocephalic arteriovenous fistula was done. The mean hospital stay was 5.2 +/- 0.4 days (range, 2-11 days). Seven patients required secondary procedures. Anticoagulation was maintained for 12 weeks. All 32 patients resumed unrestricted use of the upper extremity, with a median interval of 3.5 months between operation and the return to participation in competitive athletics (range, 2-10 months). The overall duration of management from symptoms to full athletic activity was significantly correlated with the time interval from venographic diagnosis to operation (r = 0.820, P < .001) and was longer in patients with persistent symptoms (P < .05) or rethrombosis before referral (P < .01). CONCLUSIONS: Successful outcomes were achieved for the management of effort thrombosis in a series of 32 competitive athletes using a multidisciplinary approach based on (1) early diagnostic venography, thrombolysis, and tertiary referral; (2) paraclavicular thoracic outlet decompression with external venolysis and frequent use of subclavian vein reconstruction; and (3) temporary postoperative anticoagulation, with or without an adjunctive arteriovenous fistula. Optimal outcomes for venous thoracic outlet syndrome depend on early recognition by treating physicians and prompt referral for comprehensive surgical management.

The relationship between magnetic resonance imaging findings and postural maneuver and physical examination tests in patients with thoracic outlet syndrome: results of a double-blind, controlled study.

OBJECTIVES: To investigate the differences in findings from magnetic resonance imaging (MRI) in the neutral and provocative positions, and to examine the relationship between these differences and the results of physical examination tests in patients with thoracic outlet syndrome (TOS). DESIGN: Prospective. SETTING: University physical medicine and rehabilitation outpatient and radiology clinics. PARTICIPANTS: Twenty-nine patients and 12 healthy controls. All of the patients had positive bilateral TOS stress tests; control group participants were symptom free and had negative TOS stress tests bilaterally. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: All participants underwent Adson's test, the Halsted maneuver, and a hyperabduction test. All were evaluated with MRI while in 2 positions: the neutral position (upper extremities adducted) and in a provocative position. Measurements were obtained at the interscalene triangle, at the costoclavicular space, and at the retropectoralis minor space. RESULTS: There was a significant difference in MRI findings between the neutral and provocative position in the patients (P<.05), but there were no significant differences in the control group. There was a significant difference in the positional change values in MRI between the patients and the control subjects (P<.05). The difference was found in the minimum costoclavicular distance between patients with a positive Halsted maneuver and a negative Halsted maneuver (P<.05). CONCLUSIONS: Our findings indicate that MRI findings in patients in a provocative position are more valuable in the diagnosis of TOS, and these findings are in accord with findings from the physical evaluation tests.

[Predictive factors of long-term functional rehabilitation in thoracic outlet syndromes: 85 patients]. / Facteurs prédictifs des résultats à long terme de la rééducation fonctionnelle des syndromes de la traversée thoracobrachiale: à propos de 85 patients.

INTRODUCTION: Thoracic outlet syndromes are expressed by various clinical manifestations. Treatment is mainly rehabilitation. We aimed to identify factors predicting long-term functional rehabilitation in patients with this treatment and recurrence of symptoms. PATIENTS AND METHODS: We performed a descriptive retrospective analysis of 84 patients who underwent rehabilitation for thoracic outlet syndrome as defined by Revel and colleagues. Data collection involved a questionnaire exploring personal information, risk factors for developing thoracic outlet syndrome, clinical signs, and x-ray results. Long-term results of treatment were evaluated by telephone questionnaire. Data analysis involved use of Stata 6 software. RESULTS: Univariate analysis: predictive factors of negative results with treatment were ligament hypermobility, sensitive disturbances at the time of diagnosis, and a positive Adson's test result. Predictive factors of positive results were absence of paresthesia at the end of the treatment, and a negative "bell sign" at the end of the treatment. Predictive factors of nonrecurring symptoms were age younger than 34, bilateral positive Adson test result, and need for a supplementary number of sessions. MULTIVARIATE ANALYSIS: predictive factors of positive results with treatment were absence of sensitive impairment at the time of diagnosis, compliance with home exercises, initial negative Adson's test result, absence of hypermobility, and absence of paresthesia at the end of treatment. Predictive factors of recurring symptoms were age younger than 34, the need for a supplementary number of sessions and bilateral positive Adson's test result. CONCLUSION: A larger number of subjects are needed to further explore the predictive factors of rehabilitation and recurring symptoms in thoracic outlet syndrome for better validity and significance.

Conservative treatment of thoracic outlet syndrome. A review of the literature.

Thoracic outlet syndrome (TOS) is a debated topic. While there are many clinical studies concerning the efficacy of surgical treatment, there are few regarding conservative treatment. It has not yet been established whether or not conservative treatment is effective and what the best treatment is. The aims of this study were to evaluate the efficacy of conservative treatment in TOS with particular reference to physiotherapy, orthotics, and taping and to make general recommendations for conservative treatment. The literature was reviewed. Medical databases consulted: Medline, Embase, CINAHL, Current Awareness, Pedro, Cochrane Library, Medscape. We used the following key words: thoracic outlet syndrome, double crush syndrome, entrapment, conservative, treatment, rehabilitation, and management. Languages of the articles reviewed: English, French, German, Spanish, Italian, and Portuguese. This analysis focussed on 10 studies of conservative treatment and 3 studies comparing the outcomes of conservative and surgical treatment, published from 1983 to 2001. This review found no randomised controlled trials, systematic reviews, or meta-analyses. Conservative treatment seems to be effective at reducing symptoms, improving function, and facilitating return to work, also when compared to surgery. We could not establish whether or not conservative treatment was better than no treatment or placebo, or what type of conservative treatment was the best.

Role of therapeutic exercises in neurogenic thoracic outlet syndrome.

BACKGROUND: Neurogenic Thoracic Outlet Syndrome (TOS) is a set of signs and symptoms existing due to compression of brachial plexus in the cervical area. We performed the study to highlight the role of therapeutic exercises on patients with neurogenic thoracic Outlet Syndrome. METHODS: This quasi-experimental study was carried out at Armed Forces Institute of Rehabilitation Medicine (AFIRM), Rawalpindi. Fifty consecutive patients of neurogenic TOS of both genders and all ages were selected. Patients were diagnosed clinically and the diagnosis was confirmed by electrodiagnosis. These patients were asked to follow a therapeutic exercises program for 6 months. Outcome measures included Visual Analogue Scale (VAS) and Ulnar Nerve Conduction Velocity across neck. Results were compared by applying relevant tests of significance on follow up visits at 3 and 6 months. RESULTS: Mean age was 39.1 +/- 7.79 years. Thirty seven (74%) cases were females and thirteen (26%) were males. On each visit, statistical analysis showed significant improvement with therapeutic exercises. After 6 months of conservative treatment, 17 (34%) of patients showed full recovery, 14 (28%) had marked improvement, 16 (32%) had partial improvement while 3 (6%) patients reported with persistent severe symptoms. CONCLUSION: Current study shows that a trial of therapeutic exercises provides relief of symptoms of Neurogenic Thoracic Outlet Syndrome in majority of patients.

[Neurorehabilitation in children with thoracic outlet syndrom and its assessment]. / Postepowanie neurorehabilitacyjne u dzieci z zespolem górnego otworu klatki piersiowej i ocena jego wyników.

OBJECTIVES: Thoracic outlet syndrome (TOS), a rare clinical condition develops as a consequence of compression of the brachial plexus and/or subclavian vessels in the thoracic outlet area. THE AIM: The aim of this research was the clinical and electrophysiological evaluation of results of therapeutic rehabilitation in female patients diagnosed with TOS. MATERIAL AND METHODS: 3 girls diagnosed in the Department of Pediatric Neurology and Neurophysiology Laboratory and treated in the Neurorehabilitation Division at the University Children's Hospital were evaluated. The TOS diagnosis was established in children aged 12-14 years with the use of doppler examination of subclavian vessels. Two girls underwent conservative management and in the third case surgical decompression and subsequent neurorehabilitation was provided. The methods of conservative management were addressed to relaxation of scalenic muscles, flexibility of cervical and thoracic vertebral column, stretching of pectoral smaller muscles, relaxation and relief of cervical vertebral column, and postural correction of shoulder girdle. The treatment plan assumed improvement of balance of muscle tone, postural correction and diaphragmatic mode of breathing. The first evaluation was conducted before rehabilitation, the control evaluation after 12 months of treatment using Lowet test, load tests, Doppler examination of subclavian vessels and electrophysiological tests (ENG, EMG and SEP) as well. RESULTS: Rehabilitation treatment increased the muscle strength, without significant proficiency improvement of patient upper extremities. The control electroneurography, electromyography and Doppler examinations did not reveal improvement after a conservative management. However, the surgical decompression led to deliberation of subclavian artery, stopped progress of muscle atrophy and normalization of SEP latencies as well. CONCLUSIONS: A 12-months of comprehensive rehabilitation treatment of children with TOS improved significantly a muscle mass and strength. Significant improvement of range of motions, however neurophysiological improvement was not observed. The surgical decompression combined with neurorehabilitation in 1 child caused normalization of somatosensory potentials.