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Biocompatible Dentistry And Painless Dentistry Are A Winning Combination
To get acquainted with the dentist San Diego residents turn to for both holistic, biocompatible dentistry and painless dentistry, get to know Dr. Daniel Vinograd. He has more than 30 years experience doing what’s right and making patients comfortable.
Biocompatible Dentistry
Biocompatible dentistry means that the dentist only puts things in your mouth that won’t react negatively with your body. That means very little use of metal and no use of mercury-laden metal fillings. While biocompatible dentistry doesn’t always involve the removal of old silver filling since there are mercury exposure risks during removal, that’s sometimes a part of the process.
Biocompatible dentistry also means using only safe and effective materials for root canals and other procedures, and those are often much different from the materials used by traditional dentists who value speed and cost over doing what’s best for you body in cases. While traditional dentists focus on doing what works, biocompatible dentists focus both on what works and what’s right for you body.
Painless Dentistry
Painless dentistry involves a special commitment by the dentist to paying attention to patient needs and the use of special procedures that limit pain. These special procedures include rubbing on a painkiller before inserting a deadening shot, doing injections more slowly to reduce the pain of the deadening medication going in and more.
Dr. Vinograd has a simple rule: he doesn’t hurt his patients. He makes sure he lives up to this standard by allowing patients to raise their hand and stop any procedure at any moment. If things start to get painful or just too intense, he stops, reassesses the situation and takes whatever action is necessary to get things back on track.
When biocompatible dentistry is combined with painless dentistry, the two parts equal San Diego dentist, Dr. Daniel Vinograd. And he could be your dentist too. Just call and ask for your first appointment.
To get acquainted with the dentist San Diego residents turn to for both holistic, biocompatible dentistry and painless dentistry, get to know Dr. Daniel Vinograd. He has more than 30 years experience doing what’s right and making patients comfortable.
Biocompatible Dentistry
Biocompatible dentistry means that the dentist only puts things in your mouth that won’t react negatively with your body. That means very little use of metal and no use of mercury-laden metal fillings. While biocompatible dentistry doesn’t always involve the removal of old silver filling since there are mercury exposure risks during removal, that’s sometimes a part of the process.
Biocompatible dentistry also means using only safe and effective materials for root canals and other procedures, and those are often much different from the materials used by traditional dentists who value speed and cost over doing what’s best for you body in cases. While traditional dentists focus on doing what works, biocompatible dentists focus both on what works and what’s right for you body.
Painless Dentistry
Painless dentistry involves a special commitment by the dentist to paying attention to patient needs and the use of special procedures that limit pain. These special procedures include rubbing on a painkiller before inserting a deadening shot, doing injections more slowly to reduce the pain of the deadening medication going in and more.
Dr. Vinograd has a simple rule: he doesn’t hurt his patients. He makes sure he lives up to this standard by allowing patients to raise their hand and stop any procedure at any moment. If things start to get painful or just too intense, he stops, reassesses the situation and takes whatever action is necessary to get things back on track.
When biocompatible dentistry is combined with painless dentistry, the two parts equal San Diego dentist, Dr. Daniel Vinograd. And he could be your dentist too. Just call and ask for your first appointment.
Heart Health And Neutralizing pH Are Two Great Reasons To Make Your Own Toothpaste
The best toothpaste to use is one you make yourself. That way, you can control what’s in it and leave out all the toxic chemicals that find their way into commercial brands.
Need more reasons to make homemade toothpaste? Maintaining good heart health and a healthy mouth pH level are two great reasons why making your own toothpaste is a sensible idea.
And making your own toothpaste is remarkable simple when you follow the right recipe. All you need is some coconut oil as a base, essential oil for flavoring, baking soda as a mild abrasive and Xylitol for sweetness and to kill bacteria. When combined, these ingredients make a top-notch fluoride-free toothpaste.
Maintaining good oral health allows you to maintain good overall health. Simply maintaining a healthy oral cavity can reduce your risk of heart disease and stroke as well as respiratory disorders and even problems during pregnancy.
Remember that a toothpaste labeled “natural” may still have problem ingredients, so making your own is best.
The toothpaste recipe mentioned above also helps create a neutral pH condition in your mouth, contributing to overall health as well. Acids destroy tooth structure and allow plaque to build up, and bacteria love an acidic environment. The bacteria in your mouth is the same kind that can cause heart disease, so the idea of a neutral mouth and a healthy heart are linked together.
Some toothpastes on the market contain the active ingredient in antifreeze. Others contain SLS, a surfactant than can alter your taste temporarily and worsen canker sores and increase dry mouth. And almost all store-bought toothpaste has fluoride, an unnecessary and potentially harmful ingredient that modern sciences shows isn’t really necessary.
So how many reasons do you need to make your own toothpaste?
Full recipe available at: www.homemadetoothpaste.net
The best toothpaste to use is one you make yourself. That way, you can control what’s in it and leave out all the toxic chemicals that find their way into commercial brands.
Need more reasons to make homemade toothpaste? Maintaining good heart health and a healthy mouth pH level are two great reasons why making your own toothpaste is a sensible idea.
And making your own toothpaste is remarkable simple when you follow the right recipe. All you need is some coconut oil as a base, essential oil for flavoring, baking soda as a mild abrasive and Xylitol for sweetness and to kill bacteria. When combined, these ingredients make a top-notch fluoride-free toothpaste.
Maintaining good oral health allows you to maintain good overall health. Simply maintaining a healthy oral cavity can reduce your risk of heart disease and stroke as well as respiratory disorders and even problems during pregnancy.
Remember that a toothpaste labeled “natural” may still have problem ingredients, so making your own is best.
The toothpaste recipe mentioned above also helps create a neutral pH condition in your mouth, contributing to overall health as well. Acids destroy tooth structure and allow plaque to build up, and bacteria love an acidic environment. The bacteria in your mouth is the same kind that can cause heart disease, so the idea of a neutral mouth and a healthy heart are linked together.
Some toothpastes on the market contain the active ingredient in antifreeze. Others contain SLS, a surfactant than can alter your taste temporarily and worsen canker sores and increase dry mouth. And almost all store-bought toothpaste has fluoride, an unnecessary and potentially harmful ingredient that modern sciences shows isn’t really necessary.
So how many reasons do you need to make your own toothpaste?
Full recipe available at: www.homemadetoothpaste.net
Thoractic Outlet Syndrome Audio Transcript
source: http://vimeo.com/22362794
Dr. James Stoxen: Good afternoon audience my name is Dr. Stoxen, I wanted to thank, first of all the American Academy of Anti-Aging Medicine for inviting me here today to speak to you and also Dr. Bob Goldman, the present, and also Dr. Ron Klatz, it's a pleasure to be here. I’m going to talk today about conservative management of thoracic outlet syndrome. It’s a very controversial subject. I’m going to talk about sports trauma and postural epidemiology and we’re going to bring up some information that I hope that when we get done today, you're going to be able to take this back to your practice and actually help your patients. My office is in Chicago, in the south side, yes on the south side of Chicago and the name of the practice is called Team Doctors Treatment Centers.
I'm going to talk about, like I've said, thoracic outlet syndrome, it's a very controversial subject. A lot of doctors don’t even think it exists. Thoracic outlet syndrome is the most difficult neuro-vascular compression syndrome to manage of the extremities and this is because it's got a very, variety, variability of complaints and the difficulty of patient compliance in the treatment and reduction of the causative factors. We're going to talk about what causes thoracic outlet syndrome and I think it’s going to provide you with some insight as to why it's difficult to manage. From what I can gather from the 300 plus research articles and abstracts that I read, there are some observations that we have met, made as to the causative factors of thoracic outlet syndrome, none of which was mentioned in any of the literature, so it's hard to say whether or not these, all these physicians and scientists are missing something but that's what research is all about and sharing of information. I'm hoping we're going to bring some observations that we've found, maybe add to the other research that has been done and we'll be able to have a better outcome for these patients. Conservative management has been very challenging in thoracic outlet syndrome. Majority of the patients, over 90% usually in most studies are getting surgery of the neck to remove the rib, the first rib or cervical rib and then surgery to remove muscles in the neck. I don't know about you, but no surgery looks very exciting for patients and it's a very depressing and scary experience. If it's in the knee, it's not so bad, if it’s in the neck, it's very scary. It's very close to the head, possibility of infection, patients are very frightened of any type of surgery on the neck, it's a very sensitive area and physicians have to be aware of that. We sometimes become numb to these factors, these fears that the patients have and it's time that we have to put ourselves in the position of the patient and maybe work a little harder at finding a better options with conservative therapy.
Team Doctors Treatment Centers has been in practice, we've been around for about 57 years, and it’s been a practice in the family for a long time. Over 30,000 patients have been treated than last 10 years, 1986 to 2004 from 1992 to 2004, practically 4,000 new patients came to our offices presenting with some form of peripheral nerves symptoms, originating in the neck and back, so we have numerous, statistically we have numerous thoracic outlet syndromes thatwe've looked at, we have a very great amount of experience in this field so we're going to use that to enlighten you, the audience.
Thoracic outlet syndrome is the often misdiagnosed cause of neck pain, shoulder pain, and arm disability. It is thought to be neuro-vascular compression seen at the thoracic outlet, which is something that anatomists still can’t agree on. The actual name doesn't even describe it properly. It consists of 3 areas of potential regions of compression consisting of the intra-scalene triangle, as we have pointed out here, we the anterior scalene and the middle scalene and the posterior scalene.
The thoracic bundle, consisting of the super-clavicular or the sub-clavian vein, the sub-clavian artery and the brachial plexus emanate from this triangle and it’s an area where the, these area, these structures can actually become compressed and cause symptomatology. Also notice the costoclavicular space which is down here lower, the costoclavicular space is represented by the area which is above the clavicle and below, or below the clavicle and above the first rib. Not many people really realize that the ribs actually go up right above, at the base of the neck, few patients understand that. In a matter of fact, even few doctors understand that. The last space is called intrapectoral space and that is right underneath the pectoralis minor, as seen on the graphic on the right and that area can also be an area of compression. So doctors have to be aware of these multiple areas of vascular and nerve compression and have an understanding of what symptoms can be related to each area so they can better treat the patient.
The three neuro-vascular structures that pass through the thoracic outlet as I mention before is the brachial plexus, which is a nerve bundle consisting of cervical C5, C6, C7, C8 and T1. The subclavian artery which is the artery that supplies the arm with blood, oxygen and nutrients and the subclavian vein which obviously drains the blood away from the arm and back to the heart. All these structures can be compressed leading to an array of different symptomatology. Thoracic outlet syndrome relates to nerve and vascular compression; leads to upper back pain, neck pain, shoulder complaints and numbness and even extremity weakness. Some more serious complications of thoracic outlet syndrome, because of the vascular obstruction from the various structures compressing those, the artery and the vein, you can have and upper extremity emboli which means that there's, the emboli occurs when the blood supply is reduced or diminished and the emboli forms and releases into the arm causing the, kind of stroke of the arm and potential even for gangrene, 'cause no blood or nutrients can get to the area and the fingers actually will die. The second most common serious complications of thoracic outlet, in my opinion, which is not listed in the literature of course 'cause most of the literatures written by medical physicians that do surgery is unnecessary surgery.
Of course if you're already done the surgery, it was necessary, otherwise you won't have done the surgery. But if more appropriate conservative methods or more effective conservative methods can be had to reduce the number of surgeries and if we found a way to reduce the number of surgeries then, obviously, then the surgery would not be necessary. As I mentioned before, if you brought this type of surgery to the patient's attention that you were going to do an operation on the side of their neck or underneath their armpit to remove ribs and various different muscular structures from the neck, the patient is not going to be very excited about it, they're going to be very scared. Also, you can have subclavian aneurysms and also when the compromise of the neurovascular structures become quite severe leading to weakness in the arm and the hand and the grip strength, you can have accidents related to functional muscle weakness. I've had patients who have dropped, I had a patient that came to me who we started treating and when we talked to the patient about the, what he was experiencing in the last 6 months before he came to our office. His wife had remarked that he had dropped full cups of coffee that he was unaware that he was going to drop them without any warning, he dropped full cups of hot coffee, he dropped tools.
He's a paramedic, he was having difficulty performing his job and these finite movements of the hand, which are very important in some occupations, become compromised and you can have dangerous consequences of that. Physicians say, some physicians say that it's under-diagnosed. I read a letter to the editor, one of the publications, surgical publications saying that, this physician felt that the syndrome was under diagnosed, that more thoracic outlet syndromes actually existed, and then other's physicians say it's over diagnosed. It's our opinion that this syndrome is underdiagnosed and we're going to spell that out for you why we feel it's that way in our discussion today. The problem with this syndrome and the difficulty that many physicians have with this syndrome is that unlike cervical disk or herniated disk or aneurysm of the brain, there is no gold standard test for thoracic outlet syndrome.
In order to diagnose thoracic outlet syndrome, you have to put together an array of historical findings, physical findings and a couple of provocative orthopedic tests of the region of the neck and the shoulder to be able to make that diagnosis. The most common treatment today, currently, is surgery. According to the literature, that if you have a group of 500 patients with thoracic outlet syndrome they decided that practically 90% or only 10% of the patients will respond to conservative therapy, 90% are going to surgery. Some doctors have even given up on conservative therapy and just go directly to surgery. Surgery and, versus conservative care, first of all have to put ourselves, like I said before, in the position of the patient. Why would any patient want to have this surgery if you can see on this graphic here, we have a, the surgery of the neck. There are a lot of very tiny structures in that area. Patients are in great fear of surgery, especially in the neck; the answer to the question is that no patient wants to have this surgery. We have a very high rate of recovery from thoracic outlet syndrome with conservative care, and I am very happy to present that method of treatment to you today. I have not had 1 patient in 17 years started surgery with thoracic outlet syndrome that's approximate 30,000 clients. I'm going to show that rate of success with you. I was very shocked in fact when I discussed, when I looked into the literature. I was aware of the rhizectomy or removal of the first rib or conservative, cervical ribs. It was an afterthought in fact.
After practicing for about 15 years , 16 years, with such great results with the thoracic outlet syndrome just diagnosed in the clinical setting, I decided to look into the research because it was something of interest to me and I was really shocked to find out that, in fact, it was such a depressing rate of improvement with conservative therapy with other uses of therapies in various different stretching and what the procedures that or protocols that the doctors or the therapist were using to try to help this patient conservatively. I think that when I get done with my talk today, you going to find out why these treatments were unsuccessful. And you're to see if you have a better understanding of how this problem starts and with causative factors of thoracic outlet syndrome, you'll see why they were not successful and why, with a better understanding, you will be successful with this, with the treatment. Galen was the first person who mentioned the cervical rib; in 1910, Murphy firsted the first effective resection of the ribs to relieve thoracic outlet syndrome. Adson who's Adson's test which is one of the orthopedic test for thoracic outlet syndrome started the scalenectomy without rib resection, removal of the scalene muscles from the neck, scalene muscles are very important otherwise they wouldn't be there. They are very important in respiration but they remove them. Deete determined that, gave the term Thoracic Outlet Syndrome and here we go.
First of all, we feel that the most common cause of thoracic outlet syndrome is simply a combination of things but primarily it is a superior subluxation of the first rib. In other words, the patient is fine for 30 years of their life, they come to you with at age 32, they've had some upper extremity paresthesias and weakness for approximately a year, maybe 2 years, it's getting worse What is the difference between the patient at the age 32 and the patient at the age, who has got all the peripheral nerve and arterial occlusion symptoms and the patient at age 30 who had the same structures but no symptoms?
What I'm trying to say is that if we find that the patient has , had a normal life without peripheral vascular nerve symptoms and all of a sudden they have a peripheral vascular nerve symptoms, compression symptoms then all we need to do is determine what has changed reverse the change and the patient has been treated properly. The first rib can subluxate, either from trauma or static postural stress. I feel that while trauma is the very significant source of damage to the neck as in a car accident or sports injury, we have to, I fell that static postural stress is by far more common cause of this problem. We're going to talk about that more in fact some mention has made of static postural stress in the literature but I have feeling, it is my opinion that they, that there needs to be a correction of thought regarding what kind of static postural stress is causing this syndrome, we're going discuss that today.
Epidemiology of thoracic outlet syndrome should be broken down into two main components. In this particular slide, we have it broken down into 7. I'm going to clarify that. Traumatic injury and static postural stress as I have mentioned before are the number 1 and 2 causes of thoracic outlet syndrome and the remainder are problems that “predispose” the patient to thoracic outlet syndrome. In other words traumatic injury such as a whiplash or an auto accident or the patient is in the car and is struck from behind causing a violent, who would you call it, trauma to the anterior muscles of the neck, also similarly a clip in football or a very hard punch in boxing or some sort of work injury can cause traumatic stress in the anterior cervical and scalene muscles and also elevate the first rib as a result of misalignment due to the trauma.
Static postural stress is, I feel, the most popular and the most common. It's a position where the neck is held static in extended position. And in literature, it discusses the neck is held forward flexing position. A neck that is held in a forward flexing position causes static muscle strain on the extensor muscles. Scalene muscles are not extensor muscles, they are muscles of flexion. So, while the literature discusses muscles of extension, I feel that some more careful review of the actual causative factors should be put on muscle of flexion. For instance, if you're to take your arm and hold a purse or a maybe a some liter of Coca-Cola for approximately 1 hour and your arm in this position pretty soon, your biceps tendons and your joints in your elbow and your shoulder would become very sore and stiff and if you are the same type of philosophy or theory is that if you are in the bed with two pillows propping you up, watching your favorite television show in this position for approximately 1 to 2 hours, the muscles of the, scalene muscles will be in tonic contractile state for long period of time, in the same thing will happen to these muscles.
The scalene muscles attach on the first rib, so as the tension is increased on the scalene muscles, we feel that the scalene muscles actually elevate the first rib and causes the subluxation, the scalene muscles also become will become inflamed as a result of the subluxation, the entire area, as well as the scalene muscles will become inflamed and cause a compression of the thoracic outlet group of structures. Computer use where you’re actually leaning back in a reclining chair, or reading in bed, like I have mentioned before, just as much as watching television in bed, which I feel is the most common cause, or laying on a recliner or sofa, with the neck in an extended position.
Operation of a motor vehicle with the neck extended as well. Nowadays, you have your seat which can be reclined; it can be made to be straight, reclined, various different positions. A lot of young people think it’s really cool to lean the seat way back, and sit like this and they may be on a long route, for an hour. Half an hour, an hour or they may be in the car quite a bit; this constant stress on the anterior cervical muscles causes imbalance and raise the ribs, first ribs and causes the compression and thoracic outlet syndrome. <inaudible> syndrome is not, I don't feel it's a cause of thoracic outlet syndrome. I feel that it's a predisposing factor. I've seen patients that come to me. They have lower back pain and when they come to me they said they hip into their physician and the doctors said they had scoliosis that was the reason why they had back pain. While the scoliosis is very minor, and we know that scoliosis does not cause back pain in itself, the patient actually had some sort of biomechanical problem that cause the back pain and the scoliosis was an incidental finding. This is what I feel <inaudible> syndrome, bilateral cervical ribs, anomalous cervical, anomalous first ribs and other problems that predispose the patient to thoracic outlet syndrome are associated.
In other words, anomalous first ribs would be where the ribs are actually not formed according to normal, what we consider normal genetic anatomical structure. Those will predispose the patient to thoracic outlet syndrome, especially if you have a patient whose 19 or 20 and has never had a symptoms of thoracic outlet syndrome or maybe they're 25 years old, they're at full maturity, as far as their growth, they just have a recent incident of thoracic outlet syndrome symptoms. They've had anomalous first ribs for 25 years but no symptoms. So how is it all of a sudden that the structure have not changed but the symptoms have been brought on and there is no change in the structure. So in that cause and effect type of relationship, you cannot consider this <inaudible> syndrome, bilateral cervical ribs, anomalous cervical ribs and other findings to be related to thoracic outlet syndrome epidemiology.
Clavicular fracture malunion certainly can be cause of thoracic outlet syndrome if in fact the malunion also is accompanied by scar tissue formation, however, I've seen this kind of case in my office before and even with that kind of malunion and compression of the thoracic outlet group of structures, we found that by adjusting the first rib and treatment of the masculature around that area, we've been able to reduce the patient's symptoms and handle the problem for the patient without any surgery.
Yeah. Traumatic epidemiology such as whiplash is seen in sports. As you can see here a group of boxers that are getting hit, obviously that causes strain on the anterior cervical area and can lead to thoracic outlet syndrome, automobile accidents and traumatic work injuries, as I mentioned before.
However, what we talked about before, which is most common cause, in my opinion, was static postural epidemiology. You could see in this picture right here, we have this gentleman who is actually leaning back in the chair, you can't see it, but his thorax is approximately at a 75-degree angle. He is just watching television and as you can see, in order to keep his head from flipping backwards, because he is on an angle, he has to tense up the anterior cervical muscles, including the scalenes to keep his head in that position. The head weighs about 8 or 9 pounds and that may not seem like a lot of weight, but if you had to sit in that position, it would certainly take its toll on the anterior scalene, middle scalene and the anterior cervical muscles.
And in the literature, it discusses the posture of leaning forward, as in looking at the computer, as a posture that is not a good for thoracic outlet syndrome. As I have mentioned before, the static posture of leaning forward really puts more stress on the extensor muscles of the cervical spine, which do not really compromise any nerve structures. However only in a case of hyper-extension and maybe a disc injury, but those are usually seen with traumatic injuries and not necessarily with static postures. What we’d rather say is the causative factor, is when, as I mentioned before, the patient leans back, the anterior cervical muscles have to maintain the head in this particular position for a long period of time as in the picture with the girl seated at the end of the slide there.
If you take your hand and you put it on your anterior cervical muscles on either side of your trachea and your esophagus, and you lean back, you’ll note that there will be a hardening or tension of these muscles and you’ll be able to see for yourself just by palpating your own neck, that these muscles will tense, and like I mentioned before, even if you’re holding a small item for a long period of time, the amount of tension can cause damage to the joints and the muscles.
So, the differential diagnosis that you want to include in your, when you’re doing your physical and you want to keep in mind are pan coast tumors, which is apical lung tumors, of course you're going to do chest radiograph to determine whether or not if there's any type of lesions in the apical lung area also, also time these pan coast tumors develop on 1 side not 2, thoracic outlet syndrome is usually a bilateral problem. Carpal tunnel syndrome, I feel is very easy to differentiate between thoracic outlet syndrome because if you have a pinching of the nerve or the vascular supply to the hand, the symptoms will be distal to the compression, in other words, you shouldn’t have numbness in your forearm with carpal tunnel syndrome. If you have numbness in your forearm, it cannot be carpal tunnel syndrome, unless it's a double crunch which is the carpal tunnel syndrome and thoracic outlet overlaid on top of each other where the patient has two problems.
So, the other one could be herniated disc nerve compression and in this situation an MRI will rule that out. IF you take and MRI and the patient has a cervical disc, perhaps maybe, 1 mm, 2, 3 and there is no compression on the fecal sac or nerve bundles then even though they have a cervical disc, you cannot rule out the fact that they still have a concomitant thoracic outlet syndrome causing the deficit in nerve and nerve supply and the concomitant numbness and weakness.
So in other words, even if I do an MRI scan on a patient, and I find that the patient has a posterior herniated disc of 1, 2 mm that is not compressing the nerve, according to the radiologist's report, my view of the MRI scan, then I don't feel that that cervical disc is the cause of the peripheral nerve symptoms. Sure there's a disc but it's no consequence to the nerve supply, <inaudible> anything, it should not elicit symptoms. Sure we have to treat it, but we have to still dig deeper to see where that peripheral vascular type of symptomatology is coming from and you should not overlook the fact that it could be coming from some form of thoracic outlet syndrome. Reynaud's Phenomenon is very similar and differential diagnosis is very difficult at times because they're very common. Sometimes I feel Reynaud's Phenomenon is thoracic outlet, sometimes I feel that thoracic outlet is Reynaud's Phenomenon.
There's a lot of patients that are not getting care for thoracic outlet syndrome that have Reynaud's Phenomenon that need to be looked at. They have a similar type of symptoms in fact when you cut off the blood supply or you reduce the blood supply to the hand when you have elevated first rib or scalene swelling causing compression of the subclavian artery, not enough blood supply will get to the distal areas of the fingers and the hands and that is rarely common Reynaud's Phenomenon, the coldness.
Subclavian arteries we already discussed. Spinal cord neoplasms, we can, differential diagnose that by way of obviously some form of imaging, diagnostic imaging a and b, with our reflex testing, other diagnostic test can bring that out blood test and array of different evaluations to differentially diagnose spinal cord neoplasms from thoracic outlet syndrome. One other component of thoracic outlet syndrome which is not as much commonly mentioned is that, in my opinion, the initial symptom is usually the symptoms related to compression of the subclavian vein and I feel the reason is because it's lower down and the area of the scalene, intra scalene triangle and so it's usually the first affected, a and b, the vein is a drainage, doesn't have a muscular layer, its more susceptible to compression and we can find this symptoms by looking at the hands to see if they have any swelling of the hands and forearms. Usually it’s better if you take a photograph of the hands and evaluate it that way. I found that it can be a very helpful tool, because sometimes you don’t see it, you see it better on a photograph. Second thing is you're going to look at the tendons of the hands. If the tendons have been obliterated by edema, you might be looking at a patient who has had difficulty in drainage of the blood from the extremity. It kind of balloons out and they’re going to get a little bit of tingling – that’s when its starts to affect the arterial blood supply. In this situation, the patient starts to get a little worried, that's usually when they come to see you.
Brachial Neuritis usually doesn’t have these vascular symptoms. Cervical spondylosis is a component of thoracic outlet syndrome that's been there for a period of time and vice-versa. Myofascial pain syndrome, obviously you're not going to have the tingling sensations, you're going to have as much of the neurologic complaints with myofascial pain syndrome. But myofascial pain syndrome, in a way, is a component of thoracic outlet syndrome because the structures have been subluxaed and there is inflammatory proceess going on and swelling and pain and that is what myofascial pain syndrome is. So <inaudible> overlap there, subclavian steel syndrome and angina pectoris, I think that you're going to be able to figure those two out fairly easily.
Something to keep in mind though, the history of these patients is usually fairly common and repeatable. When we are faced with a patient that may have thoracic outlet syndrome, it is extremely important that we do a careful history to determine what kind of lifestyle this patient has, and ask that pertinent questions to see if they have the causative factors that create this problem. Like I mentioned before, I usually ask the patient, “Are you reading in bed” "Do you have a television set in your bedroom?" "Do you watch TV in bed?" and "how often do you watch it a week and how many hours a day?" And look to the patient who is going to underestimate that time, they don’t want you to think that they are just sort of lazily lying in bed all day long and watching television. If they tell you it’s 5 hours a week, you could pretty much guarantee it’s between 8 and 10. That's what we’ve found. When we press the patient for the truth, usually they tell us that it’s more time.
Diagnosis is difficult, like I said before, because there is no gold standard test, so historical findings and physical findings are extremely important and the diagnosis because the diagnosis is based on these historical and physical findings that are corroborated by maybe some imaging, diagnostic testing and imaging, nerve conduction, sensory, velocity testing and SSEP tests, and if you care to use those. We haven’t had the need to use those kinds of tests because we are treating the patients clinically as I mentioned we're getting good results.
I like to order diagnostic test images, when I’m not getting the results that I’m looking for, rather than order these tests on every patient that walks into the office. I feel that clinically if I can help the patient within the first two weeks, I’m on the road to recovery and there is no need to do these diagnostic tests. Of course, if I’m not getting the results that I’m looking for, and I may have to dig deeper for something I’m missing, that’s when I order these tests.
Now, basically the common symptoms of thoracic outlet syndrome, it usually begins with some stiffness in the upper thoracic area like in the ribs around the neck area, specifically in the traps and the upper back. A lot of patients complain of stiffness in the neck and they feel the need to stretch their neck at work and crack their neck even and it’s very common with children, they crack their neck, that's called self-adjusting. Actually what I found is that stretching of the neck is actually contra-indicated in this syndrome because the attachment of the scalene muscles is between the 2nd, 3rd, 4th, 5th and 6th cervical and the first rib, so by laterally flexing and stretching the muscle on the left, what is actually happening is that the patient is using the scalene to levitate or elevate the first rib on the left side. So in fact, when you’re stretching the neck, you’re in fact actually even subluxating the rib even further into a position of superior subluxation. So in the literature, it discusses the treatment for thoracic outlet syndrome is to laterally flex and stretch the neck, and in fact if you’re wondering why you’re not getting good results, because laterally flexing the neck actually makes the condition, in my opinion, worse. Our goal in mind here in the treatment of this patient is to lower or bring the ribs inferiorly and reduce the tension of the scalene muscles. Those are the two main goals of therapy. By positioning the rib in a lower position, it will allow more space in the costoclavicular area for the structures to pass. There are no real muscles that actually pull that rib down, so it has to be manipulated. It has to be manually adjusted. I haven’t been able to find any other way to reposition the first rib or cervical ribs, except for manual adjustments.
Of course you can remove some of the muscle spasms which will remove some of the tension on the first rib of the muscles that actually attach on the first rib, being the scalene muscles. If you are going to reposition the rib so that it allows for better passage of the structures, then you’re going to have to manipulate it. Lot of the, the majority, 99% of the articles that are published on thoracic outlet syndrome and studies that are been made on thoracic outlet syndrome have been made by medical community whereas chiropractic community only practitioners that actually make the correction of the rib in the inferior position. There is no wonder results are not good. We’re not looking at any particular profession; we’re looking at a procedure that will remove pressure on neurovascular structures – Plain and simple. We’re not looking at who is better or who’s not. We’re looking at a procedure that is in the doctor’s bag of procedures that is going to be able to relieve the patient’s symptoms by way of repositioning the bone that is causing compression on the structures.
In these patients that stretch and crack the neck, sometimes they, if you ask them, they will crack and stretch the neck 10 times a day. When I see a patient doing that, I just tell them “You’re going to have stop that. I have a way of correcting that” They feel the urge. With treatment, this urge will diminish and be eliminated. They will no longer feel the urge to crack their neck all the time, because the stiffness will be reduced. What usually happens is that the subluxation is actually not in the neck; it’s in the upper thoracic area. So when the stiffness is in the upper thoracic and lower cervical area by cracking the neck because if there's so many different supportive structures with the ribs and the pectorals and the muscles of the upper back as well as in the shoulders. By moving or self-adjusting, you only, adjusting that is going to take place is in the middle cervical area, which only causes a hyper mobility as well as as I mentioned before, lateral flexion to this side will actually have the scalene muscles elevating the rib even further causing further compression of those structures that emanate. So the controversy could be explained a little bit better with some of these more logical explanations. The pain and stiffness actually travels from the upper thoracic area into the ribs and patients actually complain of chest pain and difficulty breathing. Talk about chest pain and stiffness and shortness or labored breathing; you know they don’t sometimes realize it until you bring it to their attention. You just have ask them “Have you noticed lately that you felt that your chest is tight and you have not been able to breathe as well?” And they will say, “Yes, as a matter of fact I did.” It really wasn’t something they were thinking about because the overwhelming sensation of numbness and tingling and the weakness in the hand is a far more of a concern than the shortness of breath. But in fact the reason why the patient has a shortness of breath is because when the first rib subluxates in superiorly, the intercostal muscles which connects the ribs actually allow for the first rib to subluxate superiorly but it takes, the first rib takes the 2nd 3rd 4th 5th ribs with it because they're connected.
So what you are going to see is superior subluxation of the ribs of the upper thoracic spine and not just the first and second. The other thing they have is recurring headaches. The reason why is that they are, in this position watching television, their neck is actually in this position for so long that when they get up, they're actually more with the neck in a straightened or retrolisthesis position. If they leave their head in this position, they're not going to be able see where they are going.
It may seem silly, but postural reflexes kick in what happens is there is tucking mechanism that occurs 1st and 2nd cervical and the base of the skull that has the patient extend their neck back in this way and this hyperextension at level skull C1, C2, plus axis complex will actually cause compression of the first and second nerve of the spine and radiating headache pain as a result of this compression of the nerves and the suboccipital region. Like I had mentioned to you, these headaches are fairly common in thoracic outlet patients. What you have to do you’re going to have to make a decision when you make correction of the spinal misalignment. I found that if you try to correct the upper neck and the lower neck, sometimes there is a problem and there is too much stimuli to the spine. Sometimes you have to work on the lower neck to realign or correct the subluxation of the first rib with neuromuscular reeducation or muscle deep tissue work and adjustments and mainly do deep tissue work in the upper cervical area and start the correction in about a week or two after treatment is transpired to sort of calmed down the lower cervical region. I think it's a better clinical, a better way of treating the patient clinically that I found the <inaudible> experience.
As I mentioned to, also you have tingling in the fingertips, this usually in the morning. The reason why I feel that this is happening because, even though provocative tests have the patient elevating the arm, causing these symptoms, I feel that the vascular compression that causes the numbness, a lot of the numbness as seen in Adson's Test, we're going to talk about that soon. When the patient is reaching for a broom, or can of something out of a cupboard or waving to a friend, this elevation of the clavicle allows for blood supply to seep through into the arm and allows for the arm to be supplied with spurts of blood because the compression is relieved. When the patient is sleeping, they're in a static posture and there is really not a lot of movement to stimulate the blood flow, and that is why the patient has the tingling in the fingertips in the morning. They also, the patient has the highest degree of swelling in the hands and the swelling sensation called “glove sign”. In the morning, the patient feels the need to shake their hands out. Sometimes, the shaking method actually does bring blood down into the extremities, because they are elevating the clavicle which allows the blood to come in and they are shaking the blood down into the extremity. This is something that the patient understands, based on instinct, when in fact they are actually correcting their problem.
The swelling in the supraclavicular space is amazing to me because it’s so obvious and so blatant and I have had numerous patients who have come to me with swelling in the supraclavicular space. They have been to several physicians, none of which has made comments in their notes. As you can see on the top picture here, you can see the upper border of the clavicle on the patient and this patient below was involved in a motor vehicle accident at a fairly high speed. She has bilateral thoracic outlet syndrome. As you can see from the photograph, the superior border of the clavicle is obliterated. Also, we don’t see the sternocleidomastoid muscles and we don’t see any striations in the muscles in these patients and they are thin. Thinner patients, it is more obvious. There is really no fat there. So it’s not fat, it’s swelling. And swelling of the supraclavicular space is in you should look for patients.
I have patients who come in my office and they walk up to me and I look at that region and the left side is more swollen than the right, they come in for a lower back problem, and I just ask them when I see the left side is swollen in the supraclavicular space more than the right, I say “Do you have numbness in your left hand periodically, more than your right?"
And nine times out of ten, they’ll say, “Yes and how did you know?” Like I’m a magician or a soothsayer. How did you know I had numbness in my hand, when in fact no documentation on the initial paper works where the patient is filling out the forms to discuss their symptoms. Nobody had made mentioned to me or the staff about this symptom, and they weren’t even interested in discussing it with us. They came in for their lower back. It was an incidental that started maybe a month or two prior maybe six months have been going on. But just by my observation, I can see that the supraclavicular space was swollen and the patient, I feel, has this thoracic outlet syndrome. So next time you go into your office, please take a look at your patients a little more carefully because you're going to find a lot more TOS's patients by being a little bit more observant. Cervical ribs or anomalous first ribs like I had mentioned to you before, do not cause thoracic outlet syndrome. As like I said before, just because the patient has scoliosis doesn’t mean that we have to do surgery to correct it. Patients have scoliosis of 5 10 15 degrees, live very comfortable and normal pain free lives. 35 year old patient walks in to the office, has never had back or neck pain, upper back pain in their life, they have recent onset of pain, you take an x ray and you find out they have scoliosis.
They had scoliosis when they we're 21. They had scoliosis when they we're 15. They did not have pain when they were 21 and 15. The scoliosis has been there for 30 years, the scoliosis is not the cause of the pain in that particular patient and in this situation if the patient comes in into your office and they have recent onset maybe their 40 35 40 years old, recent onset of thoracic outlet syndrome, you take an x ray of their thoracic spine and cervical spine and you find cervical ribs, just because you find cervical ribs doesn’t mean they have to be surgically resected. If the patient was able to live a comfortable life with those cervical ribs before, my feeling is that all you have to do is reposition the cervical ribs so they do not cause a compressive type of syndrome and the patient will be fine.
In these particular pictures, these are actual photos of patients that have thoracic outlet in my office. This particular patient that you're looking at, the hands on the top is the lady in the previous photograph that had the supraclavicular swelling. As you can see on the right hand, the right hand is much larger than the left and in fact, this enlargement or is an edema, is a swelling and is a result of the fact that the venous return is blocked because of the superior rib subluxation or some intrascalene type of compression on the subclavian vein not allowing the blood to escape from the hand. On the lower picture, we have a gentleman who has the same syndrome as you can see. If you look carefully, not only does his hand bigger on the right, appears to be bigger, but the wrist and the forearm appears to be bigger and larger too. What I have done, you have to understand is that what I did here, I saw vaguely that there were some differences but when I took a photograph of the patient, it became very obvious. My feeling is that that is something that you should you use as a tool because it seems to brings out the differences a lot more strikingly.
Now in this particular slide, we’re talking about postural evaluation. And what you’re going to do is sit down in a chair in your office and you’re going to demonstrate the posture that the patient is in that causes the tension on the anterior scalene muscles which is the gentleman on the bottom picture and the young lady who is leaning back in the chair. You know as well as I do that this is how a lot of us sit and a lot of kids sit; and a lot of people have thoracic outlet syndrome. As I mentioned, do I think it's over diagnosed? Absolutely not.
I think it's under diagnosed and I think that the reason for why it's under diagnosed is because a lot of people sit this way. In the forward tilt position as I have mentioned before, when the neck is in this position while you are watching television an hour or two for sometimes 3 4 5 6 10 years, the neck becomes frozen more or less in this position as a result of tension in the scalenes as well as elevation of the first rib, the structures come together and this forward tilting can be seen in x-ray as a retroslethesis, also the rounded or protracted shoulders. When the, you're gonna see that, when the rib elevates, it affects the shoulders and causes shoulder pains, shoulder stiffness even in <inaudible> syndromes and rotator cuff syndromes. So the shoulders should actually evaluate concomitantly with the neck. Orthopedic test should be performed, muscle test, orthopedic test <inaudible> should be performed on the shoulder as well as the cervical and thoracic region.
Cervical range of motion and flexion; we have a decreased range of motion and stiffness in the lower cervical and upper thoracic area. Cervical range of motion and flexion that I have seen, let's say that it's not the most prevalent decrease in range of motion but it is apparent and the, there’s mainly just the pain they usually complain of pain in the upper thoracic area around C6, C7, and T1. Extension when they extend back, they feel a pinching sensation or pain in the 1st 2nd 3rd thoracic ribs in the spine area. Rotation usually is pretty good with rotation. I find that majority of them can rotate about 70 – 75 degrees. That's not significantly altered as much as lateral flexion.
With these patients you try lateral flexion, and they’re getting maybe 5, 10 15 at the most degrees when normal is 45 degrees. Also what you’re seeing in lateral flexion when you laterally flex the left, the right scalene will become prominent. You put your finger on it and it feels so tense. It feels like a palpable hard band and it’s very stiff. When the range of motion in the cervical area and the anatomical structures are affected as well as the biomechanics become abnormal in the neck area.
Because of all the attachments of the muscles on the neck and the shoulder area, you’re also going to find that the shoulder range of motion is will be affected. It’s affected or decreased in 44% of thoracic outlet syndrome patients according to a very large study that I reviewed. What happens is the elevation of the first rib causes an altered biomechanics of the shoulder, because the shoulder articulates on the dome that is represented by the first, second, third ribs. So if you’re going to alter the foundation by which the structure moves upon, you’re going to actually cause damage to that structure. It’s no different from the foundation of a building affecting the first, second and third floors. It’s very simple.
Other muscles originating from the chest, neck and shoulder are further affected predisposing the patient to rotator cuff syndromes and impingement syndromes. The first muscle that is usually affected is the superspinatus. I am going to demonstrate to you the biomechanics of what goes wrong. First rib subluxates, causing a rising of the clavicle, and as a result added tension is placed on the superspinatus. The superspinatus muscle test is usually weak, and I’d say that on 50 – 60% of those patients that have long standing thoracic outlet syndrome for more than 3 or 4 months. So you need to do an evaluation of the shoulder mechanism also because this usually is the second area of emphasation of the thoracic outlet syndrome.
The spinal examination will yield a superior subluxation on one or both of the first ribs. Various different studies of motion of the first ribs having the doctor placing the thumb on the first rib in the back of the neck and actually tilting the head to the side and back in extension – what you’re finding is that rib does not move. Usually what is supposed to do, it is supposed to disappear down into the thorax and then bringing you back to allow it to reappear.
What you’re finding is that you find an endplate or end field, which is very stiff, no mobility does not disappear. It just feels like it’s immobile; that’s when the bone is not moving. What happened if the ribs do not move? Ribs have to move in order for normal respiration to occur. They have to move up and back. If the ribs do not move, the patient will have labored breathing as we mentioned before.
Subluxation of the upper thoracic vertebral segments in costa chondral and costa transverse junctions or joints- As I mentioned before, when the rib subluxates superiorly, due to the fact that it is connected through the intercostal muscles, to the 2nd, 3rd and 4th ribs, what you’ll find here is that you're going to find arthritic changes in these areas. I’m going to go over that in a minute. You’re going to look for those on the radiographs, you’re going to look at the costochondral junctions, costovertebral, costotransverse junctions, and you’re going to look for increase in the white calcium deposits and buildup of calcium deposits on these joints.
When evaluating thoracic outlet syndrome, one of the physical evaluations, which is very important in your physical, you want to do manual muscle testing. A doctor who is astute in manual muscle testing can usually isolate muscles that have been put into a tonic protective spasm or a weakened position. After a lot of practice, you can become very skillful at this.
Muscle groups that are commonly affected are the anterior cervical muscles as I mentioned to you because of the fact that you’re holding the muscles in a contracted position for a long time. These muscles should not be put in a contracted position for this long time and that’s why they become weak and spastic and lead to elevation of the first rib. The superspinatus as I had mentioned and also the latissimus dorsi, intrinsic muscles of the fingers – when you’re doing your physical examination you should measure the strengths of the intrinsic muscles of the fingers because that’s the first area of weakness that you’re going to find that the patient will experience when they start to lose grip strength and strength in the hand as a result of a fairly lengthy compressive forces, the forces that are occurring in the brachial plexus, subclavian artery and vein.
The rotator cuff, obviously, in advanced cases , <inaudible> it doesn't take long to evaluate the rotator cuff, so you should do it, it’s necessary. In the x-ray findings, you’re going to find a loss or a cervical curve or a retrolisthesis, called a military spine, whiplash spine, I don’t care what you call it, the bottom line is that either A) it’s straight or B) it’s curved in the opposite direction of the way it’s supposed to. What you have to understand is that the cervical curve is designed in such a way, the curve; the spine is designed in such a way to function with a curve.
As an engineer, you take the spine out of its normal position and normal alignment, what you're going to find out is that the joints re going to wear out faster, just like if your vehicle is out of alignment, your tires are going to wear out faster, any moving part of machinery that has a moving part, any moving part, if it's out alignment, that moving parts will wear out faster, same thing with the cervical spine or any other joint.
What we’re going to find that this retrolisthesis or military spine is found in 80% of the patients. Why? Because like I said, attachment of the scalene muscles is on the anterior portion of the transverse processes of C2, C3, C4, C5 and C6 and when you have to hold the head up for a very long period of time what it does is it actually pulls the curvature out of the spine and this is not a very good thing long term.
Also as a result of the malposition of the first rib, you’re going to find degenerative joint disease and the sternal costal junction. In other words, when the first rib loops around to the front, it attaches to the sternum. If you look very carefully, a lot of time you’re going to find a lot of calcium deposits and deformation in the joint. Lot of people overlooked this. It’s been overlooked quite a bit and also that you're going to see degenerative joint disease of the costal transverse of the upper ribs.
Here’s a picture I found in a book discussing how the patient had just gotten out of surgery. In fact and had the left cervical rib removed as a result of long standing thoracic outlet syndrome that did not respond to conservative care. And if you look very carefully where the arrows are on the right what I found is that on the cervical rib, the first rib, second, third and fourth, there is a fairly large amount of calcium deposit that’s on the costal transverse junctions and the costoclavicular, vertebral junctions, you’ll see the darkened areas of the joint space and adjacent to those areas you’ll going to see the calcium deposits, which means that the normal biomechanics have been altered and that is evidence that in fact, what I had mentioned before that when the first rib is elevated, because of the intercostals, connect those ribs 1, 2, 3 and 4 together that when the first rib elevates, it starts to bring all the other ribs with it. It does affect locking the costal transverse joints and causing degenerative joint disease in that area.
When treating these areas, you need to manipulate or bring motion back into those segments, those ribs; you have to have a fairly good technique for adjusting ribs, because ribs have funky movement. They are difficult to treat, difficult adjust, because of their attachment on the two areas of the vertebral spine and their motion is very strange. Sometimes when adjusting ribs, the patient can feel sharp pain during the adjustment and then relief immediately after. I use a very gentle technique. I have had rib problems from a car accident in the past; I understand it better because I have gone through it. I have studied have these rib techniques, adjustments and manipulation, manual manipulation of the ribs in great detail so I feel confident about it. I know that in the beginning it is quite difficult to master the art of manipulating ribs because of their strange configuration. You really practice it.
Like I mentioned, in an orthopedic test, which are what most practitioners rely on for diagnosis of thoracic outlet syndrome, there are very provocative tests that have been developed over the years that assist the clinician in recreating the symptomatology to locate the area of vascular and nerve compression. I think that locating the exact area of vascular nerve compression is important, but from what I have been finding in my clinical work is that the majority of these tests are all positive when you have thoracic outlet syndrome most of them are all positive and I’m going to tell you why.
But also, what the doctors complain about is that these tests create a lot of false positives. I will tell you that there could be a very valid explanation for this. When the first rib elevates and causes a compressive force upon the brachial plexus, subclavian vein and artery, then we would say that that rib is subluxated to a large degree.
There are varying degrees of subluxation that has the rib elevated maybe less than that amount on that particular patient; in other words, that there subclinical, there are rib subluxations that do not illicit numbness or full blown thoracic outlet syndrome, but when stressed, you will have to say that the patient because of the biomechanics of the ribs, the ribs are subluxated, but not enough to cause numbness or compression of the subclavian artery vein and brachial plexus. However, when put in a provocative position, they are subluxated just enough to cause the positive test, but not enough to cause frank symptoms in the patient.
Because, I feel that this posture of leaning back, watching the television, leaning back in the car, the multiple, many traumas that we have in car, everybody, everybody in the United States has had on average of at least one car accident in their life. So, these traumas as well as increase in sports injuries, to affect the anterior cervical area are so prevalent that I believe that some are clinical, some are subclinical. Some of these provocative tests were performed on normal individuals. These patients were not probably were normal. More detailed evaluation of the motion of the first rib to determine whether or not that rib was in a good position, or aligned properly or whether or not it was slightly affected should have been performed and these were not done according to the literature. So we cannot say that false positives were elicited. But we may say that it’s a possibility that we found sub clinical versions of thoracic outlet syndrome and not necessarily false positives. I hope you understand that.
I feel that, this more or less shows the vulnerability of the area of the thoracic outlet's phases in that. Anytime that you have some pain syndromes in the neck area and the upper back, maybe the shoulder, careful evaluation of the motion of the first rib and positioning of the first rib as well as the tension on the scalene muscles and the muscles around the head, neck and shoulder should be done. In other words like i said, there are degrees of subluxation. Let's go over those; first of all you have hyperabduction maneuver in this particular situation, as you can see, what we are doing is elevating the arm. This will put a strain on the thoracic outlet bundle ,the subclavian artery and vein and the brachial plexus because if the pectoralis minor is in a spasm or has tension, not allowing the shoulder to move properly, then of course, those vascular structures, nerve and vascular structures will be compromised and the patient will have symptoms. What you’re talking about abduction 280 will illicit, you’re going to actually going to take the radial pulse, it's going to illicit a decrease in the radial pulse or diminished radial pulse or complete, you cannot feel the radial pulse at all. The patient complains of subsequent numbness immediately following the test. Now normally nerves don’t act that way; usually vascular structures act that way.
The elevated arm test or Roos test is considered the most reliable test for thoracic outlet syndrome where the patient put their arms in this position, opening and closing the hand for approximately 3 minutes. You know, the movement of the hand should stimulate blood flow into the arm, but in these particular patients, blood flow is not good enough due to the compressive forces that are brought out by the malposition of the ribs and the structures in the thoracic outlet area. So this is the most reliable.
According to literature, doctors were doing this hyperabduction, Adson’s costaclavicular tests and then saying okay it’s time to do surgery when the tests were positive. I think that’s jumping the gun in a big way – something that we never did. I am shocked that this is happening. Because like I said we find the same findings they do <inaudible> exact orthopedic findings and when we make correction of the first rib to lower it, to remove the subluxation and work on the muscles around the cervical thoracic area around the shoulder, these problems are going away.
The Adson’s maneuver is when a patient takes a deep breath and holds it. When the patient takes a deep breath, obviously, the thoracic ribs will elevate. When they hold the breath that keeps the ribs in that position, they are going to hyperextend the neck, which is going to cause the scalene muscles to be stretched back across the subclavian artery vein and the brachial plexus area. If the patient has an elevated rib, this involvement the scalene muscles, in fact that will cut off the blood supply or cause the compression of the brachial plexus and illicit the numbness. In fact, what we find is that the symptom is reduced arterial blood flow; there is no more pulse within 3 to 5 seconds. The patient then complains of numbness. “Is your arm going numb?” “Yes, it is.” You don’t say anything; the patient says “you know I’m feeling some tingling sensations in my fingers.” The costaclavicular test narrows the costaclavicular space by bringing the clavicle close to the first rib and second rib.
When the patient draws the shoulder downward, and then that causes the compression of the subclavian artery and the brachial plexus. Positive tests obviously when the radial pulse is diminished. These diagnostic tests are very good to show that there is some compressive force in the thoracic outlet area, but by no means do they point towards immediate surgery. Like I said, there is no gold standard test we’ve been going over and over it again for thoracic outlet syndrome. The clinical judgment has to be used. There are some diagnostic tests such as electrophysiological evaluation, multi-detector CT and 3-D reconstruction, Venography, Magnetic Resonance Angiography, Radiology, obviously we talked about that, Doppler ultrasonography and SSEP potentials. Electrophysiological tests from the literature, some maybe three or four of the studies that I read, said that it was effective in determining thoracic outlet brachial plexus bundle compression. What you have to understand about the brachial plexus is that they distribute themselves superior to inferiorly 5,6,7,8 T-1. The most commonly affected is T-1 because it’s closer to the first rib causes numbness down the ulnar distribution. What I’m finding is the whole arm is numb.
However, according to the studies, impairment of the nerve conduction, primarily F-waves were decreased in amplitude in the ulnar and sometimes the median nerve. Obviously, ulnar is more of the T-1/C-8 distribution than the median, which represents more of the gamut of the brachial plexus. This could help localize the brachial plexus lesion and may help to rule out segmental systemic neuropathy such as herniated disc in a particular area of the cervical spine if you do not have access to an MRI or have not ordered it yet. We see this impairment after the arms are raised in a provocative position in other words, the F-wave is normal and the patient is in a neutral position but when the arm is raised in a provocative position as in Adsons, Hyperabduction Maneuver, Costaclavicular Maneuver, you will see that the symptoms or the F-wave will be diminished.
In more recent studies of these symptoms are related to thoracic outlet syndrome and the electrophysiologic test is that this test is only used for a long-standing anomalies and severe atrophy because in the initial phase of this problem, the F-waves are not diminished and you’re not going to find this a very effective test for a recent onset of thoracic outlet syndrome. Therefore, I don’t feel it’s really necessary. Do I order these tests in my office? No I don’t. The reason is because like I said before, I only order the tests when I’m not getting the results. I've never really had a problem with thoracic outlet syndrome in my office. I’m getting very good results with it, so there is no need to expose the patient to diagnostic tests which are medically unnecessary. You must document the need for a diagnostic test.
A need for a diagnostic test is to determine, differentially diagnose or determine to a better extent what is wrong with the patient. If I feel that the patient is recovering in the first four five or six visits and making progress, I am going to continue with care, it looks like I am on track, and I am not going to order these diagnostic tests. If there's a turn for the worse, or if I’m not getting the results I’m looking for, certainly I will order the diagnostic tests to look into it further to determine whether I haven’t really seen what I need to see or I need to see something that I can’t see based upon the orthopedic tests, the history or physical examination I performed. That’s obviously protocols for any type of orthopedic, chiropractic or neurologic type of practice.
Multi-detector CT and 3-dimensional reconstructions: There has only been one study I saw. It says it's very promising. I don’t know I haven’t really had a lot of time to look into it; it wasn’t, not a lot literature on it. I am not going to run out and order multi-directional CT scans on every patient that walks in my office with tingling in the fingertips. Like I said before, I use these tests sparingly. Doctors use them more often that’s your clinical judgment. One author stated in his paper that venography was the only reliable diagnostic tool to for diagnosing thoracic outlet syndrome. Doppler ultrasonagraphy was another test that was mentioned, few studies discusses on that. There was no real discussion of reliability or sensitivity of this particular test. It was considered as promising.
Magnetic Resonance Angiography, what you have to do is, you have to do an MRI scan of the patient in the normal position, and then you have to actually do another MRI with the the patient in the provocative position. This MRI must be done in an open MRI scanning unit because of the fact that you have to alter the position of the arms, cannot be done in a closed MRI scanning unit. That’s something you have to understand. Also, you have to find a radiologist who understands thoracic outlet syndrome, anatomy, biomechanics, as well as being willing to do two MRI’s of the body: one in the provocative and one not in the provocative or in normal position. This was done by one particular group of practitioners looking for some sort way of diagnosing with images, diagnostic imaging the thoracic outlet. I don’t think it should be done routinely in practices.
CT Angiogram: This is a very interesting study that I found in the literature that actually showed a visual of the thinning of the subclavian artery as it passed through the intrascalene muscles. It was very nice evidence that actually occurs. Radiology; When you take your x-rays, you’re going to take cervical flat plate films and thoracic flat plate, AP lateral films. The first thing you always do when you evaluate the patient, that's the first thing we do, we're looking for the bilateral cervical ribs. You know what? Cervical ribs are in less than 1% of the population. As I mentioned before, we have seen thousands and thousands and thousands of cases. A lot of these patients are x-rayed as a result of traumas and peripheral nerve type of neuropathies. We are not finding cervical ribs on a lot of patients. I would say that it’s not less than 1%, I'd say it’s less than 1/10th of 1% or less.
I remember, maybe 1 case of cervical ribs out of the entire array of patients that I have seen in approximately 18 years of practice including 2-4,000 new patients per year. You’re looking at variable heights of the first ribs as well as you’re looking for the intercostal spaces. The spaces between the ribs should be equal. If there’s a greater space on the right than on the left, then obviously on the right there's been some ribs elevated or on the left, some ribs have actually subluxated inferiorly. You’re looking for the arthritic changes in costal transverse junctions. That’s arthritic changes as a result of some lack of movement or poor movement or aberrant movement in these ribs. You’re looking for military neck, retrolisthesis and degenerative joint disease in the first rib in the sternum as well as in the costal transverse junctions, we already mentioned that, when you’re looking at, determining whether conservative care is recommended or surgery, always conservative care.
According to literature conservative care was successful in only 10- 15% of the patients. And I have mentioned to you, the reason why I feel this is possible, is that if you do not tell the patients to stop sitting in this position for a long time, they are going to recreate the problem for you. You’re may do some therapy, you may do some adjustments of the first rib and if they lay there on the bed for 2 hours watching TV, these muscles are going to tighten up and lift the rib right back up again. So without really understanding causal relationship between this postures and how it brings out thoracic outlet syndrome you really not going be able to be effective in reducing the causative factor and you’re not going to get the patient well. In my studies of the over 300 articles I read and studied very carefully, I do not find one mention of this factor in the treatment of the patient. Not one mention of this position or how it affects the first ribs. 90% of these patients get first rib or cervical rib resection or scalenectomy.
Nine out of ten are getting surgery of the neck. I haven’t had one patient get surgery at the neck yet. It is very difficult for me to understand and that’s all I’m going to say. If there's a way of treating this conservatively, who would want surgery? Nobody. Nobody wants to have an operation on their neck. So it is better to go through the course of conservative treatment. The results of surgery seems to be 65% long-term success rate, partially 20% of the population and 50% have no relief. So you went through surgery of your neck and your symptoms are the same. I don’t think that’s a good situation. The rate of occurrence is between 5 and 10% of these people who have 60% long-term partial relief and the reason is because of scar tissue. They recommend that nerve gliding exercises immediately after surgery will help to reduce the scar tissue formation causing the recurrence. Conservative care, I believe that if there was an insidious onset of thoracic outlet syndrome, that if we can see what changed and we can reverse the changes to the original positions or biomechanics that were present when the patients did not have pain, then we can actually normalize this condition and bring the patient back to normal.
I think that thoracic outlet syndrome is a lot more prevalent than we think. It’s based upon poor sleeping habits and posture. Postural correction is critical to the management of this thoracic outlet syndrome as I mentioned. The patient compliance is critical in eliminating causative factors. You have to be a nag. You have to ask that patient constantly. Are you sure you’re not watching television in bed, you are not reading in the bed? Because if you don’t they will do it. They don’t think it’s important because you’re not saying anything about it, maybe only in passing, you need to stress it. So what we’re going to do is we're going to apply the appropriate treatment to correct this actual problem. Pain management can be seen with medication. That’s optional. We don’t use any medication in our office. No anti-inflammatories or painkillers are recommended and our patients seem to do just fine.
In fact, I’d like to note that the actual changes in the biomechanics are reducing the pain, and not the painkillers. If we use the painkillers, we don’t know whether our treatment is effective or not. I think that is worse than actually just diminishing some of the pain. The patient can handle it. You just tell the patient that hey the pain is a warning signal telling us whether our treatment is working or not. It’s a guide, it's a way of use determining whether or not we're being successful in the treatment your condition. Sure I don’t mind if a patient takes medication prior to bed to be able to sleep at night. But the use of medication, I think is unnecessary. I have never had a patient absolutely beg for medication. ‘Please, please, find me a medical doctor to get me some drugs so that I could sleep at night.’ I’ve just never had it happen – not in 18 years. Therapeutic exercises that were mentioned in the literature are contraindicated. No wonder they are not getting results. As I mentioned, stretching, or lateral bending, neck rotation exercises, and flexion exercises actually lift the ribs and make it worse. This is something that I don’t recommend; in fact, it’s contraindicated, and if you do it, you are not going to get any better. That’s the way it is.
The recommended conservative treatment protocol is, you must address the abnormal ergonomics or posture. Like I've mentioned, we have to beat it into their head on a daily basis and keep talking about it and talking about it until they can’t stand hearing about it anymore. You have to address their sleeping posture. They must have a pillow a patient asks about pillow. It can’t be too thick because it causes strain on this side. It can’t be too thin, because it causes strain on this side. The pillow should provide a nice comforting support for the head to allow the neck to be in a neutral position throughout the sleeping. That’s all, and the patient has to go out to and have to look into that. They have to research it themselves and find a pillow that’s going to work for them. What I recommend is when they’re at a store, they can lie down and look in some sort of mirror to see whether their neck is in a neutral position or not. Is it straight? Yes or no. If it is angled, then it’s no good. Don’t buy it. No other neck stretching exercises are recommended.
Physiotherapy such as ultrasound on the upper thoracic area and the lower cervical can help to reduce the inflammatory process and promote healing. Physiotherapy such as electrical muscle stimulation can help to reduce the spasms in the upper thoracic area. I do not recommend it around the scalene as you got the carotid sinus in that area. We do not use electrical muscle stims on the anterior cervical area. However, we do use it on chest muscles; we use it as long as it is not by the heart. We do use it on the upper thoracic ribs. It does provide comfort and it does reduce spasms for the patient and it promotes healing.
The goal of this phase is to eliminate the protective muscle spasms that are actually tonic and constant in the cervical spine, chest and shoulder region with I call neuromuscular re-education. It’s basically called deep tissue; you call it whatever you want, it’s also referred to as trigger point, Nemo technique, blah blah blah. There's many different names for it but I call it neuromuscular re-education. You use it on the scalenes, the muscles of cervical flexion, the clavicular division of the pectoralis minor and the subclavius muscle which is an often overlooked muscle, pec major, latissimus dorsi, anterior deltoid, upper and middle trapezius and other rotator cuff muscles.
Here we have a picture of the subclavius muscle, which is right underneath the clavicle. When that muscle is in tension, it can actually cause a compressive force on the brachial plexus and the subclavian artery and vein. The way I do this, is I actually lay the patient on their side, I hold the patient from their back and I put my thumb right up underneath the clavicle and shove it right up underneath the clavicle and I hold that position. I say, “It hurts, doesn’t it?” they say, “Yes it does, a lot of pain”.
I ask “Is it a 10 out of 10, 10 being the worse pain?” “Yes it is.” “Alright, what’s going to happen is that this pain is going to go down in chunks, it’s going to melt away when it’s melted away to 0, I want you to tell me. But if you tell me that it’s melted down to zero, when in fact it’s a 1 or a 2, I will guarantee you that tomorrow you will have achiness all over. So you’re going to do the right thing and tell me when it’s gone down to 0. Right? "Yes." Okay, that way, you won’t ache tomorrow right? Right. Ok let’s go to work. So I take my thumb, I shove it right up into the subclavius muscle, I apply deep tissue pressure, I hold it, do not move it and I wait for the muscle spasm to melt.
Here we have treatment of the scalene muscles and I’ll tell you that when you apply neuromuscular re-education, or deep tissue pressure of a constant variety to this muscle, it hurts bad. The patient is wincing. They are in a lot of pain. They’re begging you to stop. It recreates the numbness down the arm. Their arm is going numb; they can’t stand it any longer. Just say “relax, cool down’. Sometimes you have to tell them a joke. Tell them it doesn't hurt you as much as it hurts them. Get them to laugh a little bit. It’s going to be difficult to get them to talk because it’s close to the trachea and the esophagus area, but you just have to do it.
The bottom line is that if you don’t reduce the spasm, the scalene muscles will remain in tension and continually elevate the first rib. It has to be done. Pain will shoot all over the arm. They’ll complain of the shooting pain in the arm. Just get through it. It will be about 3 or 4 points. You’re going to work your way up to the base of the skull hitting all those points. There will be about 3 or 4 points on each side and they get through it. Pretty soon you’re going to go back each day and you're gonna work that muscle and pretty soon After about 10 treatments, if it’s done properly and you have not missed any muscle areas, that when you put a pressure on there, the pain will drop about approximately 10%, and the spasm will drop 10% per visit so after approximately 10 visits, plus or minus 1 or 2 really, you’re going to see that there won’t be any pain in the scalene area.
They are going to put the pressure there and you're gonna say remember when I put pressure on that muscle the first visit and you almost jumped out of your skin, your hair stood up, and your eyes rolled to the back of your head, and you turned red and you looked like Don King? Yeah. Well you don’t look like that anymore; you’re not feeling those pains any more, are you? And they say "No". Okay it’s because you’re getting better. And you are getting better, aren’t you? Yes I am, in fact I am getting better. That’s what happens, they get better.
The neuromuscular re-education can also address the abnormal muscle spasms or tenacity of the spasticity of the area of the supraspinatus and here we show the application around the supraspinatus in the top right. On the lower right you’re going to see where I’m going to apply the neuromuscular re-education to the lower cervical area so I can get a better adjustment of the first rib. That’s attachment of the first rib to the lower first thoracic spine area. Manual manipulation is a key component as well to successful outcome of thoracic outlet syndrome. Superior first rib subluxations cause compression of the thoracic outlet area, so therefore manual first rib adjustments inferiorly is the only treatment procedure will establish normal biomechanics in position of the first rib, included on the costal transverse and the costavertebral junction. You also have to adjust the upper thoracic spine. Thoracic rib subluxation must be reduced and must be reduced and must be reestablished or you will not get the patient well.
I don’t care how much therapy you use, how drugs you give the patient, you’re not going to get the results, how much stretching you , you’re not going to get the results, until you move the first rib. If I could not move or adjust the first rib, nobody in my office would be getting well. I rely on that specifically as a way of reducing the thoracic outlet, opening up the thoracic outlet spaces and without it; I don’t think I would have any success whatsoever. It’s mandatory. Therapeutic exercises or rehabilitation for thoracic outlet syndrome is only done after all spasms have been reduced and the subluxation is fairly well reduced. Do not incorporate exercises when there are spasms or pain still elicited upon deep tissue work and neuromuscular re-education. Exercises to strengthen rotator cuff muscles, specifically the superspinatus, posture muscles like the trapezius and levator scapular will actually elevate the shoulder and take the pressure off the nerves and the arteries. Exercises <inaudible> deep breathing will also help because as I mentioned, the ribs are subluxated as a result of lifting of the first rib. The first rib has the tension on the intercostals muscles and they subsequently move the first rib as well. Deep inspirations as well as flies and flat pull downs, incline and flat bench with deep inspirations. Take a big deep breath--- stretch out the chest --- and sometimes you’ll actually hear cracking or “tronar” as they say in Spanish – or a release of the sternal costal junctions. There is some release of pressure there and subsequent feeling of well-being.
Phase II is when all the muscle spasms have been reduced. You have to constantly re-evaluate the patient for spasticity of those postural muscles that were once involved because sometimes they slip and go back to reading in bed or reading on the couch, or they go back to watching TV in bed. You have to keep a careful eye on them and reinforce your recommendation for proper posture and proper anatomical position both at work, in the car, in the bed, on the couch are the main areas. Continue to manipulate the first thoracic rib. I saw in one study that said wean the patient off the first thoracic rib adjustments after Phase I. It’s just the opposite. You maintain the adjustment of the first rib and here’s the situation. You cannot adjust the first rib. I urge you practitioners to find a physician or an allied health care professional that can perform manual manipulation and neuromuscular re-education of these areas, because it’s about the patient. If you can’t do it, then you need to find somebody who can.
When do you need surgery? Surgery consultation should occur if the patient is compliant and still has not reached some relief after about 12 weeks. Surgery consists of removal of the first rib and scalenes. Surgery should be followed up with nerve gliding exercises. Surgery is either from the cervical area or the transactulate area. What I can tell you about this is that as I said before, in 18 years of practice with thousands of patients, I have not yet had one patient who went for surgery for scalenectomy or thoracic outlet syndrome type surgery. I think there is something to be said for that. Conservative care is a viable solution to thoracic outlet syndrome. More research needs to be done and people should take note of the findings that we have in this presentation.
I want to thank everybody for coming out to the presentation; I want to thank the American Academy of anti-aging medicine for inviting to this international conference, most Dr. Bob Goldman and Dr. Ron Klatz for inviting me and thank you audience for being receptive to our program. Thank you.
source: http://vimeo.com/22362794
Dr. James Stoxen: Good afternoon audience my name is Dr. Stoxen, I wanted to thank, first of all the American Academy of Anti-Aging Medicine for inviting me here today to speak to you and also Dr. Bob Goldman, the present, and also Dr. Ron Klatz, it's a pleasure to be here. I’m going to talk today about conservative management of thoracic outlet syndrome. It’s a very controversial subject. I’m going to talk about sports trauma and postural epidemiology and we’re going to bring up some information that I hope that when we get done today, you're going to be able to take this back to your practice and actually help your patients. My office is in Chicago, in the south side, yes on the south side of Chicago and the name of the practice is called Team Doctors Treatment Centers.
I'm going to talk about, like I've said, thoracic outlet syndrome, it's a very controversial subject. A lot of doctors don’t even think it exists. Thoracic outlet syndrome is the most difficult neuro-vascular compression syndrome to manage of the extremities and this is because it's got a very, variety, variability of complaints and the difficulty of patient compliance in the treatment and reduction of the causative factors. We're going to talk about what causes thoracic outlet syndrome and I think it’s going to provide you with some insight as to why it's difficult to manage. From what I can gather from the 300 plus research articles and abstracts that I read, there are some observations that we have met, made as to the causative factors of thoracic outlet syndrome, none of which was mentioned in any of the literature, so it's hard to say whether or not these, all these physicians and scientists are missing something but that's what research is all about and sharing of information. I'm hoping we're going to bring some observations that we've found, maybe add to the other research that has been done and we'll be able to have a better outcome for these patients. Conservative management has been very challenging in thoracic outlet syndrome. Majority of the patients, over 90% usually in most studies are getting surgery of the neck to remove the rib, the first rib or cervical rib and then surgery to remove muscles in the neck. I don't know about you, but no surgery looks very exciting for patients and it's a very depressing and scary experience. If it's in the knee, it's not so bad, if it’s in the neck, it's very scary. It's very close to the head, possibility of infection, patients are very frightened of any type of surgery on the neck, it's a very sensitive area and physicians have to be aware of that. We sometimes become numb to these factors, these fears that the patients have and it's time that we have to put ourselves in the position of the patient and maybe work a little harder at finding a better options with conservative therapy.
Team Doctors Treatment Centers has been in practice, we've been around for about 57 years, and it’s been a practice in the family for a long time. Over 30,000 patients have been treated than last 10 years, 1986 to 2004 from 1992 to 2004, practically 4,000 new patients came to our offices presenting with some form of peripheral nerves symptoms, originating in the neck and back, so we have numerous, statistically we have numerous thoracic outlet syndromes thatwe've looked at, we have a very great amount of experience in this field so we're going to use that to enlighten you, the audience.
Thoracic outlet syndrome is the often misdiagnosed cause of neck pain, shoulder pain, and arm disability. It is thought to be neuro-vascular compression seen at the thoracic outlet, which is something that anatomists still can’t agree on. The actual name doesn't even describe it properly. It consists of 3 areas of potential regions of compression consisting of the intra-scalene triangle, as we have pointed out here, we the anterior scalene and the middle scalene and the posterior scalene.
The thoracic bundle, consisting of the super-clavicular or the sub-clavian vein, the sub-clavian artery and the brachial plexus emanate from this triangle and it’s an area where the, these area, these structures can actually become compressed and cause symptomatology. Also notice the costoclavicular space which is down here lower, the costoclavicular space is represented by the area which is above the clavicle and below, or below the clavicle and above the first rib. Not many people really realize that the ribs actually go up right above, at the base of the neck, few patients understand that. In a matter of fact, even few doctors understand that. The last space is called intrapectoral space and that is right underneath the pectoralis minor, as seen on the graphic on the right and that area can also be an area of compression. So doctors have to be aware of these multiple areas of vascular and nerve compression and have an understanding of what symptoms can be related to each area so they can better treat the patient.
The three neuro-vascular structures that pass through the thoracic outlet as I mention before is the brachial plexus, which is a nerve bundle consisting of cervical C5, C6, C7, C8 and T1. The subclavian artery which is the artery that supplies the arm with blood, oxygen and nutrients and the subclavian vein which obviously drains the blood away from the arm and back to the heart. All these structures can be compressed leading to an array of different symptomatology. Thoracic outlet syndrome relates to nerve and vascular compression; leads to upper back pain, neck pain, shoulder complaints and numbness and even extremity weakness. Some more serious complications of thoracic outlet syndrome, because of the vascular obstruction from the various structures compressing those, the artery and the vein, you can have and upper extremity emboli which means that there's, the emboli occurs when the blood supply is reduced or diminished and the emboli forms and releases into the arm causing the, kind of stroke of the arm and potential even for gangrene, 'cause no blood or nutrients can get to the area and the fingers actually will die. The second most common serious complications of thoracic outlet, in my opinion, which is not listed in the literature of course 'cause most of the literatures written by medical physicians that do surgery is unnecessary surgery.
Of course if you're already done the surgery, it was necessary, otherwise you won't have done the surgery. But if more appropriate conservative methods or more effective conservative methods can be had to reduce the number of surgeries and if we found a way to reduce the number of surgeries then, obviously, then the surgery would not be necessary. As I mentioned before, if you brought this type of surgery to the patient's attention that you were going to do an operation on the side of their neck or underneath their armpit to remove ribs and various different muscular structures from the neck, the patient is not going to be very excited about it, they're going to be very scared. Also, you can have subclavian aneurysms and also when the compromise of the neurovascular structures become quite severe leading to weakness in the arm and the hand and the grip strength, you can have accidents related to functional muscle weakness. I've had patients who have dropped, I had a patient that came to me who we started treating and when we talked to the patient about the, what he was experiencing in the last 6 months before he came to our office. His wife had remarked that he had dropped full cups of coffee that he was unaware that he was going to drop them without any warning, he dropped full cups of hot coffee, he dropped tools.
He's a paramedic, he was having difficulty performing his job and these finite movements of the hand, which are very important in some occupations, become compromised and you can have dangerous consequences of that. Physicians say, some physicians say that it's under-diagnosed. I read a letter to the editor, one of the publications, surgical publications saying that, this physician felt that the syndrome was under diagnosed, that more thoracic outlet syndromes actually existed, and then other's physicians say it's over diagnosed. It's our opinion that this syndrome is underdiagnosed and we're going to spell that out for you why we feel it's that way in our discussion today. The problem with this syndrome and the difficulty that many physicians have with this syndrome is that unlike cervical disk or herniated disk or aneurysm of the brain, there is no gold standard test for thoracic outlet syndrome.
In order to diagnose thoracic outlet syndrome, you have to put together an array of historical findings, physical findings and a couple of provocative orthopedic tests of the region of the neck and the shoulder to be able to make that diagnosis. The most common treatment today, currently, is surgery. According to the literature, that if you have a group of 500 patients with thoracic outlet syndrome they decided that practically 90% or only 10% of the patients will respond to conservative therapy, 90% are going to surgery. Some doctors have even given up on conservative therapy and just go directly to surgery. Surgery and, versus conservative care, first of all have to put ourselves, like I said before, in the position of the patient. Why would any patient want to have this surgery if you can see on this graphic here, we have a, the surgery of the neck. There are a lot of very tiny structures in that area. Patients are in great fear of surgery, especially in the neck; the answer to the question is that no patient wants to have this surgery. We have a very high rate of recovery from thoracic outlet syndrome with conservative care, and I am very happy to present that method of treatment to you today. I have not had 1 patient in 17 years started surgery with thoracic outlet syndrome that's approximate 30,000 clients. I'm going to show that rate of success with you. I was very shocked in fact when I discussed, when I looked into the literature. I was aware of the rhizectomy or removal of the first rib or conservative, cervical ribs. It was an afterthought in fact.
After practicing for about 15 years , 16 years, with such great results with the thoracic outlet syndrome just diagnosed in the clinical setting, I decided to look into the research because it was something of interest to me and I was really shocked to find out that, in fact, it was such a depressing rate of improvement with conservative therapy with other uses of therapies in various different stretching and what the procedures that or protocols that the doctors or the therapist were using to try to help this patient conservatively. I think that when I get done with my talk today, you going to find out why these treatments were unsuccessful. And you're to see if you have a better understanding of how this problem starts and with causative factors of thoracic outlet syndrome, you'll see why they were not successful and why, with a better understanding, you will be successful with this, with the treatment. Galen was the first person who mentioned the cervical rib; in 1910, Murphy firsted the first effective resection of the ribs to relieve thoracic outlet syndrome. Adson who's Adson's test which is one of the orthopedic test for thoracic outlet syndrome started the scalenectomy without rib resection, removal of the scalene muscles from the neck, scalene muscles are very important otherwise they wouldn't be there. They are very important in respiration but they remove them. Deete determined that, gave the term Thoracic Outlet Syndrome and here we go.
First of all, we feel that the most common cause of thoracic outlet syndrome is simply a combination of things but primarily it is a superior subluxation of the first rib. In other words, the patient is fine for 30 years of their life, they come to you with at age 32, they've had some upper extremity paresthesias and weakness for approximately a year, maybe 2 years, it's getting worse What is the difference between the patient at the age 32 and the patient at the age, who has got all the peripheral nerve and arterial occlusion symptoms and the patient at age 30 who had the same structures but no symptoms?
What I'm trying to say is that if we find that the patient has , had a normal life without peripheral vascular nerve symptoms and all of a sudden they have a peripheral vascular nerve symptoms, compression symptoms then all we need to do is determine what has changed reverse the change and the patient has been treated properly. The first rib can subluxate, either from trauma or static postural stress. I feel that while trauma is the very significant source of damage to the neck as in a car accident or sports injury, we have to, I fell that static postural stress is by far more common cause of this problem. We're going to talk about that more in fact some mention has made of static postural stress in the literature but I have feeling, it is my opinion that they, that there needs to be a correction of thought regarding what kind of static postural stress is causing this syndrome, we're going discuss that today.
Epidemiology of thoracic outlet syndrome should be broken down into two main components. In this particular slide, we have it broken down into 7. I'm going to clarify that. Traumatic injury and static postural stress as I have mentioned before are the number 1 and 2 causes of thoracic outlet syndrome and the remainder are problems that “predispose” the patient to thoracic outlet syndrome. In other words traumatic injury such as a whiplash or an auto accident or the patient is in the car and is struck from behind causing a violent, who would you call it, trauma to the anterior muscles of the neck, also similarly a clip in football or a very hard punch in boxing or some sort of work injury can cause traumatic stress in the anterior cervical and scalene muscles and also elevate the first rib as a result of misalignment due to the trauma.
Static postural stress is, I feel, the most popular and the most common. It's a position where the neck is held static in extended position. And in literature, it discusses the neck is held forward flexing position. A neck that is held in a forward flexing position causes static muscle strain on the extensor muscles. Scalene muscles are not extensor muscles, they are muscles of flexion. So, while the literature discusses muscles of extension, I feel that some more careful review of the actual causative factors should be put on muscle of flexion. For instance, if you're to take your arm and hold a purse or a maybe a some liter of Coca-Cola for approximately 1 hour and your arm in this position pretty soon, your biceps tendons and your joints in your elbow and your shoulder would become very sore and stiff and if you are the same type of philosophy or theory is that if you are in the bed with two pillows propping you up, watching your favorite television show in this position for approximately 1 to 2 hours, the muscles of the, scalene muscles will be in tonic contractile state for long period of time, in the same thing will happen to these muscles.
The scalene muscles attach on the first rib, so as the tension is increased on the scalene muscles, we feel that the scalene muscles actually elevate the first rib and causes the subluxation, the scalene muscles also become will become inflamed as a result of the subluxation, the entire area, as well as the scalene muscles will become inflamed and cause a compression of the thoracic outlet group of structures. Computer use where you’re actually leaning back in a reclining chair, or reading in bed, like I have mentioned before, just as much as watching television in bed, which I feel is the most common cause, or laying on a recliner or sofa, with the neck in an extended position.
Operation of a motor vehicle with the neck extended as well. Nowadays, you have your seat which can be reclined; it can be made to be straight, reclined, various different positions. A lot of young people think it’s really cool to lean the seat way back, and sit like this and they may be on a long route, for an hour. Half an hour, an hour or they may be in the car quite a bit; this constant stress on the anterior cervical muscles causes imbalance and raise the ribs, first ribs and causes the compression and thoracic outlet syndrome. <inaudible> syndrome is not, I don't feel it's a cause of thoracic outlet syndrome. I feel that it's a predisposing factor. I've seen patients that come to me. They have lower back pain and when they come to me they said they hip into their physician and the doctors said they had scoliosis that was the reason why they had back pain. While the scoliosis is very minor, and we know that scoliosis does not cause back pain in itself, the patient actually had some sort of biomechanical problem that cause the back pain and the scoliosis was an incidental finding. This is what I feel <inaudible> syndrome, bilateral cervical ribs, anomalous cervical, anomalous first ribs and other problems that predispose the patient to thoracic outlet syndrome are associated.
In other words, anomalous first ribs would be where the ribs are actually not formed according to normal, what we consider normal genetic anatomical structure. Those will predispose the patient to thoracic outlet syndrome, especially if you have a patient whose 19 or 20 and has never had a symptoms of thoracic outlet syndrome or maybe they're 25 years old, they're at full maturity, as far as their growth, they just have a recent incident of thoracic outlet syndrome symptoms. They've had anomalous first ribs for 25 years but no symptoms. So how is it all of a sudden that the structure have not changed but the symptoms have been brought on and there is no change in the structure. So in that cause and effect type of relationship, you cannot consider this <inaudible> syndrome, bilateral cervical ribs, anomalous cervical ribs and other findings to be related to thoracic outlet syndrome epidemiology.
Clavicular fracture malunion certainly can be cause of thoracic outlet syndrome if in fact the malunion also is accompanied by scar tissue formation, however, I've seen this kind of case in my office before and even with that kind of malunion and compression of the thoracic outlet group of structures, we found that by adjusting the first rib and treatment of the masculature around that area, we've been able to reduce the patient's symptoms and handle the problem for the patient without any surgery.
Yeah. Traumatic epidemiology such as whiplash is seen in sports. As you can see here a group of boxers that are getting hit, obviously that causes strain on the anterior cervical area and can lead to thoracic outlet syndrome, automobile accidents and traumatic work injuries, as I mentioned before.
However, what we talked about before, which is most common cause, in my opinion, was static postural epidemiology. You could see in this picture right here, we have this gentleman who is actually leaning back in the chair, you can't see it, but his thorax is approximately at a 75-degree angle. He is just watching television and as you can see, in order to keep his head from flipping backwards, because he is on an angle, he has to tense up the anterior cervical muscles, including the scalenes to keep his head in that position. The head weighs about 8 or 9 pounds and that may not seem like a lot of weight, but if you had to sit in that position, it would certainly take its toll on the anterior scalene, middle scalene and the anterior cervical muscles.
And in the literature, it discusses the posture of leaning forward, as in looking at the computer, as a posture that is not a good for thoracic outlet syndrome. As I have mentioned before, the static posture of leaning forward really puts more stress on the extensor muscles of the cervical spine, which do not really compromise any nerve structures. However only in a case of hyper-extension and maybe a disc injury, but those are usually seen with traumatic injuries and not necessarily with static postures. What we’d rather say is the causative factor, is when, as I mentioned before, the patient leans back, the anterior cervical muscles have to maintain the head in this particular position for a long period of time as in the picture with the girl seated at the end of the slide there.
If you take your hand and you put it on your anterior cervical muscles on either side of your trachea and your esophagus, and you lean back, you’ll note that there will be a hardening or tension of these muscles and you’ll be able to see for yourself just by palpating your own neck, that these muscles will tense, and like I mentioned before, even if you’re holding a small item for a long period of time, the amount of tension can cause damage to the joints and the muscles.
So, the differential diagnosis that you want to include in your, when you’re doing your physical and you want to keep in mind are pan coast tumors, which is apical lung tumors, of course you're going to do chest radiograph to determine whether or not if there's any type of lesions in the apical lung area also, also time these pan coast tumors develop on 1 side not 2, thoracic outlet syndrome is usually a bilateral problem. Carpal tunnel syndrome, I feel is very easy to differentiate between thoracic outlet syndrome because if you have a pinching of the nerve or the vascular supply to the hand, the symptoms will be distal to the compression, in other words, you shouldn’t have numbness in your forearm with carpal tunnel syndrome. If you have numbness in your forearm, it cannot be carpal tunnel syndrome, unless it's a double crunch which is the carpal tunnel syndrome and thoracic outlet overlaid on top of each other where the patient has two problems.
So, the other one could be herniated disc nerve compression and in this situation an MRI will rule that out. IF you take and MRI and the patient has a cervical disc, perhaps maybe, 1 mm, 2, 3 and there is no compression on the fecal sac or nerve bundles then even though they have a cervical disc, you cannot rule out the fact that they still have a concomitant thoracic outlet syndrome causing the deficit in nerve and nerve supply and the concomitant numbness and weakness.
So in other words, even if I do an MRI scan on a patient, and I find that the patient has a posterior herniated disc of 1, 2 mm that is not compressing the nerve, according to the radiologist's report, my view of the MRI scan, then I don't feel that that cervical disc is the cause of the peripheral nerve symptoms. Sure there's a disc but it's no consequence to the nerve supply, <inaudible> anything, it should not elicit symptoms. Sure we have to treat it, but we have to still dig deeper to see where that peripheral vascular type of symptomatology is coming from and you should not overlook the fact that it could be coming from some form of thoracic outlet syndrome. Reynaud's Phenomenon is very similar and differential diagnosis is very difficult at times because they're very common. Sometimes I feel Reynaud's Phenomenon is thoracic outlet, sometimes I feel that thoracic outlet is Reynaud's Phenomenon.
There's a lot of patients that are not getting care for thoracic outlet syndrome that have Reynaud's Phenomenon that need to be looked at. They have a similar type of symptoms in fact when you cut off the blood supply or you reduce the blood supply to the hand when you have elevated first rib or scalene swelling causing compression of the subclavian artery, not enough blood supply will get to the distal areas of the fingers and the hands and that is rarely common Reynaud's Phenomenon, the coldness.
Subclavian arteries we already discussed. Spinal cord neoplasms, we can, differential diagnose that by way of obviously some form of imaging, diagnostic imaging a and b, with our reflex testing, other diagnostic test can bring that out blood test and array of different evaluations to differentially diagnose spinal cord neoplasms from thoracic outlet syndrome. One other component of thoracic outlet syndrome which is not as much commonly mentioned is that, in my opinion, the initial symptom is usually the symptoms related to compression of the subclavian vein and I feel the reason is because it's lower down and the area of the scalene, intra scalene triangle and so it's usually the first affected, a and b, the vein is a drainage, doesn't have a muscular layer, its more susceptible to compression and we can find this symptoms by looking at the hands to see if they have any swelling of the hands and forearms. Usually it’s better if you take a photograph of the hands and evaluate it that way. I found that it can be a very helpful tool, because sometimes you don’t see it, you see it better on a photograph. Second thing is you're going to look at the tendons of the hands. If the tendons have been obliterated by edema, you might be looking at a patient who has had difficulty in drainage of the blood from the extremity. It kind of balloons out and they’re going to get a little bit of tingling – that’s when its starts to affect the arterial blood supply. In this situation, the patient starts to get a little worried, that's usually when they come to see you.
Brachial Neuritis usually doesn’t have these vascular symptoms. Cervical spondylosis is a component of thoracic outlet syndrome that's been there for a period of time and vice-versa. Myofascial pain syndrome, obviously you're not going to have the tingling sensations, you're going to have as much of the neurologic complaints with myofascial pain syndrome. But myofascial pain syndrome, in a way, is a component of thoracic outlet syndrome because the structures have been subluxaed and there is inflammatory proceess going on and swelling and pain and that is what myofascial pain syndrome is. So <inaudible> overlap there, subclavian steel syndrome and angina pectoris, I think that you're going to be able to figure those two out fairly easily.
Something to keep in mind though, the history of these patients is usually fairly common and repeatable. When we are faced with a patient that may have thoracic outlet syndrome, it is extremely important that we do a careful history to determine what kind of lifestyle this patient has, and ask that pertinent questions to see if they have the causative factors that create this problem. Like I mentioned before, I usually ask the patient, “Are you reading in bed” "Do you have a television set in your bedroom?" "Do you watch TV in bed?" and "how often do you watch it a week and how many hours a day?" And look to the patient who is going to underestimate that time, they don’t want you to think that they are just sort of lazily lying in bed all day long and watching television. If they tell you it’s 5 hours a week, you could pretty much guarantee it’s between 8 and 10. That's what we’ve found. When we press the patient for the truth, usually they tell us that it’s more time.
Diagnosis is difficult, like I said before, because there is no gold standard test, so historical findings and physical findings are extremely important and the diagnosis because the diagnosis is based on these historical and physical findings that are corroborated by maybe some imaging, diagnostic testing and imaging, nerve conduction, sensory, velocity testing and SSEP tests, and if you care to use those. We haven’t had the need to use those kinds of tests because we are treating the patients clinically as I mentioned we're getting good results.
I like to order diagnostic test images, when I’m not getting the results that I’m looking for, rather than order these tests on every patient that walks into the office. I feel that clinically if I can help the patient within the first two weeks, I’m on the road to recovery and there is no need to do these diagnostic tests. Of course, if I’m not getting the results that I’m looking for, and I may have to dig deeper for something I’m missing, that’s when I order these tests.
Now, basically the common symptoms of thoracic outlet syndrome, it usually begins with some stiffness in the upper thoracic area like in the ribs around the neck area, specifically in the traps and the upper back. A lot of patients complain of stiffness in the neck and they feel the need to stretch their neck at work and crack their neck even and it’s very common with children, they crack their neck, that's called self-adjusting. Actually what I found is that stretching of the neck is actually contra-indicated in this syndrome because the attachment of the scalene muscles is between the 2nd, 3rd, 4th, 5th and 6th cervical and the first rib, so by laterally flexing and stretching the muscle on the left, what is actually happening is that the patient is using the scalene to levitate or elevate the first rib on the left side. So in fact, when you’re stretching the neck, you’re in fact actually even subluxating the rib even further into a position of superior subluxation. So in the literature, it discusses the treatment for thoracic outlet syndrome is to laterally flex and stretch the neck, and in fact if you’re wondering why you’re not getting good results, because laterally flexing the neck actually makes the condition, in my opinion, worse. Our goal in mind here in the treatment of this patient is to lower or bring the ribs inferiorly and reduce the tension of the scalene muscles. Those are the two main goals of therapy. By positioning the rib in a lower position, it will allow more space in the costoclavicular area for the structures to pass. There are no real muscles that actually pull that rib down, so it has to be manipulated. It has to be manually adjusted. I haven’t been able to find any other way to reposition the first rib or cervical ribs, except for manual adjustments.
Of course you can remove some of the muscle spasms which will remove some of the tension on the first rib of the muscles that actually attach on the first rib, being the scalene muscles. If you are going to reposition the rib so that it allows for better passage of the structures, then you’re going to have to manipulate it. Lot of the, the majority, 99% of the articles that are published on thoracic outlet syndrome and studies that are been made on thoracic outlet syndrome have been made by medical community whereas chiropractic community only practitioners that actually make the correction of the rib in the inferior position. There is no wonder results are not good. We’re not looking at any particular profession; we’re looking at a procedure that will remove pressure on neurovascular structures – Plain and simple. We’re not looking at who is better or who’s not. We’re looking at a procedure that is in the doctor’s bag of procedures that is going to be able to relieve the patient’s symptoms by way of repositioning the bone that is causing compression on the structures.
In these patients that stretch and crack the neck, sometimes they, if you ask them, they will crack and stretch the neck 10 times a day. When I see a patient doing that, I just tell them “You’re going to have stop that. I have a way of correcting that” They feel the urge. With treatment, this urge will diminish and be eliminated. They will no longer feel the urge to crack their neck all the time, because the stiffness will be reduced. What usually happens is that the subluxation is actually not in the neck; it’s in the upper thoracic area. So when the stiffness is in the upper thoracic and lower cervical area by cracking the neck because if there's so many different supportive structures with the ribs and the pectorals and the muscles of the upper back as well as in the shoulders. By moving or self-adjusting, you only, adjusting that is going to take place is in the middle cervical area, which only causes a hyper mobility as well as as I mentioned before, lateral flexion to this side will actually have the scalene muscles elevating the rib even further causing further compression of those structures that emanate. So the controversy could be explained a little bit better with some of these more logical explanations. The pain and stiffness actually travels from the upper thoracic area into the ribs and patients actually complain of chest pain and difficulty breathing. Talk about chest pain and stiffness and shortness or labored breathing; you know they don’t sometimes realize it until you bring it to their attention. You just have ask them “Have you noticed lately that you felt that your chest is tight and you have not been able to breathe as well?” And they will say, “Yes, as a matter of fact I did.” It really wasn’t something they were thinking about because the overwhelming sensation of numbness and tingling and the weakness in the hand is a far more of a concern than the shortness of breath. But in fact the reason why the patient has a shortness of breath is because when the first rib subluxates in superiorly, the intercostal muscles which connects the ribs actually allow for the first rib to subluxate superiorly but it takes, the first rib takes the 2nd 3rd 4th 5th ribs with it because they're connected.
So what you are going to see is superior subluxation of the ribs of the upper thoracic spine and not just the first and second. The other thing they have is recurring headaches. The reason why is that they are, in this position watching television, their neck is actually in this position for so long that when they get up, they're actually more with the neck in a straightened or retrolisthesis position. If they leave their head in this position, they're not going to be able see where they are going.
It may seem silly, but postural reflexes kick in what happens is there is tucking mechanism that occurs 1st and 2nd cervical and the base of the skull that has the patient extend their neck back in this way and this hyperextension at level skull C1, C2, plus axis complex will actually cause compression of the first and second nerve of the spine and radiating headache pain as a result of this compression of the nerves and the suboccipital region. Like I had mentioned to you, these headaches are fairly common in thoracic outlet patients. What you have to do you’re going to have to make a decision when you make correction of the spinal misalignment. I found that if you try to correct the upper neck and the lower neck, sometimes there is a problem and there is too much stimuli to the spine. Sometimes you have to work on the lower neck to realign or correct the subluxation of the first rib with neuromuscular reeducation or muscle deep tissue work and adjustments and mainly do deep tissue work in the upper cervical area and start the correction in about a week or two after treatment is transpired to sort of calmed down the lower cervical region. I think it's a better clinical, a better way of treating the patient clinically that I found the <inaudible> experience.
As I mentioned to, also you have tingling in the fingertips, this usually in the morning. The reason why I feel that this is happening because, even though provocative tests have the patient elevating the arm, causing these symptoms, I feel that the vascular compression that causes the numbness, a lot of the numbness as seen in Adson's Test, we're going to talk about that soon. When the patient is reaching for a broom, or can of something out of a cupboard or waving to a friend, this elevation of the clavicle allows for blood supply to seep through into the arm and allows for the arm to be supplied with spurts of blood because the compression is relieved. When the patient is sleeping, they're in a static posture and there is really not a lot of movement to stimulate the blood flow, and that is why the patient has the tingling in the fingertips in the morning. They also, the patient has the highest degree of swelling in the hands and the swelling sensation called “glove sign”. In the morning, the patient feels the need to shake their hands out. Sometimes, the shaking method actually does bring blood down into the extremities, because they are elevating the clavicle which allows the blood to come in and they are shaking the blood down into the extremity. This is something that the patient understands, based on instinct, when in fact they are actually correcting their problem.
The swelling in the supraclavicular space is amazing to me because it’s so obvious and so blatant and I have had numerous patients who have come to me with swelling in the supraclavicular space. They have been to several physicians, none of which has made comments in their notes. As you can see on the top picture here, you can see the upper border of the clavicle on the patient and this patient below was involved in a motor vehicle accident at a fairly high speed. She has bilateral thoracic outlet syndrome. As you can see from the photograph, the superior border of the clavicle is obliterated. Also, we don’t see the sternocleidomastoid muscles and we don’t see any striations in the muscles in these patients and they are thin. Thinner patients, it is more obvious. There is really no fat there. So it’s not fat, it’s swelling. And swelling of the supraclavicular space is in you should look for patients.
I have patients who come in my office and they walk up to me and I look at that region and the left side is more swollen than the right, they come in for a lower back problem, and I just ask them when I see the left side is swollen in the supraclavicular space more than the right, I say “Do you have numbness in your left hand periodically, more than your right?"
And nine times out of ten, they’ll say, “Yes and how did you know?” Like I’m a magician or a soothsayer. How did you know I had numbness in my hand, when in fact no documentation on the initial paper works where the patient is filling out the forms to discuss their symptoms. Nobody had made mentioned to me or the staff about this symptom, and they weren’t even interested in discussing it with us. They came in for their lower back. It was an incidental that started maybe a month or two prior maybe six months have been going on. But just by my observation, I can see that the supraclavicular space was swollen and the patient, I feel, has this thoracic outlet syndrome. So next time you go into your office, please take a look at your patients a little more carefully because you're going to find a lot more TOS's patients by being a little bit more observant. Cervical ribs or anomalous first ribs like I had mentioned to you before, do not cause thoracic outlet syndrome. As like I said before, just because the patient has scoliosis doesn’t mean that we have to do surgery to correct it. Patients have scoliosis of 5 10 15 degrees, live very comfortable and normal pain free lives. 35 year old patient walks in to the office, has never had back or neck pain, upper back pain in their life, they have recent onset of pain, you take an x ray and you find out they have scoliosis.
They had scoliosis when they we're 21. They had scoliosis when they we're 15. They did not have pain when they were 21 and 15. The scoliosis has been there for 30 years, the scoliosis is not the cause of the pain in that particular patient and in this situation if the patient comes in into your office and they have recent onset maybe their 40 35 40 years old, recent onset of thoracic outlet syndrome, you take an x ray of their thoracic spine and cervical spine and you find cervical ribs, just because you find cervical ribs doesn’t mean they have to be surgically resected. If the patient was able to live a comfortable life with those cervical ribs before, my feeling is that all you have to do is reposition the cervical ribs so they do not cause a compressive type of syndrome and the patient will be fine.
In these particular pictures, these are actual photos of patients that have thoracic outlet in my office. This particular patient that you're looking at, the hands on the top is the lady in the previous photograph that had the supraclavicular swelling. As you can see on the right hand, the right hand is much larger than the left and in fact, this enlargement or is an edema, is a swelling and is a result of the fact that the venous return is blocked because of the superior rib subluxation or some intrascalene type of compression on the subclavian vein not allowing the blood to escape from the hand. On the lower picture, we have a gentleman who has the same syndrome as you can see. If you look carefully, not only does his hand bigger on the right, appears to be bigger, but the wrist and the forearm appears to be bigger and larger too. What I have done, you have to understand is that what I did here, I saw vaguely that there were some differences but when I took a photograph of the patient, it became very obvious. My feeling is that that is something that you should you use as a tool because it seems to brings out the differences a lot more strikingly.
Now in this particular slide, we’re talking about postural evaluation. And what you’re going to do is sit down in a chair in your office and you’re going to demonstrate the posture that the patient is in that causes the tension on the anterior scalene muscles which is the gentleman on the bottom picture and the young lady who is leaning back in the chair. You know as well as I do that this is how a lot of us sit and a lot of kids sit; and a lot of people have thoracic outlet syndrome. As I mentioned, do I think it's over diagnosed? Absolutely not.
I think it's under diagnosed and I think that the reason for why it's under diagnosed is because a lot of people sit this way. In the forward tilt position as I have mentioned before, when the neck is in this position while you are watching television an hour or two for sometimes 3 4 5 6 10 years, the neck becomes frozen more or less in this position as a result of tension in the scalenes as well as elevation of the first rib, the structures come together and this forward tilting can be seen in x-ray as a retroslethesis, also the rounded or protracted shoulders. When the, you're gonna see that, when the rib elevates, it affects the shoulders and causes shoulder pains, shoulder stiffness even in <inaudible> syndromes and rotator cuff syndromes. So the shoulders should actually evaluate concomitantly with the neck. Orthopedic test should be performed, muscle test, orthopedic test <inaudible> should be performed on the shoulder as well as the cervical and thoracic region.
Cervical range of motion and flexion; we have a decreased range of motion and stiffness in the lower cervical and upper thoracic area. Cervical range of motion and flexion that I have seen, let's say that it's not the most prevalent decrease in range of motion but it is apparent and the, there’s mainly just the pain they usually complain of pain in the upper thoracic area around C6, C7, and T1. Extension when they extend back, they feel a pinching sensation or pain in the 1st 2nd 3rd thoracic ribs in the spine area. Rotation usually is pretty good with rotation. I find that majority of them can rotate about 70 – 75 degrees. That's not significantly altered as much as lateral flexion.
With these patients you try lateral flexion, and they’re getting maybe 5, 10 15 at the most degrees when normal is 45 degrees. Also what you’re seeing in lateral flexion when you laterally flex the left, the right scalene will become prominent. You put your finger on it and it feels so tense. It feels like a palpable hard band and it’s very stiff. When the range of motion in the cervical area and the anatomical structures are affected as well as the biomechanics become abnormal in the neck area.
Because of all the attachments of the muscles on the neck and the shoulder area, you’re also going to find that the shoulder range of motion is will be affected. It’s affected or decreased in 44% of thoracic outlet syndrome patients according to a very large study that I reviewed. What happens is the elevation of the first rib causes an altered biomechanics of the shoulder, because the shoulder articulates on the dome that is represented by the first, second, third ribs. So if you’re going to alter the foundation by which the structure moves upon, you’re going to actually cause damage to that structure. It’s no different from the foundation of a building affecting the first, second and third floors. It’s very simple.
Other muscles originating from the chest, neck and shoulder are further affected predisposing the patient to rotator cuff syndromes and impingement syndromes. The first muscle that is usually affected is the superspinatus. I am going to demonstrate to you the biomechanics of what goes wrong. First rib subluxates, causing a rising of the clavicle, and as a result added tension is placed on the superspinatus. The superspinatus muscle test is usually weak, and I’d say that on 50 – 60% of those patients that have long standing thoracic outlet syndrome for more than 3 or 4 months. So you need to do an evaluation of the shoulder mechanism also because this usually is the second area of emphasation of the thoracic outlet syndrome.
The spinal examination will yield a superior subluxation on one or both of the first ribs. Various different studies of motion of the first ribs having the doctor placing the thumb on the first rib in the back of the neck and actually tilting the head to the side and back in extension – what you’re finding is that rib does not move. Usually what is supposed to do, it is supposed to disappear down into the thorax and then bringing you back to allow it to reappear.
What you’re finding is that you find an endplate or end field, which is very stiff, no mobility does not disappear. It just feels like it’s immobile; that’s when the bone is not moving. What happened if the ribs do not move? Ribs have to move in order for normal respiration to occur. They have to move up and back. If the ribs do not move, the patient will have labored breathing as we mentioned before.
Subluxation of the upper thoracic vertebral segments in costa chondral and costa transverse junctions or joints- As I mentioned before, when the rib subluxates superiorly, due to the fact that it is connected through the intercostal muscles, to the 2nd, 3rd and 4th ribs, what you’ll find here is that you're going to find arthritic changes in these areas. I’m going to go over that in a minute. You’re going to look for those on the radiographs, you’re going to look at the costochondral junctions, costovertebral, costotransverse junctions, and you’re going to look for increase in the white calcium deposits and buildup of calcium deposits on these joints.
When evaluating thoracic outlet syndrome, one of the physical evaluations, which is very important in your physical, you want to do manual muscle testing. A doctor who is astute in manual muscle testing can usually isolate muscles that have been put into a tonic protective spasm or a weakened position. After a lot of practice, you can become very skillful at this.
Muscle groups that are commonly affected are the anterior cervical muscles as I mentioned to you because of the fact that you’re holding the muscles in a contracted position for a long time. These muscles should not be put in a contracted position for this long time and that’s why they become weak and spastic and lead to elevation of the first rib. The superspinatus as I had mentioned and also the latissimus dorsi, intrinsic muscles of the fingers – when you’re doing your physical examination you should measure the strengths of the intrinsic muscles of the fingers because that’s the first area of weakness that you’re going to find that the patient will experience when they start to lose grip strength and strength in the hand as a result of a fairly lengthy compressive forces, the forces that are occurring in the brachial plexus, subclavian artery and vein.
The rotator cuff, obviously, in advanced cases , <inaudible> it doesn't take long to evaluate the rotator cuff, so you should do it, it’s necessary. In the x-ray findings, you’re going to find a loss or a cervical curve or a retrolisthesis, called a military spine, whiplash spine, I don’t care what you call it, the bottom line is that either A) it’s straight or B) it’s curved in the opposite direction of the way it’s supposed to. What you have to understand is that the cervical curve is designed in such a way, the curve; the spine is designed in such a way to function with a curve.
As an engineer, you take the spine out of its normal position and normal alignment, what you're going to find out is that the joints re going to wear out faster, just like if your vehicle is out of alignment, your tires are going to wear out faster, any moving part of machinery that has a moving part, any moving part, if it's out alignment, that moving parts will wear out faster, same thing with the cervical spine or any other joint.
What we’re going to find that this retrolisthesis or military spine is found in 80% of the patients. Why? Because like I said, attachment of the scalene muscles is on the anterior portion of the transverse processes of C2, C3, C4, C5 and C6 and when you have to hold the head up for a very long period of time what it does is it actually pulls the curvature out of the spine and this is not a very good thing long term.
Also as a result of the malposition of the first rib, you’re going to find degenerative joint disease and the sternal costal junction. In other words, when the first rib loops around to the front, it attaches to the sternum. If you look very carefully, a lot of time you’re going to find a lot of calcium deposits and deformation in the joint. Lot of people overlooked this. It’s been overlooked quite a bit and also that you're going to see degenerative joint disease of the costal transverse of the upper ribs.
Here’s a picture I found in a book discussing how the patient had just gotten out of surgery. In fact and had the left cervical rib removed as a result of long standing thoracic outlet syndrome that did not respond to conservative care. And if you look very carefully where the arrows are on the right what I found is that on the cervical rib, the first rib, second, third and fourth, there is a fairly large amount of calcium deposit that’s on the costal transverse junctions and the costoclavicular, vertebral junctions, you’ll see the darkened areas of the joint space and adjacent to those areas you’ll going to see the calcium deposits, which means that the normal biomechanics have been altered and that is evidence that in fact, what I had mentioned before that when the first rib is elevated, because of the intercostals, connect those ribs 1, 2, 3 and 4 together that when the first rib elevates, it starts to bring all the other ribs with it. It does affect locking the costal transverse joints and causing degenerative joint disease in that area.
When treating these areas, you need to manipulate or bring motion back into those segments, those ribs; you have to have a fairly good technique for adjusting ribs, because ribs have funky movement. They are difficult to treat, difficult adjust, because of their attachment on the two areas of the vertebral spine and their motion is very strange. Sometimes when adjusting ribs, the patient can feel sharp pain during the adjustment and then relief immediately after. I use a very gentle technique. I have had rib problems from a car accident in the past; I understand it better because I have gone through it. I have studied have these rib techniques, adjustments and manipulation, manual manipulation of the ribs in great detail so I feel confident about it. I know that in the beginning it is quite difficult to master the art of manipulating ribs because of their strange configuration. You really practice it.
Like I mentioned, in an orthopedic test, which are what most practitioners rely on for diagnosis of thoracic outlet syndrome, there are very provocative tests that have been developed over the years that assist the clinician in recreating the symptomatology to locate the area of vascular and nerve compression. I think that locating the exact area of vascular nerve compression is important, but from what I have been finding in my clinical work is that the majority of these tests are all positive when you have thoracic outlet syndrome most of them are all positive and I’m going to tell you why.
But also, what the doctors complain about is that these tests create a lot of false positives. I will tell you that there could be a very valid explanation for this. When the first rib elevates and causes a compressive force upon the brachial plexus, subclavian vein and artery, then we would say that that rib is subluxated to a large degree.
There are varying degrees of subluxation that has the rib elevated maybe less than that amount on that particular patient; in other words, that there subclinical, there are rib subluxations that do not illicit numbness or full blown thoracic outlet syndrome, but when stressed, you will have to say that the patient because of the biomechanics of the ribs, the ribs are subluxated, but not enough to cause numbness or compression of the subclavian artery vein and brachial plexus. However, when put in a provocative position, they are subluxated just enough to cause the positive test, but not enough to cause frank symptoms in the patient.
Because, I feel that this posture of leaning back, watching the television, leaning back in the car, the multiple, many traumas that we have in car, everybody, everybody in the United States has had on average of at least one car accident in their life. So, these traumas as well as increase in sports injuries, to affect the anterior cervical area are so prevalent that I believe that some are clinical, some are subclinical. Some of these provocative tests were performed on normal individuals. These patients were not probably were normal. More detailed evaluation of the motion of the first rib to determine whether or not that rib was in a good position, or aligned properly or whether or not it was slightly affected should have been performed and these were not done according to the literature. So we cannot say that false positives were elicited. But we may say that it’s a possibility that we found sub clinical versions of thoracic outlet syndrome and not necessarily false positives. I hope you understand that.
I feel that, this more or less shows the vulnerability of the area of the thoracic outlet's phases in that. Anytime that you have some pain syndromes in the neck area and the upper back, maybe the shoulder, careful evaluation of the motion of the first rib and positioning of the first rib as well as the tension on the scalene muscles and the muscles around the head, neck and shoulder should be done. In other words like i said, there are degrees of subluxation. Let's go over those; first of all you have hyperabduction maneuver in this particular situation, as you can see, what we are doing is elevating the arm. This will put a strain on the thoracic outlet bundle ,the subclavian artery and vein and the brachial plexus because if the pectoralis minor is in a spasm or has tension, not allowing the shoulder to move properly, then of course, those vascular structures, nerve and vascular structures will be compromised and the patient will have symptoms. What you’re talking about abduction 280 will illicit, you’re going to actually going to take the radial pulse, it's going to illicit a decrease in the radial pulse or diminished radial pulse or complete, you cannot feel the radial pulse at all. The patient complains of subsequent numbness immediately following the test. Now normally nerves don’t act that way; usually vascular structures act that way.
The elevated arm test or Roos test is considered the most reliable test for thoracic outlet syndrome where the patient put their arms in this position, opening and closing the hand for approximately 3 minutes. You know, the movement of the hand should stimulate blood flow into the arm, but in these particular patients, blood flow is not good enough due to the compressive forces that are brought out by the malposition of the ribs and the structures in the thoracic outlet area. So this is the most reliable.
According to literature, doctors were doing this hyperabduction, Adson’s costaclavicular tests and then saying okay it’s time to do surgery when the tests were positive. I think that’s jumping the gun in a big way – something that we never did. I am shocked that this is happening. Because like I said we find the same findings they do <inaudible> exact orthopedic findings and when we make correction of the first rib to lower it, to remove the subluxation and work on the muscles around the cervical thoracic area around the shoulder, these problems are going away.
The Adson’s maneuver is when a patient takes a deep breath and holds it. When the patient takes a deep breath, obviously, the thoracic ribs will elevate. When they hold the breath that keeps the ribs in that position, they are going to hyperextend the neck, which is going to cause the scalene muscles to be stretched back across the subclavian artery vein and the brachial plexus area. If the patient has an elevated rib, this involvement the scalene muscles, in fact that will cut off the blood supply or cause the compression of the brachial plexus and illicit the numbness. In fact, what we find is that the symptom is reduced arterial blood flow; there is no more pulse within 3 to 5 seconds. The patient then complains of numbness. “Is your arm going numb?” “Yes, it is.” You don’t say anything; the patient says “you know I’m feeling some tingling sensations in my fingers.” The costaclavicular test narrows the costaclavicular space by bringing the clavicle close to the first rib and second rib.
When the patient draws the shoulder downward, and then that causes the compression of the subclavian artery and the brachial plexus. Positive tests obviously when the radial pulse is diminished. These diagnostic tests are very good to show that there is some compressive force in the thoracic outlet area, but by no means do they point towards immediate surgery. Like I said, there is no gold standard test we’ve been going over and over it again for thoracic outlet syndrome. The clinical judgment has to be used. There are some diagnostic tests such as electrophysiological evaluation, multi-detector CT and 3-D reconstruction, Venography, Magnetic Resonance Angiography, Radiology, obviously we talked about that, Doppler ultrasonography and SSEP potentials. Electrophysiological tests from the literature, some maybe three or four of the studies that I read, said that it was effective in determining thoracic outlet brachial plexus bundle compression. What you have to understand about the brachial plexus is that they distribute themselves superior to inferiorly 5,6,7,8 T-1. The most commonly affected is T-1 because it’s closer to the first rib causes numbness down the ulnar distribution. What I’m finding is the whole arm is numb.
However, according to the studies, impairment of the nerve conduction, primarily F-waves were decreased in amplitude in the ulnar and sometimes the median nerve. Obviously, ulnar is more of the T-1/C-8 distribution than the median, which represents more of the gamut of the brachial plexus. This could help localize the brachial plexus lesion and may help to rule out segmental systemic neuropathy such as herniated disc in a particular area of the cervical spine if you do not have access to an MRI or have not ordered it yet. We see this impairment after the arms are raised in a provocative position in other words, the F-wave is normal and the patient is in a neutral position but when the arm is raised in a provocative position as in Adsons, Hyperabduction Maneuver, Costaclavicular Maneuver, you will see that the symptoms or the F-wave will be diminished.
In more recent studies of these symptoms are related to thoracic outlet syndrome and the electrophysiologic test is that this test is only used for a long-standing anomalies and severe atrophy because in the initial phase of this problem, the F-waves are not diminished and you’re not going to find this a very effective test for a recent onset of thoracic outlet syndrome. Therefore, I don’t feel it’s really necessary. Do I order these tests in my office? No I don’t. The reason is because like I said before, I only order the tests when I’m not getting the results. I've never really had a problem with thoracic outlet syndrome in my office. I’m getting very good results with it, so there is no need to expose the patient to diagnostic tests which are medically unnecessary. You must document the need for a diagnostic test.
A need for a diagnostic test is to determine, differentially diagnose or determine to a better extent what is wrong with the patient. If I feel that the patient is recovering in the first four five or six visits and making progress, I am going to continue with care, it looks like I am on track, and I am not going to order these diagnostic tests. If there's a turn for the worse, or if I’m not getting the results I’m looking for, certainly I will order the diagnostic tests to look into it further to determine whether I haven’t really seen what I need to see or I need to see something that I can’t see based upon the orthopedic tests, the history or physical examination I performed. That’s obviously protocols for any type of orthopedic, chiropractic or neurologic type of practice.
Multi-detector CT and 3-dimensional reconstructions: There has only been one study I saw. It says it's very promising. I don’t know I haven’t really had a lot of time to look into it; it wasn’t, not a lot literature on it. I am not going to run out and order multi-directional CT scans on every patient that walks in my office with tingling in the fingertips. Like I said before, I use these tests sparingly. Doctors use them more often that’s your clinical judgment. One author stated in his paper that venography was the only reliable diagnostic tool to for diagnosing thoracic outlet syndrome. Doppler ultrasonagraphy was another test that was mentioned, few studies discusses on that. There was no real discussion of reliability or sensitivity of this particular test. It was considered as promising.
Magnetic Resonance Angiography, what you have to do is, you have to do an MRI scan of the patient in the normal position, and then you have to actually do another MRI with the the patient in the provocative position. This MRI must be done in an open MRI scanning unit because of the fact that you have to alter the position of the arms, cannot be done in a closed MRI scanning unit. That’s something you have to understand. Also, you have to find a radiologist who understands thoracic outlet syndrome, anatomy, biomechanics, as well as being willing to do two MRI’s of the body: one in the provocative and one not in the provocative or in normal position. This was done by one particular group of practitioners looking for some sort way of diagnosing with images, diagnostic imaging the thoracic outlet. I don’t think it should be done routinely in practices.
CT Angiogram: This is a very interesting study that I found in the literature that actually showed a visual of the thinning of the subclavian artery as it passed through the intrascalene muscles. It was very nice evidence that actually occurs. Radiology; When you take your x-rays, you’re going to take cervical flat plate films and thoracic flat plate, AP lateral films. The first thing you always do when you evaluate the patient, that's the first thing we do, we're looking for the bilateral cervical ribs. You know what? Cervical ribs are in less than 1% of the population. As I mentioned before, we have seen thousands and thousands and thousands of cases. A lot of these patients are x-rayed as a result of traumas and peripheral nerve type of neuropathies. We are not finding cervical ribs on a lot of patients. I would say that it’s not less than 1%, I'd say it’s less than 1/10th of 1% or less.
I remember, maybe 1 case of cervical ribs out of the entire array of patients that I have seen in approximately 18 years of practice including 2-4,000 new patients per year. You’re looking at variable heights of the first ribs as well as you’re looking for the intercostal spaces. The spaces between the ribs should be equal. If there’s a greater space on the right than on the left, then obviously on the right there's been some ribs elevated or on the left, some ribs have actually subluxated inferiorly. You’re looking for the arthritic changes in costal transverse junctions. That’s arthritic changes as a result of some lack of movement or poor movement or aberrant movement in these ribs. You’re looking for military neck, retrolisthesis and degenerative joint disease in the first rib in the sternum as well as in the costal transverse junctions, we already mentioned that, when you’re looking at, determining whether conservative care is recommended or surgery, always conservative care.
According to literature conservative care was successful in only 10- 15% of the patients. And I have mentioned to you, the reason why I feel this is possible, is that if you do not tell the patients to stop sitting in this position for a long time, they are going to recreate the problem for you. You’re may do some therapy, you may do some adjustments of the first rib and if they lay there on the bed for 2 hours watching TV, these muscles are going to tighten up and lift the rib right back up again. So without really understanding causal relationship between this postures and how it brings out thoracic outlet syndrome you really not going be able to be effective in reducing the causative factor and you’re not going to get the patient well. In my studies of the over 300 articles I read and studied very carefully, I do not find one mention of this factor in the treatment of the patient. Not one mention of this position or how it affects the first ribs. 90% of these patients get first rib or cervical rib resection or scalenectomy.
Nine out of ten are getting surgery of the neck. I haven’t had one patient get surgery at the neck yet. It is very difficult for me to understand and that’s all I’m going to say. If there's a way of treating this conservatively, who would want surgery? Nobody. Nobody wants to have an operation on their neck. So it is better to go through the course of conservative treatment. The results of surgery seems to be 65% long-term success rate, partially 20% of the population and 50% have no relief. So you went through surgery of your neck and your symptoms are the same. I don’t think that’s a good situation. The rate of occurrence is between 5 and 10% of these people who have 60% long-term partial relief and the reason is because of scar tissue. They recommend that nerve gliding exercises immediately after surgery will help to reduce the scar tissue formation causing the recurrence. Conservative care, I believe that if there was an insidious onset of thoracic outlet syndrome, that if we can see what changed and we can reverse the changes to the original positions or biomechanics that were present when the patients did not have pain, then we can actually normalize this condition and bring the patient back to normal.
I think that thoracic outlet syndrome is a lot more prevalent than we think. It’s based upon poor sleeping habits and posture. Postural correction is critical to the management of this thoracic outlet syndrome as I mentioned. The patient compliance is critical in eliminating causative factors. You have to be a nag. You have to ask that patient constantly. Are you sure you’re not watching television in bed, you are not reading in the bed? Because if you don’t they will do it. They don’t think it’s important because you’re not saying anything about it, maybe only in passing, you need to stress it. So what we’re going to do is we're going to apply the appropriate treatment to correct this actual problem. Pain management can be seen with medication. That’s optional. We don’t use any medication in our office. No anti-inflammatories or painkillers are recommended and our patients seem to do just fine.
In fact, I’d like to note that the actual changes in the biomechanics are reducing the pain, and not the painkillers. If we use the painkillers, we don’t know whether our treatment is effective or not. I think that is worse than actually just diminishing some of the pain. The patient can handle it. You just tell the patient that hey the pain is a warning signal telling us whether our treatment is working or not. It’s a guide, it's a way of use determining whether or not we're being successful in the treatment your condition. Sure I don’t mind if a patient takes medication prior to bed to be able to sleep at night. But the use of medication, I think is unnecessary. I have never had a patient absolutely beg for medication. ‘Please, please, find me a medical doctor to get me some drugs so that I could sleep at night.’ I’ve just never had it happen – not in 18 years. Therapeutic exercises that were mentioned in the literature are contraindicated. No wonder they are not getting results. As I mentioned, stretching, or lateral bending, neck rotation exercises, and flexion exercises actually lift the ribs and make it worse. This is something that I don’t recommend; in fact, it’s contraindicated, and if you do it, you are not going to get any better. That’s the way it is.
The recommended conservative treatment protocol is, you must address the abnormal ergonomics or posture. Like I've mentioned, we have to beat it into their head on a daily basis and keep talking about it and talking about it until they can’t stand hearing about it anymore. You have to address their sleeping posture. They must have a pillow a patient asks about pillow. It can’t be too thick because it causes strain on this side. It can’t be too thin, because it causes strain on this side. The pillow should provide a nice comforting support for the head to allow the neck to be in a neutral position throughout the sleeping. That’s all, and the patient has to go out to and have to look into that. They have to research it themselves and find a pillow that’s going to work for them. What I recommend is when they’re at a store, they can lie down and look in some sort of mirror to see whether their neck is in a neutral position or not. Is it straight? Yes or no. If it is angled, then it’s no good. Don’t buy it. No other neck stretching exercises are recommended.
Physiotherapy such as ultrasound on the upper thoracic area and the lower cervical can help to reduce the inflammatory process and promote healing. Physiotherapy such as electrical muscle stimulation can help to reduce the spasms in the upper thoracic area. I do not recommend it around the scalene as you got the carotid sinus in that area. We do not use electrical muscle stims on the anterior cervical area. However, we do use it on chest muscles; we use it as long as it is not by the heart. We do use it on the upper thoracic ribs. It does provide comfort and it does reduce spasms for the patient and it promotes healing.
The goal of this phase is to eliminate the protective muscle spasms that are actually tonic and constant in the cervical spine, chest and shoulder region with I call neuromuscular re-education. It’s basically called deep tissue; you call it whatever you want, it’s also referred to as trigger point, Nemo technique, blah blah blah. There's many different names for it but I call it neuromuscular re-education. You use it on the scalenes, the muscles of cervical flexion, the clavicular division of the pectoralis minor and the subclavius muscle which is an often overlooked muscle, pec major, latissimus dorsi, anterior deltoid, upper and middle trapezius and other rotator cuff muscles.
Here we have a picture of the subclavius muscle, which is right underneath the clavicle. When that muscle is in tension, it can actually cause a compressive force on the brachial plexus and the subclavian artery and vein. The way I do this, is I actually lay the patient on their side, I hold the patient from their back and I put my thumb right up underneath the clavicle and shove it right up underneath the clavicle and I hold that position. I say, “It hurts, doesn’t it?” they say, “Yes it does, a lot of pain”.
I ask “Is it a 10 out of 10, 10 being the worse pain?” “Yes it is.” “Alright, what’s going to happen is that this pain is going to go down in chunks, it’s going to melt away when it’s melted away to 0, I want you to tell me. But if you tell me that it’s melted down to zero, when in fact it’s a 1 or a 2, I will guarantee you that tomorrow you will have achiness all over. So you’re going to do the right thing and tell me when it’s gone down to 0. Right? "Yes." Okay, that way, you won’t ache tomorrow right? Right. Ok let’s go to work. So I take my thumb, I shove it right up into the subclavius muscle, I apply deep tissue pressure, I hold it, do not move it and I wait for the muscle spasm to melt.
Here we have treatment of the scalene muscles and I’ll tell you that when you apply neuromuscular re-education, or deep tissue pressure of a constant variety to this muscle, it hurts bad. The patient is wincing. They are in a lot of pain. They’re begging you to stop. It recreates the numbness down the arm. Their arm is going numb; they can’t stand it any longer. Just say “relax, cool down’. Sometimes you have to tell them a joke. Tell them it doesn't hurt you as much as it hurts them. Get them to laugh a little bit. It’s going to be difficult to get them to talk because it’s close to the trachea and the esophagus area, but you just have to do it.
The bottom line is that if you don’t reduce the spasm, the scalene muscles will remain in tension and continually elevate the first rib. It has to be done. Pain will shoot all over the arm. They’ll complain of the shooting pain in the arm. Just get through it. It will be about 3 or 4 points. You’re going to work your way up to the base of the skull hitting all those points. There will be about 3 or 4 points on each side and they get through it. Pretty soon you’re going to go back each day and you're gonna work that muscle and pretty soon After about 10 treatments, if it’s done properly and you have not missed any muscle areas, that when you put a pressure on there, the pain will drop about approximately 10%, and the spasm will drop 10% per visit so after approximately 10 visits, plus or minus 1 or 2 really, you’re going to see that there won’t be any pain in the scalene area.
They are going to put the pressure there and you're gonna say remember when I put pressure on that muscle the first visit and you almost jumped out of your skin, your hair stood up, and your eyes rolled to the back of your head, and you turned red and you looked like Don King? Yeah. Well you don’t look like that anymore; you’re not feeling those pains any more, are you? And they say "No". Okay it’s because you’re getting better. And you are getting better, aren’t you? Yes I am, in fact I am getting better. That’s what happens, they get better.
The neuromuscular re-education can also address the abnormal muscle spasms or tenacity of the spasticity of the area of the supraspinatus and here we show the application around the supraspinatus in the top right. On the lower right you’re going to see where I’m going to apply the neuromuscular re-education to the lower cervical area so I can get a better adjustment of the first rib. That’s attachment of the first rib to the lower first thoracic spine area. Manual manipulation is a key component as well to successful outcome of thoracic outlet syndrome. Superior first rib subluxations cause compression of the thoracic outlet area, so therefore manual first rib adjustments inferiorly is the only treatment procedure will establish normal biomechanics in position of the first rib, included on the costal transverse and the costavertebral junction. You also have to adjust the upper thoracic spine. Thoracic rib subluxation must be reduced and must be reduced and must be reestablished or you will not get the patient well.
I don’t care how much therapy you use, how drugs you give the patient, you’re not going to get the results, how much stretching you , you’re not going to get the results, until you move the first rib. If I could not move or adjust the first rib, nobody in my office would be getting well. I rely on that specifically as a way of reducing the thoracic outlet, opening up the thoracic outlet spaces and without it; I don’t think I would have any success whatsoever. It’s mandatory. Therapeutic exercises or rehabilitation for thoracic outlet syndrome is only done after all spasms have been reduced and the subluxation is fairly well reduced. Do not incorporate exercises when there are spasms or pain still elicited upon deep tissue work and neuromuscular re-education. Exercises to strengthen rotator cuff muscles, specifically the superspinatus, posture muscles like the trapezius and levator scapular will actually elevate the shoulder and take the pressure off the nerves and the arteries. Exercises <inaudible> deep breathing will also help because as I mentioned, the ribs are subluxated as a result of lifting of the first rib. The first rib has the tension on the intercostals muscles and they subsequently move the first rib as well. Deep inspirations as well as flies and flat pull downs, incline and flat bench with deep inspirations. Take a big deep breath--- stretch out the chest --- and sometimes you’ll actually hear cracking or “tronar” as they say in Spanish – or a release of the sternal costal junctions. There is some release of pressure there and subsequent feeling of well-being.
Phase II is when all the muscle spasms have been reduced. You have to constantly re-evaluate the patient for spasticity of those postural muscles that were once involved because sometimes they slip and go back to reading in bed or reading on the couch, or they go back to watching TV in bed. You have to keep a careful eye on them and reinforce your recommendation for proper posture and proper anatomical position both at work, in the car, in the bed, on the couch are the main areas. Continue to manipulate the first thoracic rib. I saw in one study that said wean the patient off the first thoracic rib adjustments after Phase I. It’s just the opposite. You maintain the adjustment of the first rib and here’s the situation. You cannot adjust the first rib. I urge you practitioners to find a physician or an allied health care professional that can perform manual manipulation and neuromuscular re-education of these areas, because it’s about the patient. If you can’t do it, then you need to find somebody who can.
When do you need surgery? Surgery consultation should occur if the patient is compliant and still has not reached some relief after about 12 weeks. Surgery consists of removal of the first rib and scalenes. Surgery should be followed up with nerve gliding exercises. Surgery is either from the cervical area or the transactulate area. What I can tell you about this is that as I said before, in 18 years of practice with thousands of patients, I have not yet had one patient who went for surgery for scalenectomy or thoracic outlet syndrome type surgery. I think there is something to be said for that. Conservative care is a viable solution to thoracic outlet syndrome. More research needs to be done and people should take note of the findings that we have in this presentation.
I want to thank everybody for coming out to the presentation; I want to thank the American Academy of anti-aging medicine for inviting to this international conference, most Dr. Bob Goldman and Dr. Ron Klatz for inviting me and thank you audience for being receptive to our program. Thank you.