Research-Based Physical Therapy for Thoracic Outlet Syndrome

In one research study, a protocol of treatment for the physical therapy management of the thoracic outlet syndrome has been established at Amsterdam Memorial Hospital, Amsterdam, New York. Certain orthopedic manual therapy procedures are utilized to increase the mobility of specific areas of the patient's shoulder girdle, upper thorax, and if indicated, the cervical and upper thoracic spine. Previous training in orthopedic manual therapy is a prerequisite to employing this approach to the treatment of the thoracic outlet syndrome. This particular regime of manual therapy plus postural improvement, corrective exercises, improved body mechanics, and other procedures relating to the patient's activities of daily living have proven to be an effective method to relieve the signs and symptoms produced by this TOS. Paresthesia and numbness were the predominant symptoms of the patients that underwent treatment. The patients ranged in age from 27-60 years. (6)

Research-Based Osteopathy for Thoracic Outlet Syndrome

Treatment may also include cervical mobilization/manipulation and/or shoulder mobilization/manipulation to improve mobility, increase range of motion and decrease joint and muscle tension.
Patients with thoracic outlet syndrome have been treated with osteopathic manipulation to alleviate dysfunction and restriction of the pectoralis minor muscle and the resulting compression of the brachial plexus. Diagnostic ultrasound has been used to locate abnormalities in the thoracic outlet that are amenable to osteopathic manipulation such as tight pecoralis minor that pulls down on the coracoids process at the first rib. Diagnostic ultrasound can then be used to monitor progress. One report identified pectoralis minor muscle deformation and brachial plexus compression in a 32-year-old woman with TOS who was treated successfully with osteopathic manipulation. (7) Diagnostic ultrasound results were used to measure the degree of pectoralis minor muscle deformation using the pectoral bowing ratio and confirm the diagnosis. Osteopathic manipulation treatment was applied and monitored using ultrasound to confirm that the operator's manipulating hand had direct contact with the pectoralis minor muscle. Symptoms abated immediately after treatment. Results of a follow-up ultrasound examination showed that the pectoral bowing ratio decreased into the normal range and thus confirmed that pectoralis minor muscle deformation had been resolved. (7)

Self-care Strategies for Thoracic Outlet Syndrome

Properly educating the patient to achieve behavior modification is important to reinforce therapeutic interventions.  This may include home exercises such as stretching or strengthening, postural correction exercises, and modification of the biomechanics of activities of daily living. (4) Self-stretching exercises are always a complement to the treatment of TOS. The best effect has been observed with high-frequency, progressive stretching (3 repetitions of deepening stretches done3 times per day). The stretches can be tapered to a maintenance level (3 repetitions of deepening stretches done once a day) as symptoms diminish. Stretching should be demonstrated "hands on" with the patient to optimize effectiveness and reviewed regularly.

Research-Based Botulinium Toxin for Thoracic Outlet Syndrome

BTX-A is a neurotoxin that has been used to treat a variety of localized muscle hyperactivity conditions, including muscle spasticity and dystonia. (13) The toxin blocks pre-synaptic nerve terminals from releasing acetylcholine. (13) Research has suggested benefits from localized injection of botox in the treatment of chronic neuropathic pain, myofascial pain syndromes, chronic neck and low back pain, and joint pain.(13) The rationale for botox injections in TOS is that weakening the muscles that specifically impinge upon the brachial plexus may lead to symptom reduction. A number of studies have shown promise for the use of botox injections in the treatment of TOS.(13)

Research-Based Surgical Treatment of Thoracic Oulet Syndrome

More invasive treatments for TOS are very controversial.  The general consensus is that acute arterial compromise warrants surgery.(2) With neurogenic TOS, progressive neurologic dysfunction that continues after 4-6 months of conservative treatment may warrant surgical intervention. The objective of surgery is to decompress the nerve or vessels with either a release of the anterior and medial scalene muscles or possible resection of the first rib or cervical rib. (12) Unfortunately, long-term surgical outcomes have been inconsistent.(2)

Research-Based Contraindications of Massage Therapy for Thoracic Outlet Syndrome

Arterial TOS is often treated more aggressively due to the potential of life-threatening complications and therefor massage therapy is contraindicated in acute conditions. Consultation with a vascular surgeon is the initial step in management and an immediate referral is essential.(2) With the other types of TOS, massage therapy is not contraindicated, except in cases where patients have acute neurologic or vascular symptoms that require a referral to a neurologist or vascular specialist. Any severe nerve symptoms into the upper extremities or skin discoloration are signs of neurologic or vascular comprimise and need to be addressed medically as soon as possible.

Summary of Research-Based Massage for Thoracic Outlet Syndrome

Although treatment of Thoracic Outlet Syndrome can be a complex and challenging problem, conservative treatment continues to dominate, except in the case of acute arterial TOS. Conservative treatment integrates manual therapy like massage and mobilization with exercise intervention and patient self-care strategies, like postural awareness, home exercises and modifying the biomechanics of occupational duties and activities of daily living. In the author’s experience, massage therapy has a beneficial effect on reducing the pain and referred neurologic symptoms associated with TOS.

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