Chapter 6: Break These Laws . . . Get Sentenced to a Lifetime of Suffering

I mean, if a person acts irresponsibly in his own life, he will pay the consequences. And it’s not so much divine retribution as it’s built into the laws of nature.

—Pat Robertson

Activities of Daily Living That Increase the Risk, Cause, or Perpetuate TOS

In this chapter, you will learn new ways of thinking about what lifestyle choices to make to be sure you don’t cause additional compression of your human spring.

You should find this all makes sense, because it follows the basic principles of the laws of physics, the laws of nature, and engineering that are easy for anyone who is a logical thinker to grasp. In this chapter, I will point out the most common activities of daily life that put your spring in a position to trigger the strain receptors that will create the reflex from the brain that will cause muscle spasms to further compress your neck, shoulder, upper back, and thoracic outlet.

I am going to teach you what to do and what not to do.

The human body is an object that exists on the planet Earth. Therefore, it is subjected to the same laws as any other objects. Breaking these laws, you’ll not live in peace and harmony, rather you will become incarcerated in a jail cell of chronic pain and suffering.

The successful therapies I have described are not the result of some “medical miracle.” They came about because of an understanding that your body is a mechanical lever series and an integrated spring. The tension is moderated or controlled by the brain (laws of nature). We can see how the laws of physics and nature apply to the human body. Because you are a spring, you must learn to read your “owner’s manual” to fully understand how it works, the important functions it serves, how it breaks down and locks, and how it affects so many aspects of your health. How it is engineered and how the nervous system reacts to changes in positions relative to the pull of gravity is an extremely important component of the owner’s manual.

I tell my patients all the time, “If you do not learn how the human spring works and how positions and movements during everyday activities, such as sleeping, sitting, standing, and walking affects its function, it is impossible for a doctor of any kind to help you.” Not even my approach stands a chance. In fact, when a patient’s posture is off perpendicular I correct it. I don’t want to be blamed for why the treatment did not correct the TOS. That is how important this is.

Once you learn how to work with these reflexes, you will finally be able to live a more stress-free and strain-free life, and your TOS will finally go away.

Break These Laws... Get Sentenced to a Lifetime of Suffering

Activities of Daily Life That Cause Compression of Your Spring

In Chapter 5, you learned that the cause of the compression of your magnificent human spring was muscle super contractions. These muscle spasms have been created and programmed into your body as a result of the activities of your daily life.

1. Sustained contraction of muscles
2. Unhealthy number of muscle contractions without adequate rest between
3. Repetitive strained motions on muscles, tendons, ligaments, and bone
4. Single overloading strain on muscles, tendons, ligaments, and bone
5. Sustained, Constant Contraction of Muscles

Sports science has come to the conclusion that it’s best to exercise with 3–4 sets of exercises, with at least 90 seconds of rest between. That is so the blood can flow back into the muscle to deliver oxygen to the muscles that were depleted of oxygen.

If the activity involving the healthy alternating phases of contraction and relaxation, as in the case with most repetitive resistance training, then blood flow will proceed during the relaxation phases and decrease the likelihood of fatigue being produced by a lack of oxygen in the muscle, leading to trigger points and eventual super contractions.

However, if the exercise involves sustained (isometric) contractions, lasting more than about six seconds, this circulatory cause of fatigue will be significant. This explains why activities involving sustained contractions result in more rapid and more depleting fatigue than dynamic activity. The lack of healthy blood flow back into the muscle will deplete muscles of oxygen and increase the level of lactic acid in the region.

The best example of a sustained, tonic, or isometric muscle contraction is when the muscle contracts to one length and stays that length so your bones don’t move, like holding your cell phone up to your ear or your eyes. A tonic contraction is defined as the sustained contraction of a muscle, as is necessary for maintaining posture.

These tonic, sustained, muscle contractions can lead to the formation of trigger points, which can lead to the super contractions mentioned in the last chapter.

• Examples of tonic, sustained contractions in daily life are when you are holding some object for a long time.
• Another example would be when muscles contract to hold a posture for a long time

Activities Causing Compression of the Interscalene Triangle

Sleeping Posture and Sustained Contraction

When sleeping, it is necessary to maintain an equilibrium posture in the neck to avoid a sustained contraction, leading to compression of your joints. Equilibrium posture during sleeping is when there is an equal amount of tension of all neck muscles. Pillows are intended to support the head and neck in a neutral position to minimize biomechanical stresses on cervical structures while sleeping. That is because they maintain the neck in a horizontal position to gravity.

One recent study investigated which pillow types produce different types and frequencies of waking symptoms in pain-free adults. Subjects were encouraged to test each trial pillow for a whole seven nights (completers), unless symptom production, or lack of sleep, necessitated cessation of its use.

The number of subjects having the lowest percentage of completers (67.3 percent) was the people who tested a feather pillow. The feather trial pillow performed least well, producing the highest frequency of waking symptoms. The latex pillow performed best, with 97 percent of the subjects who tested the latex pillow able to complete the seven-day trial. The foam contour pillow performed no better than the foam regular pillow.

The key to finding a pillow that will maintain an equilibrium posture in the neck is to test it in the store. Lie down with the pillow under your head and have someone take a photo horizontal to your spine to see if your head is level, angled above, or below horizontal.

Muscles Affected: trapezius, levator scapula and scalenes Using a pillow that is too thin or no pillows can put the head, neck and upper spine out of a neutral alignment leading to cause strain on the neck.

Muscles Affected: trapezius, levator scapula and scalenes The head, neck and upper body must be in alignment while sleeping. That means your pillow cannot be too thick or too thin.

Muscles Affected: Opposite side trapezius,

levator scapula and scalenes The other thing that is important is for the pillow to maintain that thickness for as long as possible. When the pillow thins from use, your neck muscles will need to contract all night in an attempt to maintain your 9–12-pound head in the horizontal position.

It is common to find many who develop the chronic habit of adopting an abnormal posture of keeping the arm above the head under the pillow. Poor posture while sitting or standing happens when you lean your body outside perpendicular to the pull of gravity. Poor posture while sleeping happens when you lean your body or head outside of the perfectly horizontal posture to the pull of gravity. Poor sleeping posture can be a cause of thoracic outlet syndrome (1). Oftentimes, we have developed this habit to give a lift to the thinned-out pillow, so it maintains our head level, to avoid strain on the neck muscles. For those of you who cannot break the habit of putting your arm under the pillow, you might want to try pinning the sleeve of your pajama arm to the pajama leg. You should sleep on the opposite side and avoid lying on your stomach. Pillows might be placed under each arm when lying on your back (2).

One thing that has helped me in those situations is to stuff the base of the pillow with a folded towel between the pillow and the pillowcase to thicken the pillow, so it is thick enough to maintain the horizontal position of the neck and the head.

Standing Posture, Sitting Posture, and Sustained Contraction

The neck is the most complex musculoskeletal system in the body. The neck (cervical spine) has 37 joints and seven discs, which are described in the human spring model as compression springs. The scalene muscles and other muscles have control and provide the ultimate balance of the head on top of the spine, allowing you to rest perpendicular to Earth’s gravity every second of the day you are upright.

The key to maintaining perfect balance of equilibrium in the neck, upper back, and shoulder muscles is to have your base of support (buttocks), center of gravity, and head perpendicular to gravity. This should also maintain your eyes level with the horizon.

The muscle spindles in the neck and the six living spring or bubble levels (vestibular system) are sending messages to the reflex centers of your brain every second. Whenever your body leans to one side, the vestibular system senses the tilt of the head, and the muscle spindle cells sense the strain on the neck.

Within a nanosecond, the brain triggers a reflex muscle contraction of the neck muscles on the opposite side to right the head to the perpendicular position. This is the righting reflex we discussed in Chapter 4.

The Rules of Gravity and the Righting Reflex

• Body lean right causes scalene contraction on the left to tilt the head left, muscle super contractions on the left, and a greater risk for TOS to develop on the left.
• Body lean left causes scalene contraction on the right to tilt the head right, muscle super contractions on the right, and a greater risk for TOS to develop on the right.

Sitting with the body leaning back can cause strain of the muscles of the neck.

• Sitting with the body leaning back causes the scalene and anterior neck muscles to contract continuously. These sustained, contracted, muscular, super contractions can cause compression of the thoracic outlet in the interscalene triangle.

Break These Laws... Get Sentenced to a Lifetime of Suffering

Leaning Back Can Lock Your Neck

Many of us lean to one side when we sit on the couch, at the desk, in the car, and even in the bed. Here is the most important rule you must follow to reverse your thoracic outlet syndrome. When sitting anywhere (car, couch, bed), you cannot allow your back to touch the seat back. If you do, your spring has drifted outside perpendicular, causing the sensory system stimuli to trigger a muscle contraction to try to right the head to perpendicular.

A telltale sign is when patients will go to bed with minimal or no symptoms and wake in the morning with symptoms (3). This indicates to me that the cause of these conditions is definitely involved with sleep positions or activity that strained the muscles of the neck right before bedtime, such as leaning back in the bed watching TV or reading a book.

One patient argued with me and said that this couldn’t be the case, because he didn’t watch TV that long while in bed, and he was practically straight. Of course, he was just rationalizing, because he enjoyed watching TV in bed and didn’t want to give it up. So, I asked him how long he watched TV, and he told me 30 minutes.

I handed him a 10-pound weight. “Now bend your arm and hold the weight in this position for a while, as I treat a patient.” In about five minutes, he asked to put it down, due to muscle fatigue and burning pain.

The average head weighs 9–12 pounds. So, why wouldn’t you expect to develop trigger points and super contractions in your scalene muscles when you are asking them to have a sustained contraction attempting to hold the 9–12-pound weight in a position outside perpendicular for more than a few minutes?

I can almost predict with 100 percent accuracy not only the way they lean when they sit, I can also predict on which side of the body the thoracic outlet syndrome will be worse.

Too Much Body Lean Can Lead to Headaches, Dizziness, Vertigo, and Nausea

The scalene muscles, sternocleidomastoid muscles, and anterior and posterior cervical muscles control the movement of the head in flexion extension and rotation (turning your head and leaning your head backwards). There is a group of smaller muscles, known as the suboccipital muscles. These assist in providing the ultimate stress-free and strain-free position of the head in relationship to gravity.

These suboccipital muscles are muscles at the base of your skull. They are found to have the densest concentration of spindle cells of any muscles in the body. These sensory receptors act as a strain gauge that sends information on the degree of strain to the central nervous system as feedback on the status of the posture of your head relative to your neck.

Muscle spindles are stretch-sensitive receptors that provide the brain and spinal cord with information about the muscle’s length, tension’ and speed of contraction. Therefore, muscle spindles play an important role in providing feedback to your brain about the movements you are making every second of the day.

The reflexes create super contractions between your skull in your first and second vertebrae. The contraction of these muscles pulls your skull closer to your first and second vertebrae, leading to compression of nerves that cause headaches, commonly referred to as tension headaches.

When the pressure gets insanely high, these headaches can be extreme. They can cause the same symptoms as those of migraine headaches. In fact, the extreme headaches are most commonly called migraine headaches, just because they are severe.

Many patients who have whiplash injury or head trauma complained of dizziness and vertigo for years.

This can be the result of damage to the upper cervical joint receptors. That is why it is essential to be evaluated for active and latent suboccipital trigger point spasms, because they can compress nerves at the base of your skull, which can cause headaches.

Standing Posture and Sustained Contraction

Most of us have a favored leg to support the weight on when fatigued from standing for a long time.

Many of us even get so tired we lean on doorjambs, walls, desks, and even people. The same rules of gravity and the righting reflex that apply to sitting also apply to standing postures. If your body leans one direction, the righting reflex triggers a contraction of the opposite side neck muscles to contract to right the head to the horizon. Think about your habits in everyday life.

Extremity Posture and Sustained Contraction

Standing or Sitting with Your Arms Unsupported

Spring engineering suggests that your center spring supports the load of your shoulders and upper extremities. Everyone’s arms have a different weight. To get a better idea what your arms weigh, lie down with your arm on the scale, elbow locked, and palm up, so you aren’t touching the floor. Your arms can typically weigh more than your head.

Your upper trapezius muscle and levator scapulae muscles suspend the arms. These muscles must maintain a sustained contraction to maintain the position of the arms hanging off the center spring. These are also the only two muscles that suspend the shoulder off the thoracic outlet from above. When these muscles go into fatigue, they drop the shoulder girdle and all its weight into your thoracic outlet.

So, if you have muscle superspasms pulling your shoulder down into the outlet, with the levator scapulae and upper trapezius muscle group too weak and fatigued to suspend the shoulder off the thoracic outlet and tunnel, you have doubled the compressive forces on the outlet.

There is an orthopedic test called the Cyriax test to determine if your trapezius is fatigued, causing your shoulder to be dropped into the thoracic outlet and tunnel. It involves the passive elevation of the arms and shoulders from the elbows to remove the weight of your upper extremities from your outlet and tunnel. If the TOS symptoms subside, the test is considered to be positive.

There are some jobs that require you to maintain your arms in elevated positions (barbers, switchboard operators, assembly lines) with the head or shoulders flexed forward (secretaries, computer operators), along with painters, masons, or forestry workers, but also people with jobs such as switchboard operators, assembly line workers, dentists, physiotherapists, hairdressers, and musicians (4-5).

I have been invited to work on more than 100 tours where one or more musicians had chronic neck, upper back, and shoulder pain, and many have had or have thoracic outlet syndrome.

My ex-wife, Michelle McGovern, is an accomplished flute player. I can remember her six-hour practice sessions with her arms held in one place for so long.

It used to be that the severity of the thoracic outlet syndrome was directly related to the amount of time that they practiced. Not anymore. Now you have to add the amount of time musicians are on the computer, driving the car, carrying the instrument, watching TV in bed, and the talk and text time on their smartphones. One violin player had such severe spasms in her forearms that she had pitting edema.

If you are a musician and have to practice 6–8 hours a day, then there is no escaping the muscular fatigue spasms. For those who are not in Chicago, and cannot find a good practitioner, I recommend they just buy the powerful Massage Assist power massager and treat themselves before and after practice sessions until all tenderness has gone away.

1. When you carry a weight, like a 10-pound purse on the left shoulder, you have the extra weight to support with the left side trapezius, levator scapulae, and scalenes on that side.
2. Also, most important, your head tilts to counterbalance the weight on the opposite side.

So, now, you have a double compressive force on the thoracic outlet, neck, upper back, and shoulders.

The best option is to lighten the load and set the object down as soon as you can to avoid contraction of these muscles for a sustained period of time. You don’t need a bottle of water in your purse.

Break These Laws... Get Sentenced to a Lifetime of Suffering

Sustained Contraction of the Shoulder Muscles

When you reach your arm and hand outside perpendicular for longer than a few minutes, you are engaging a sustained contraction of muscles that depress and compress the shoulder down into the thoracic outlet and tunnel. When you reach out your arm to manipulate an object in front of you, a series of muscle contractions occur that can cause a narrowing of the costoclavicular space and the subpectoral space.

1. The lower trapezius and latissimus dorsi contract to pull the shoulder girdle down to stabilize and anchor the shoulder to the chest to provide a solid platform to counterbalance the weight of the shoulder and arm in front of the body.

Muscles Affected: Opposite side trapezius,

levator scapula and scalenes

1. The pectoralis minor muscles, the coracobrachialis, and the biceps short head anchor the shoulder blade down to the chest to maintain a solid platform for the arm flexion.
2. The subclavius muscle stabilizes the collarbone to the first rib and in the process, it lifts the first rib into the outlet and pulls the collarbone down into the thoracic outlet.

The longer you hold your shoulder arm and hand in this position...

1. The longer the muscles contract.
2. The longer the muscles contract, the more they will spasm.
3. The more they spasm, the more deeply the reflex will be burned into the brain.
4. The deeper the reflex is burned into the brain, the longer it will take to reprogram.
5. The longer it takes to reprogram, the more unlikely you will have a successful physical therapy experience.
6. The more physical therapy sessions that fail you, the more likely you will either live with long-term suffering or TOS surgery you never needed.

Ma’am, please remove your hand from the smartphone, mouse, keyboard) and nobody gets hurt.

Holding your arm in fl exed for sustained period of time can happen when using your phone, tablet or other handheld.

Pectoralis Minor Muscle Spasm

Muscles Attaching to the Coracoid Process

There are other muscles, when in an abnormally contracted state or constantly contracted, that can contribute to the narrowing of the subclavian space. The pectoralis minor muscle, biceps short head muscle, the coracobrachialis, and the anterior (front) neck muscles of the shoulder can contribute to the compression of the collarbone into the thoracic tunnel. These muscles are always contracted in a super contracted state, because they all contract together when lifting the arm to the front of the body.

Costoclavicular Space Compression and Thoracic Cortical Pectoralis Space

Narrowing of the thoracic cortical pectoralis space can result from shortening of the pectoralis minor muscle (30). This hypercontracted pectoralis minor muscle, the subclavius muscle, the coracobrachialis muscle, and the biceps short head muscle can act together to compress the area. The swollen, hypercontracted pectoralis minor muscle by itself can compress the artery, vein, and nerves as they pass beneath it.

We all know a large proportion of Americans are addicted to their cell phones and other handheld devices. But there are considerable risk factors and clinical features of the musculoskeletal disorders due to the use of these devices. This includes not only mobile phones, but handheld devices, such as game controls, tablets, iPods, iPads, and other portable electronic items.

Put your hand on the opposite side of your chest just below your collarbone. Now lift the arm on that side to place your hand at the level of your eyes, as if you were looking at your cell phone. You should feel a muscle contraction under your hand on your chest. This is the pectoralis minor muscle These muscles contract to lock the shoulder to the chest wall to provide a stable platform to allow you to extend your 10-pound arm out away from the human spring. The farther away, the more pressure it exerts at the fulcrum base. Your brain thinks this constant, extended contraction of these muscles is you contracting them for a long time on purpose.

It also shifts or locks ribs three, four, and five and the ribs they connect to, which can lead to pain between the shoulder blades, where these ribs connect to the spine, and chest pain, where the ribs connect to the sternum or breastbone. Oftentimes, people think they are having a heart attack (difficulty getting a deep breath, shortness of breath, crushing chest pain, and mid back pain) and they rush to the hospital, only to find that their heart is normal.

The Single Most Super Contracted Muscle of TOS, the Subclavius Muscle

Origin: The subclavius originates from the junction of the first rib and its cartilage.

Insertion: The subclavius inserts on the inferior surface of the middle of the clavicle.

Action: The subclavius action is to depress the clavicle (collarbone).

When the subclavius is in an abnormally contracted state, it draws the clavicle (and hence the shoulder) down and forward. It also lifts the first rib up into the thoracic outlet.

The subclavius muscle is the only muscle that can compress the interscalene triangle, the costoclavicular, and the subpectoral space!

I find incredibly inflamed subclavius spasms, which are the most difficult to reprogram, in 100 percent of the cases with thoracic outlet syndrome cases.

Why isn’t this muscle included in almost all the articles on non-surgical treatment of thoracic outlet syndrome?

Why aren’t doctors cutting this muscle out with patients with thoracic outlet syndrome?

You never see it mentioned with respect to doctors injecting it with analgesics as part of the treatment for compression of the thoracic outlet area. In my many years of examining the muscles in this area, the painful spasms of the subclavian muscle are the most consistent and persistent spasms that pulled the collarbone down into the thoracic outlet.

Also, the subclavius muscle swelling expands the thickness of the muscle, which causes narrowing and possible compression of the nerves and blood vessels underneath.

Common activities that stimulate the sustained contractions of your subclavius muscles, pectoralis minor muscles, the coracobrachialis, and biceps short head muscle to contract are when you reach out your arm to work with something for a long duration. Sustained contraction of the shoulder muscles can cause trigger points and super contractions that will depress the shoulder down into the thoracic outlet and tunnel, causing not only symptoms related to thoracic outlet syndrome but even symptoms that mimic a heart attack.

If you understand thoracic outlet syndrome, you know the focus is on treatment and surgical resection (removal) of the pectoralis minor. The pectoralis minor is NOT the main muscle that causes compression of this area.

If you look at the origin, insertion, and action of the biceps short head, the coracobrachialis, the pectoralis minor, the latissimus dorsi, the lower trapezius muscles, and the subclavius muscle, you will find they all depress the shoulder down into the thoracic outlet. In my opinion, it is just the muscle that is the easiest to surgically remove without so much permanent weakness in the shoulder girdle.

I have found that the subclavius muscle is one of the most responsible muscles for compressing the costoclavicular space.

Researchers from the Tokyo Medical and Dental University in Tokyo, Japan, found the aberrant subclavius muscle, which connected the first costal cartilage and the superior margin of the scapula on postmortem examinations (cadaver dissections). It’s normally connected to the collarbone. They found that this muscle was present in 8.9 percent of the 124 cadavers they checked, which is a lot (6).

They recommended doctors take into account the possible existence of such an aberrant muscle during the examination of patients with thoracic outlet syndrome, especially in those with symptoms of venous compression because it runs right over the top of the subclavian artery and brachial plexus (nerves that supply the arm) (6).

Now don’t all go out and get an MRI to see if you have this muscle thinking it is the cause of your thoracic outlet syndrome. If it is not in a spasm then it’s not compressing the vein or nerves even if it’s lying on top of them. If your doctor is thorough at examining the 10 muscles which can compress the outlet for spasms they will find it, treat it with my treatment approach in chapter 13 and it will stop compressing the outlet.

Multitasking

Multitasking can take place when someone tries to perform two tasks simultaneously, switch from one task to another, or perform two or more tasks in rapid succession (8).

Adults daily watch 212 minutes of video, including television, online video clips, and DVDs. That involves maintaining your body in one position for three-and-a-half hours. Again, as I’ve pointed out, if you’re not sitting perpendicular while watching television, the brain gets the message that you want your muscles to remain in constant contraction, again putting your spring in the compressed lockdown state (7).

Computer Age: Handheld Devices Add an External Load to the Shoulder

Excessive Smartphone and Cell Phone Use

Cell phones are mini-computers. So, cell phones, iPads, tablets, and other devices can be classified as computers.

According to the 2016 Nielson Total Audience Report, in 2016 the average American spent 10:39 hours per day on some media platform. These platforms consist of live TV, AM/FM radio, DVD, video games, multimedia devices, Internet on a PC, smartphone, and tablets.

The amount of time we watch TV was actually 20 minutes less, at 4 hours and 30 minutes per day.

The largest increases were with time spent on smartphones, which doubled from 47 minutes to 99 minutes per day. The use of tablets almost tripled from twelve minutes to thirty-one minutes from 2014 to 2016 (7).

This casual use of smartphones and tablets demands way more muscle contractions in the neck, shoulders, arms, forearms, and hands than the body can take. This is why so many people are coming down with thoracic outlet syndrome!

Text Messaging, Browsing, and Talking on Your Cell Phone

Text messaging is the most widely used mobile data service, with 74 percent of all mobile phones used worldwide or more than 5,000,000,000 phone subscribers as of 2017.

A study conducted by Dr. Deepak Sharan at the RECOUP Neuromusculoskeletal Rehabilitation Centre, Bangalore, India, titled “Risk Factors and Clinical Features of Text Message Injuries” revealed that 70.37 percent of users had development of myofascial pain syndrome in the thumb when using the cell phone too often (9).

Other associated problems diagnosed were thoracic outlet syndrome (51.85 percent), fibromyalgia syndrome (25.93 percent), wrist pain and tendonitis (14.81 percent), and thumb pain and tendonitis (7.41 percent) (9).

Children are getting operated on more and more for thoracic outlet syndrome. If you suspect your child has thoracic outlet syndrome, take the phone away and get him or her qualified help immediately before this gets out of control.

Illustration Custom Digital Comparison Normal to Weak Trapezius Another consequence of all these handheld devices is that we have to carry more items with us for hours every day, which can strain our upper backs, shoulders, and necks. Women commonly carry a heavy purse, which holds a cell phone, iPad, and recharging devices, along with another bag for the laptop and a bottle of water to stay hydrated so the skin doesn’t age.

The result of a heavier load on the shoulder is an earlier fatigue of the upper trapezius muscle, which is the principle muscle that suspends the shoulder above the thoracic outlet and tunnel. Commonly, these patient’s necks are so fatigued, they cannot hold their head up anymore. You see them leaning on a doorjamb while they are chatting with you, and they are seen holding their head up from their chin with their hands.

Dr. Sharan did a study to determine the prevalence of different musculoskeletal problems among Indian schoolchildren who carry backpacks. Results revealed that pain in the upper back (40 percent), neck (27 percent), and shoulder (20 percent) were the most prevalent affected body regions, followed by forearm and wrist pain (7 percent) and low back (6 percent). Results further revealed that all the students who participated in this study had a pressure mark over their shoulders. And 54.55 percent of the children were diagnosed with myofascial pain and the rest with thoracic outlet syndrome (10).

I was honored to be invited to speak to the delegates at Dr. Sharan’s medical conference in Bangalore, India, October 4–5, 2017, on thoracic outlet syndrome. He and I agree that the prevalence of thoracic outlet syndrome is higher than estimated in the population.

This can lead to temporomandibular joint (TMJ) dysfunction. If you have TMJ dysfunction, you have reduced your selection of qualified physicians to reverse this disorder to a fraction. There are only a handful of doctors in the world who treat this disorder effectively. It would be rare to have one where you live. In other words, keep your hands off your jaw!

The inflammation from the chronic neck pain, TMJ syndrome, and other conditions does damage to the skin that drinking water cannot reverse. Empty the purse, leave the water at home, so you can decrease the risk of an inflammatory condition making you feel and look older than you really are!

Break These Laws... Get Sentenced to a Lifetime of Suffering

Computer Work Is Linked to Health Problems

Occupational Injuries—Statistics

Muscular injury can occur when soft tissues are exposed to single or recurrent episodes of biomechanical overloading (11), which is characteristic of chronic musculoskeletal pain and thoracic outlet syndrome at work.

Direct US workers’ compensation costs total $51.1 billion, averaging more than one billion dollars per week (12). Soreness and pain accounted for 12 percent of the total cases (12).

Musculoskeletal disorders, often referred to as ergonomic injuries, accounted for 33 percent of all workplace injuries and illnesses requiring time away from work in 2011 (12). For all occupations, back injury accounted for 42 percent of the musculoskeletal disorder cases and required a median of seven days to recuperate (12).

The most severe myofascial pain syndrome cases occur in the shoulder, requiring an average of 21 days for the worker to return to work, and accounted for 13 percent of the musculoskeletal disorder cases (12).

Studies on muscle activity during computer use are in line with these findings, since they indicate a higher loading of the hand–arm region (extensors of the wrist) than of the neck–shoulder region (trapezius muscle) (13-15).

Holding your arm in one position outside of perpendicular can alter the position of the shoulder blade, especially when holding your arm above your head for long periods of time. This causes the brain to pattern this muscle contraction to a constant state, squeezing your shoulder down to your chest and ultimately leading to compression of this area and thoracic outlet narrowing.

Neck and Upper Extremity Problems—Workplace Stressors—Causes

One category of risk factors for neck, upper back, shoulder, and arm pain, is workplace stress.

Workplace stressors include high work demands, high mental processing, high memory demands, performing multiple tasks simultaneously, time pressure, low decision authority, and working too hard for too little pay (16–18).

First, muscle activity might be affected indirectly through a changed workstyle due to these stressors, for example, increased work pace, high forces on the keyboard and mouse, and more awkward and sustained postures (19).

The causes of workplace stressors are highly varied, but one of the common likely mechanisms is that stressors increase sustained muscle activity, which in turn might lead to injury by overexertion and brain patterning. Remember, any activity repeated consistently creates fixed patterns in the brain, whether this involves athletic movements, dance or gymnastics moves, or stressful input or activity in various aspects of daily life, including work and sleep.

If you continue to maintain a muscle in a contracted state, the brain says, “I sense that you are holding the muscle in your shoulder and arm and neck for a long period of time, so obviously you want me to continue to hold that muscle in the constant contracted state.” That’s the way your body and nervous system are designed, so that is what happens.

Neck and Upper Extremity Problems—Workplace Stressors—Work Style

Muscle activity might be affected indirectly through a changed work style due to these stressors (increased work pace, high forces on the keyboard and mouse, and more awkward and sustained postures), which can lead to fatigue and thus eventually cause musculoskeletal complaints (18–19).

Doctors think that continuously increased muscular activity can lead to fatigue and thus eventually cause musculoskeletal complaints. Mental stress combined with too much activity of the muscles of the hands, wrist, shoulders, and neck can lead to a higher risk for musculoskeletal complaints (20).

The Keyboard and the Mouse

Repetition Strain Injury—Keyboards

Work-related upper extremity disorders that result from keyboarding tasks are common (20). There are many ways your human spring mechanism can be locked up during simple typing at the computer.

• You have to hold the arm in a certain position to get your fingers on the keyboard, which strains your pectoralis minor muscle, the coracobrachialis muscle, and the long and short head of the bicep muscle.
• You have the activity of the fingers when you type, putting stress on the muscles involved, which are located in the forearm.
• You have the stress of holding your head in one position, which creates torsion strains as you try to hold your shoulders, arms, and hands to work the keyboard at the same time.
• You have the constant mental stress that affects your shoulders, abdominal muscles, and neck muscles—which is where a lot of us store our mental stress.

The result can be a complete lockdown of the entire upper half of your body.

Mouse Use Duration

Another factor is the mental strain of manipulating the mouse in the exact position required, combined with the constant concentration on what you are doing on the screen. You are straining the scalenes of the neck and straining the six muscles, which drag the shoulder into the outlet at the same time.

What could be worse? But if “too long” is a problem, exactly how long is too long?

One research study found an association between use of a mouse device for more than 20 hours per week and risk of possible carpal tunnel syndrome, rather than actual duration of keyboard use (22).

I’m not recommending that you should work 20 hours or less a week and then go home. I’m just informing you of what the study reveals.

Companies that require workers to do more than 20 hours a week of the same repetitive work would probably find they could increase productivity and decrease health problems by introducing more variety in their workers’ schedules.

Computer Use Duration

Another study showed an increased risk for developing severe hand–wrist pain in the highest exposure category, which was greater than 30 hours per week of the same repetitive activity (23). One particular study revealed that time spent working with the mouse and the keyboard was an excellent predictor of elbow and wrist/hand pain (23).

So, you are more at risk for arm and hand conditions than for neck and shoulder conditions when you work long hours (22) (23) (24).

Monitor Position and Visual Stressors Your position in front of a monitor, including height, determines whether you can get your head, neck, and spine in a perfect perpendicular position to lessen the strain on your body’s integrated spring.

I used to have a laptop about 10 years ago, but I could not get my head at the level of the center of the monitor without strain. At the time there was no “Cloud,” so I had to bring my iMac back and forth to work. I even carried it with me when I lectured at medical conferences in China, Australia, Dubai, South Africa, Monte Carlo, and other parts of the world.

Think I’m crazy? I don’t mind carrying the iMac to the car for five minutes to ensure I have 5–12 hours of no stress and strain on my human spring throughout the day.

Could you imagine seeing me get on a plane with an iMac in an overhead bag with the stand sticking out of the bag? Well, that’s what I did—and I only had a problem with one flight attendant, on a flight to Malaysia, during a period of many years. That was because they could not figure out how to get the videos to feed into my PowerPoint slides, as I lectured on walking and running patterns that cause chronic conditions.

People in my building see me going in and out of the elevator with this bag with my iMac hanging out the top. They frequently ask me why I’m doing this. I explain that looking down at a laptop causes strain on my integrated spring mechanism that can lead to compressive syndromes, such as thoracic outlet syndrome. I tell them that I’m writing a book on the topic. That’s when they ask me for my business card, because so many have neck pain, upper back pain, shoulder pain, and numbness. They wonder if it’s thoracic outlet syndrome. Too often, I still see them taking their laptops with them to work. Well, sooner or later, they will likely experience the discomfort of thoracic outlet syndrome. That’s the point when they will take out my card and contact me for an appointment.

1. Too Many Muscle Contractions without Adequate Rest Between Repetitive Movements We all probably know that proper resistance exercise consists of 8–15 repetitions, where we contract the muscle to lift the weight, then relax the muscle to allow it to recover for the next repetition. It is recommended that you rest, to allow recovery of the muscles, for approximately 60–90 seconds between sets.

What makes you think that more reps and sets are healthy for your workout?

Performing more repetitions can and does cause damage to the muscles. You know from the last chapter that damage causes inflammation, and that triggers the nociceptors to send an alarm to the brain. The alarm triggers a muscle contraction of the area, and soon it can become a super contraction that compresses the area.

I know you can’t stop working, but use your time wisely. Ask to switch jobs with someone else every other day and pace yourself. You might have to adopt the recommended self-help treatment approach I outline in Chapter 13, “What Works and Why?” as a routine to fend off the inevitable inflammation, so you won’t end up with a difficult thoracic outlet syndrome condition to treat later.

1. Repetitive Strained Motions on Muscles, Tendons, Ligaments, and Bones Oftentimes I catch patients, workers, and athletes performing movements that strain the muscles.

Movements that cause strain with the first repetition happen because we do not know the optimum orientation of the joints for the strongest movement with the least amount of strain.

I have outlined a lot of this in Chapter 14, “Spring Training,” where we discuss the proper form and technique for lifting with the arms, back, chest, neck, and shoulder muscles.

1. Single Overloading Strain on Muscles, Tendons, Ligaments, and Bones Auto Accidents and Sports Injuries Research suggests that thoracic outlet syndrome most frequently occurs following a single episode of neck trauma such as a sports injury.

Research suggests that thoracic outlet syndrome most frequently occurs following a single episode of neck trauma, such as a motor vehicle accident (25).

Motor vehicle accidents resulting in whiplash are the most common causes of neck injuries with approximately 1,000,000 per year in the US.

Motor vehicle accidents resulting in whiplash are the most common causes of neck injuries with approximately 1,000,000 per year in the United States (26).

An acute injury of the muscles and joints will stimulate the receptors in the joints to alert the brain that there is an injury. The brain will then respond with a sustained, tonic, protective reflex muscle spasm that will cause compression forces on the neck, back, and shoulder. These muscle spasms cause progressive narrowing of your thoracic outlet.

Quite often, injured car accident individuals had stopped for a red traffic light, when another vehicle hit them from behind. A force like this hyperextends the neck and stretches the scalenus muscles.

These muscles stretch, bleed, hypertrophy, and shorten. This process further narrows the already crowded triangular tunnel through which the neurovascular bundle passes (26).

Injuries like this, especially a blow or jerking injury to the region of the neck or shoulder, can cause a chronic muscle spasm—which might precipitate the syndrome (28). This can occur even with minor impacts during car accidents (29). By the way, according to statistics, persistent neck pain is more common in women than men by a ratio of 70:30 (26).

Acute (Whiplash) vs. Chronic Causes I’ve found that patients with whiplash show a distinct pattern of trigger point distribution that differs significantly from other patient groups and healthy subjects. The trauma might cause scalene muscle injury, resulting in swelling of the area of the anterior and middle scalene muscles. This will show up as swelling in the front of the neck. On lean individuals, you should be able to see the muscles through the skin in the front and sides of the neck.

The best way to tell if your neck is inflamed or swollen is to look at your neck and shoulders in the mirror or take a selfie to see if you can see the outline of the muscles in the neck and the outline of the collarbone.

Look for the outline of your neck and shoulder muscles and the collar bone in the mirror, to see if your neck may be infl amed or swollen.

If you can’t see the outline of your neck and shoulder muscles and the collar bone in the mirror, your neck may be infl amed or swollen.

If these structures are obscured, then perhaps you have inflammation of the area due to the injury of the scalene muscles and other muscles of the neck. For some of you, it might require you to look at old photographs to see if you had the swelling prior to the accident. In an auto accident injury like this, it is normal for scar tissue to form in the scalene muscles (30), which could result in less-flexible, toughened, stiff muscle tissue surrounding the bundle of nerves and the artery that comes out between these muscles. One study showed a significantly increased amount of muscle scarring in the scalene muscles in those with thoracic outlet syndrome compared to those without (30).

Why do auto accidents cause chronic musculoskeletal pain and chronic thoracic outlet syndrome in so many people? You have a similar impact force with tackles in contact sports like football, which should cause the same strain on the neck, upper back, and shoulder as an auto accident. The athletes seem to recover from 20 to 50 hits every week, while you might have one hit and you are in chronic pain for the rest of your life.

The reason they can handle these hits is because they are trained athletes, who train their upper body for these impacts. They have a greater amount of spring strength, improved resting tone, and spring stiffness to protect them from these hits. They prepare for the hits in their spring strength training.

Think about it—how many of you include shoulder shrugs to develop the trapezius and levator scapula to reduce the risk of the shoulder impacting or compressing the blood vessels and nerves in the thoracic tunnel?

I will teach you this training routine in Chapter 14, “Spring Training.”

More Nontraumatic Causes of Thoracic Outlet Syndrome: Large Breasts,

Breast Implants, and Large Arms Another factor that might cause sagging of the shoulder down into the thoracic outlet, in addition to stress and strain on the upper back and rib cage is heavy breasts in females (31) or large arms in both genders.

Strain on the shoulders may be decreased by wearing a good support bra with wide, crossed, back straps.

Wearing a good support bra with wide, crossed, back straps might decrease pressure and strain on these tissues (31).

Reduction mammoplasty or breast reduction has been recommended for extreme cases (31–33).

Surgical decompression should only be considered for those patients with true neurological symptoms, such as weakness and wasting of the hand intrinsic muscles (31).

Mental Stress There’s significant proof that inflammation can be caused by mental stress. There have been studies where people had their levels of inflammation checked through blood tests, proceeded to be involved in stressful situations, and were then retested. These tests revealed an increase in inflammation following the mentally stressful experiences (35).

Inflammation also is linked to mood disorders, such as depression, anxiety, and other disorders, along with practically every disease of aging, such as heart disease, stroke, and even cancers.

I’ve given lectures on the inflammation/depression connection at medical conferences in Melbourne, Australia; Bangkok, Thailand; and Kuala Lumpur, Malaysia. I read and studied more than 3,000 scientific papers to develop these lectures. There were many experts on Alzheimer’s disease, Parkinson’s disorder, and other neurologic disorders present in these audiences. When I spoke about the high levels of inflammation soaking the musculoskeletal system as a result of abnormal movement patterns, postures, stress, and anxiety, my presentations were well received and few of the experts who were present stated that they had not thought of this idea. Many of them went back to the drawing board with this new information—that might hopefully help to shed light on the big picture of the cause of depression, anxiety, Alzheimer’s disease, and Parkinson’s disorder.

Mental/Psychogenic So, it’s clear that high job stress and other mental stresses are consistently associated with upper extremity pain. Job demands are also associated with these disorders according to most studies (36).

Moreover, muscle activity might be affected directly without any change in posture or movement due to increased mental stress and other psychogenic mechanisms (37–39).

One study showed that arm stiffness was more frequent when an individual experienced increased mental stress (36). So, forearm muscle contractions might not only be the result of stressful movements, but also occur indirectly as a result of thoughts and emotional stressors.

So now, let’s make a list of all the activities that increase the risk of thoracic outlet syndrome and get a game plan together to eliminate them from our activities of daily living.

How You Can Abide by the Laws of Gravity Sitting Rules

1. Never touch your back to the back of the chair.
2. Give your recliner to someone you don’t like.
3. Relax to let your reflexes determine perfect stress-free, strain free, equilibrium posture.
4. Your body parts should either be perpendicular or horizontal to gravity, and joints should be at 90-degree angles.
5. Keep your feet on the floor or on a footrest, if they don’t reach the floor.
6. Rest your arms on the armrest to lift your shoulders off your chest.
7. Make sure the chair has an even platform.
8. Do not cross your legs at the knees or the ankles.
9. Get up and walk around every 25 minutes.
10. Never twist your back against the chair.
11. Distribute your body weight evenly on both hips.

Correct Driving Position

1. When driving, press the accelerator and the brake with your foot and not your leg.
2. Do not work in your car.
3. Do not lean your seat back.
4. Do not lean into your armrests.

Sleeping

1. Choose a firm mattress.
2. Take the television out of the bedroom.
3. Sleep with a pillow.
4. Check your pillow thickness every two weeks. Take a photo of yourself lying on the pillow to ensure your head is horizontal.
5. Thicken your pillow with a towel if it gets too thin.
6. Do not sleep on your stomach.

Standing

1. Wear shoes with extended, medial, heel stabilizers.
2. Do not stand too long.
3. Stand on the balls of the feet.
4. Don’t shift weight to one side.
5. Set objects down as soon as possible.

Desk/Computer Work

1. Don’t use a laptop.
2. Plug the laptop into a full-size monitor that allows you to view the screen at eye level.
3. When you are done with the mouse and keyboard, take your hands off and rest your arms and hands on the arm rest of the chair.

Stress and Inflammation

1. Get your levels of inflammation tested.
2. Remove lifestyle choices that might be a source of inflammation.
3. Start eliminating the sources of inflammation.
4. Take regular deep breaths.

Important!

Accelerated aging is characterized by chronic, higher than normal levels of inflammation, termed as “inflammaging.” Inflammaging is a highly significant risk factor for conditions and diseases such as brain fog, chronic fatigue, depression, hardening of the arteries and many other diseases of aging.

So if your muscles around your head and neck are soaking in inflammation it’s easy to understand why you may feel down, lack energy or even fall into a depressed state. Read Anthony Fields book, How I Got My Wiggle Back, to find out how he overcame chronic fatigue, fibromyalgia and even 20 years of clinical depression by focusing on the reduction of inflammation.

The United States Department of Labor Occupational Safety and Health Administration (OSHA) Good Working Positions (40)

• “Hands, wrists, and forearms are straight, in-line and roughly parallel to the floor.
• Head is level, or bent slightly forward, forward facing, and balanced. Generally, it is in-line with the torso.
• Shoulders are relaxed and upper arms hang normally at the side of the body.
• Elbows stay in close to the body and are bent between 90 and 120 degrees.
• Feet are fully supported by the floor or a footrest may be used if the desk height is not adjustable.
• Back is fully supported with appropriate lumbar support when sitting vertical or leaning back slightly.
• Thighs and hips are supported by a well-padded seat and generally parallel to the floor.
• Knees are about the same height as the hips with the feet slightly forward.”

The OSHA Positions were determined by people and people make mistakes. Here is where I agree with OSHA and where I do not and why.

• Hands, wrists, and forearms — I agree.
• Head and torso— I disagree - If your head and upper body is bent slightly forward the muscles of the upper back and neck will be in a constant contraction attempting to maintain your head from falling forward. You should just stack your head directly you’re your neck and relax. Remember “Stack and Relax”.
• Shoulders and upper arms— I disagree - Your arms should not hang, as this causes fatigue in your trapezius and levator scapula muscles. Rest your arms on the arm rests.
• Elbows — I disagree - The elbows should be exactly at 90 degrees slightly above the desktop.
• Feet — I agree.
• Back — I disagree - Your back should never be supported. Your abdominal muscles support your back.
• Thighs and hips — I agree.
• Knees and feet — I disagree - All your body parts should be either horizontal or perpendicular and never on angles for an extended period of time.

If OSHA wants to challenge me on my opinions, I can prove with surface EMG testing their sitting recommendations will lead to sustained contractions of muscles therefor sustained strain on the muscles, ligaments, tendons and bones. Id love to do a study with them to prove it.

If you go to the OSHA web site listed below and look at the Computer Stations eTool you will see 4 examples of body posture changes that all provide neutral positioning for the body.

1. Upright Sitting – In this photo they say its ok to lean back on the back rest. This causes the body to lean back out of the perpendicular position. In this position the 9-12 pound head is held in a sustained angled position forcing the anterior cervical, anterior and middle scalene muscles to remain in a sustained contraction. Never sit this way.

Sitting in this position could cause and will exacerbate a thoracic outlet syndrome.

1. Standing – Standing for a sustained period of time will strain the tibialis posterior, tibialis anterior, peroneus longus, peroneus brevis muscles or what I call the arch spring suspension muscles. This constant strain on the arch of the foot can also stretch and strain the ligaments of the foot and lead to a drop and lock of the joints of the arch causing abnormal motion during walking.

Conditions caused by sustained standing include plantar fasciitis, ankle pain, knee pain, chondromalacia patella, illiotibial band syndrome, hip and lower back pain, varicose veins and more.

1. Declined Sitting – In this position the legs are not horizontal and perpendicular. If the body senses you could slide forward the gluteal muscles will contract constantly to prevent this.

Sitting for long periods of time in this position can cause lower back and hip pain.

1. Reclined Sitting – This position is the absolute worse position to sit in if you would like to prevent neck strain, neck pain, scalene spasms leading to a possible thoracic outlet syndrome or exacerbation of thoracic outlet syndrome.

Again, in this position the 9-12 pound head is held in a sustained angled position forcing the anterior cervical, anterior and middle scalene muscles to remain in a sustained contraction.

Never sit this way at work, home or anywhere. If you do you will never reverse a TOS no matter how many treatments you get.

OSHA should delete this article and apologize for misguiding the public on “good working positions”

If you are the safety director for a company and would like me to do a fun and informative workshop for your workers on on how to avoid workplace injuries, please contact us at teamdoctors@aol.com.

Let’s spring to action on this!