If You Don't Live in Harmony with Gravity... You May Spend a Lifetime Suffering.

Activities of Daily Living That Increase the Risk, Cause, or Perpetuate Thoracic Outlet Syndrome (TOS)

In this chapter, you will learn new ways of thinking about what lifestyle choices, daily activities, posture, ergonomics, movement patterns, and body mechanics to adopt so you don't cause additional compression of your human spring, brachial plexus, nerves, arteries, veins, blood vessels, or thoracic outlet. These principles form the foundation of thoracic outlet syndrome recovery and help reduce thoracic outlet compression before it becomes chronic.

You should find this all makes sense because it follows the basic principles of the laws of physics, the laws of nature, biomechanics, human movement, and engineering that are easy for anyone who is a logical thinker to grasp. These same scientific principles explain why poor posture, abnormal movement patterns, and repetitive strain contribute to thoracic outlet syndrome (TOS), nerve compression, and chronic neck and shoulder pain.

In this chapter, I will point out the most common activities of daily life, poor posture, repetitive movements, ergonomic mistakes, and movement dysfunctions that put your spring in a position to trigger the strain receptors that create reflex muscle spasms from the brain, leading to increased compression of your neck, shoulder, upper back, brachial plexus, blood vessels, and thoracic outlet. Understanding these everyday habits is one of the most effective ways to prevent brachial plexus compression, vascular compression, and thoracic outlet syndrome symptoms from becoming progressively worse.

I am going to teach you what to do and what not to do to reduce compression, improve posture, restore healthy biomechanics, and help reverse thoracic outlet syndrome naturally through better movement, posture correction, and body mechanics. These practical strategies complement non-surgical thoracic outlet syndrome treatment by addressing the mechanical causes of compression.

The human body is an object that exists on the planet Earth. Therefore, it is subjected to the same laws of physics, gravity, and nature as any other object. Breaking these laws prevents your body from functioning in harmony with gravity and instead can imprison you in a jail cell of chronic pain, nerve compression, muscle tension, inflammation, vascular compression, and thoracic outlet syndrome. Restoring proper alignment allows your body to move more efficiently while reducing unnecessary stress on your muscles, nerves, and blood vessels.

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 both a mechanical lever system and an integrated spring mechanism. Muscle tension is regulated by your brain and nervous system according to the laws of nature. Understanding how the laws of physics, biomechanics, ergonomics, and human movement apply to the human body is the key to reducing compression, improving posture, restoring normal function, and supporting long-term thoracic outlet syndrome recovery.

Because you are a spring, you must learn to read your "owner's manual" to fully understand how your human spring works, the important functions it serves, how it breaks down and locks, how it creates compression, and how it affects so many aspects of your health, posture, movement, athletic performance, recovery, and thoracic outlet syndrome. Understanding how your body is engineered and how your nervous system reacts to changes in body position relative to gravity is an essential part of that owner's manual. This knowledge helps explain why proper posture, healthy movement patterns, and good ergonomics are essential for reducing nerve compression and restoring normal function.

I tell my patients all the time, "If you do not learn how the human spring works and how your posture, body position, and movements during everyday activities, such as sleeping, sitting, standing, walking, lifting, reaching, and working at a computer affect 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 moves away from its normal position relative to gravity, I correct it immediately. I don't want to be blamed for why the treatment did not correct the thoracic outlet syndrome. That is how important proper posture, biomechanics, ergonomics, body mechanics, and movement are to successful thoracic outlet syndrome treatment and long-term recovery.

Once you learn how to work with these protective reflexes, improve your posture, reduce unnecessary muscle tension, restore normal movement patterns, and eliminate the mechanical causes of compression, you will finally be able to live a more stress-free, strain-free, pain-free life. As compression decreases, your nerves and blood vessels can function more normally, allowing your thoracic outlet syndrome symptoms, neck pain, shoulder pain, arm pain, numbness, tingling, and weakness to finally begin to resolve naturally.

Activities of Daily Life That Cause Compression of Your Human Spring

In Chapter 5, you learned that the primary cause of compression of your magnificent human spring is abnormal muscle super contractions, chronic muscle spasms, and excessive muscle tension. These muscle spasms are created and programmed into your body as a result of the activities, posture, repetitive movements, injuries, and physical stresses of everyday life.

• Sustained muscle contractions caused by prolonged sitting, poor posture, computer work, smartphone use, driving, and repetitive occupational activities.
• An unhealthy number of repeated muscle contractions without adequate rest or recovery, resulting in muscle fatigue, chronic muscle tension, overuse injuries, and repetitive strain injuries.
• Repetitive strain injuries caused by repeated stressful motions affecting muscles, tendons, ligaments, joints, nerves, fascia, and bones, leading to chronic compression and thoracic outlet syndrome.
• A single overloading strain or traumatic injury to muscles, tendons, ligaments, joints, bones, or the cervical spine, such as whiplash injuries, sports injuries, falls, work injuries, or motor vehicle accidents, that can trigger chronic muscle spasms and thoracic outlet compression.

1. 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 and nutrients to the muscle fibers that were depleted of oxygen during exercise. This recovery period helps improve blood circulation, muscle recovery, athletic performance, and exercise endurance while reducing excessive muscle fatigue.

If the activity involves healthy alternating phases of muscle contraction and muscle relaxation, as in the case with most repetitive resistance training and strength training exercises, then blood flow will proceed during the relaxation phases and decrease the likelihood of muscle fatigue being produced by a lack of oxygen in the muscle, leading to trigger points, muscle tightness, muscle spasms, and eventual super contractions. This natural pumping mechanism is one reason why dynamic exercise generally produces less muscle stiffness than prolonged static contractions.

However, if the exercise involves sustained (isometric) muscle contractions lasting more than about six seconds, this circulatory cause of muscle fatigue becomes significant. This explains why activities involving sustained contractions result in more rapid and more severe muscle fatigue than dynamic activity. The lack of healthy blood flow back into the muscle reduces oxygen delivery, decreases circulation, increases the accumulation of metabolic waste products such as lactic acid, and contributes to muscle trigger points, chronic muscle tension, myofascial pain, muscle stiffness, and delayed muscle recovery. Over time, these changes can also contribute to chronic neck pain, shoulder pain, and thoracic outlet syndrome by increasing compression around the nerves and blood vessels.

The best example of a sustained, tonic, or isometric muscle contraction is when the muscle contracts to one length and stays at that length so your bones do not 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, spinal stability, cervical posture, shoulder posture, and overall postural control. Although these contractions are necessary for normal function, they become harmful when maintained for prolonged periods without opportunities for muscle relaxation and healthy blood flow.

These tonic, sustained muscle contractions can lead to the formation of trigger points, chronic muscle tightness, muscle spasms, muscle fatigue, myofascial pain, reduced circulation, and the super contractions mentioned in the last chapter. They are a common mechanical contributor to postural dysfunction, chronic pain, and thoracic outlet syndrome because prolonged muscle tension increases compression on the brachial plexus and surrounding blood vessels.

Examples of tonic, sustained contractions in daily life include:

• Holding a cell phone to your ear for an extended period.
• Holding a book, tablet, or electronic device.
• Carrying a purse, backpack, briefcase, or shopping bag on one side.
• Gripping a steering wheel during long drives.
• Holding tools or equipment while working.
• Holding any object for a prolonged period of time without allowing the muscles to relax.

Another common example occurs when muscles contract continuously to maintain a sitting posture, standing posture, computer posture, driving posture, or any prolonged static posture. Poor ergonomics, poor posture, and prolonged sitting force the postural muscles to remain in sustained contraction, reducing circulation and increasing the risk of muscle fatigue, trigger points, chronic neck pain, shoulder pain, upper back pain, and thoracic outlet syndrome. Learning to interrupt these prolonged contractions with frequent movement, posture correction, and brief recovery breaks is one of the simplest ways to reduce muscle tension and improve long-term musculoskeletal health.

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 sustained muscle contraction, chronic neck muscle tension, and compression of the cervical joints, cervical spine, thoracic outlet, and interscalene triangle. Equilibrium posture during sleeping is when there is an equal amount of tension in all neck muscles. Maintaining this neutral sleeping posture helps reduce nerve compression, supports healthy cervical alignment, and may decrease the likelihood of developing thoracic outlet syndrome, chronic neck pain, and shoulder pain.

Pillows are intended to support the head and neck in a neutral sleeping position to minimize biomechanical stress on the cervical spine, cervical discs, cervical joints, neck muscles, and other cervical structures while sleeping. That is because they maintain the neck in a horizontal position relative to gravity. A properly fitted pillow helps preserve normal cervical posture, reduces unnecessary muscle tension, and supports healthy sleep ergonomics throughout the night.

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. Studies such as these help identify the best pillow for neck pain, improved sleeping posture, and long-term cervical spine support.

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 neck pain, shoulder pain, neck stiffness, headaches, and other 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. These findings suggest that pillow design and the ability to maintain proper cervical alignment may be more important than simply choosing a contour-shaped 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 determine whether your head is level, angled above horizontal, or below horizontal. Your goal is to maintain a neutral cervical spine position that minimizes muscle activity and reduces stress on the neck, shoulders, brachial plexus, and thoracic outlet.

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 must contract continuously throughout the night in an attempt to maintain your 9–12-pound head in the horizontal position, increasing sustained muscle contraction, muscle fatigue, neck pain, cervical muscle tension, and the risk of thoracic outlet syndrome. A pillow that loses its support can gradually contribute to poor sleeping posture, cervical muscle fatigue, brachial plexus compression, and chronic neck pain.

It is common to find many people who develop the chronic habit of sleeping with the arm above the head or under the pillow. Poor posture while sitting or standing happens when you lean your body outside a position perpendicular to the pull of gravity. Poor sleeping posture occurs when you position your body or head outside a perfectly horizontal position relative to gravity. Poor sleeping posture can contribute to thoracic outlet syndrome (1), chronic neck pain, shoulder pain, arm pain, arm numbness, tingling hands, weakness, and compression of the brachial plexus. Oftentimes, this habit develops because people unconsciously lift a flattened pillow to keep the head level and reduce 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 sleeping on your stomach. Pillows may also be placed under each arm when lying on your back (2) to reduce shoulder strain, decrease compression around the brachial plexus, improve sleeping posture, and help maintain neutral spinal alignment throughout the night.

One thing that has helped me in those situations is to place a folded towel beneath the base of the pillow between the pillow and pillowcase to restore its thickness. This helps maintain the head and neck in a neutral horizontal position, reducing sustained muscle contraction, cervical muscle fatigue, nerve compression, and compression of the thoracic outlet. Maintaining proper pillow height is one of the simplest ways to improve sleep posture, reduce thoracic outlet syndrome symptoms, and support long-term cervical spine health.

Standing Posture, Sitting Posture, and Sustained Contraction

The neck is the most complex musculoskeletal system in the body. The cervical spine contains 37 joints and seven cervical discs, which are described in the Human Spring Model as compression springs. The scalene muscles, cervical muscles, shoulder muscles, and upper back muscles provide balance and control of the head on top of the spine, allowing you to remain perpendicular to Earth's gravity every second you are upright.

The key to maintaining perfect postural balance and equilibrium in the neck, upper back, and shoulder muscles is to keep your base of support (buttocks), center of gravity, and head aligned perpendicular to gravity. This posture also maintains your eyes level with the horizon and minimizes sustained muscle contraction, muscle fatigue, cervical strain, and compression of the thoracic outlet.

The muscle spindles in the neck and the six living spring or bubble levels (vestibular system) continuously send messages to the reflex centers of your brain. Whenever your body leans to one side, the vestibular system detects the tilt of the head while the muscle spindle cells detect increased muscle tension and strain in the neck.

Within a fraction of a second, the brain activates the righting reflex, triggering reflex contraction of the neck muscles on the opposite side to restore the head to a position perpendicular to gravity. This automatic righting reflex helps maintain posture, balance, spinal alignment, and equilibrium, as discussed in Chapter 4.

The Rules of Gravity and the Righting Reflex

• Body leaning to the right causes sustained contraction of the left scalene muscles, tilting the head to the left, increasing muscle super contractions, chronic muscle tension, brachial plexus compression, compression of the interscalene triangle, and the risk of developing left-sided thoracic outlet syndrome.
• Body leaning to the left causes sustained contraction of the right scalene muscles, tilting the head to the right, increasing muscle super contractions, chronic muscle tension, brachial plexus compression, compression of the interscalene triangle, and the risk of developing right-sided thoracic outlet syndrome.

• Sitting with the body leaning backward causes the scalene muscles and anterior neck muscles to contract continuously. These sustained muscle contractions, chronic muscle spasms, trigger points, and muscle super contractions can compress the thoracic outlet, narrow the interscalene triangle, compress the brachial plexus and subclavian blood vessels, and contribute to thoracic outlet syndrome symptoms, including neck pain, shoulder pain, arm numbness, tingling hands, and weakness.

Compression of the Interscalene Triangle

(Office Syndrome, Forward Head Posture, Neck Pain, and Thoracic Outlet Syndrome)

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 bed. Here is one of the most important rules you must follow to reverse thoracic outlet syndrome (TOS), chronic neck pain, shoulder pain, upper back pain, arm numbness, and hand tingling. When sitting anywhere (car, couch, bed), you cannot allow your back to touch the seat back. If you do, your human spring has drifted outside perpendicular, causing the sensory system to trigger a sustained muscle contraction in an attempt to return your head to a perpendicular position relative to gravity.

One of the most critical mistakes patients make that contributes to thoracic outlet syndrome, neurogenic thoracic outlet syndrome, chronic neck pain, tension headaches, and cervical muscle strain is watching television or reading while leaning back on the couch or in bed propped against the headboard.

A telltale sign is when patients go to bed with minimal or no thoracic outlet syndrome symptoms and wake in the morning with neck pain, shoulder pain, arm numbness, tingling hands, headaches, or upper back pain (3). This indicates that the cause of these conditions is closely related to sleep posture, sleeping position, poor posture, forward head posture, or activities that overload the scalene muscles and cervical muscles immediately before bedtime, such as leaning back in bed while watching television or reading.

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

I handed him a 10-pound weight. "Now bend your arm and hold this weight in front of you while I treat another patient." Within about five minutes he asked if he could put it down because of muscle fatigue, muscle burning, muscle strain, and muscle pain.

The average human head weighs approximately 9–12 pounds. So why wouldn't you expect to develop myofascial trigger points, chronic muscle spasms, scalene muscle spasms, cervical muscle spasms, muscle tightness, and sustained muscle contractions when you ask your neck muscles to support a 9–12-pound weight outside a perpendicular position for 30 minutes or longer?

I can predict with nearly 100 percent accuracy not only how patients lean while sitting but also which side of the body their thoracic outlet syndrome symptoms, neck pain, shoulder pain, arm numbness, brachial plexus compression, and nerve compression will be worse.

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

The scalene muscles, sternocleidomastoid (SCM) muscles, anterior cervical muscles, posterior cervical muscles, and deep neck flexor muscles control movement of the head during flexion, extension, side bending, and rotation. There is also a group of smaller muscles known as the suboccipital muscles, which help maintain the head in the most efficient, stress-free, and strain-free position relative to gravity.

The suboccipital muscles are located at the base of the skull and contain one of the highest concentrations of muscle spindles (proprioceptors) found anywhere in the human body. These sensory receptors function as highly sensitive strain gauges that constantly send information to the brain, spinal cord, and central nervous system regarding the position of your head, neck posture, muscle tension, and movement relative to gravity.

Muscle spindles are stretch-sensitive sensory receptors that provide the brain and spinal cord with continuous information about muscle length, muscle tension, muscle stretch, posture, balance, movement, and speed of contraction. They play an essential role in maintaining postural control, head position, spinal alignment, proprioception, and normal biomechanics throughout every second of the day.

When abnormal posture persists, these protective reflexes create powerful muscle contractions and muscle spasms between the occiput (base of the skull), atlas (C1), and axis (C2). These sustained contractions pull the skull closer to the upper cervical spine, increasing upper cervical compression, nerve compression, joint compression, and muscle tension, which commonly results in tension headaches, cervicogenic headaches, neck pain, and occipital headaches.

As pressure continues to increase, these headaches can become severe enough to closely resemble migraine headaches, migraine symptoms, dizziness, lightheadedness, nausea, and vertigo. In many patients, these severe headaches are incorrectly diagnosed as migraines when the true source may be upper cervical muscle spasms, suboccipital trigger points, cervical joint dysfunction, or chronic muscle tension.

Many patients who have experienced whiplash injuries, motor vehicle accidents, head trauma, concussion, or cervical spine injuries complain of chronic dizziness, vertigo, headaches, poor balance, and nausea for years afterward. These symptoms may result from injury to the upper cervical joints, suboccipital muscles, muscle spindles, proprioceptors, and cervical sensory receptors.

That is why it is essential to evaluate patients for active and latent suboccipital trigger points, scalene muscle spasms, sternocleidomastoid trigger points, upper cervical dysfunction, and muscle tension, because these conditions can compress nerves at the base of the skull and contribute to tension headaches, cervicogenic headaches, dizziness, vertigo, neck pain, thoracic outlet syndrome symptoms, and chronic upper cervical pain.

Standing Posture and Sustained Contraction

Most of us have a favored leg to support our body weight 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 posture. If your body leans in one direction, the righting reflex triggers a sustained contraction of the muscles on the opposite side of the neck to keep the head level with the horizon. This prolonged muscle contraction can increase tension throughout the neck, shoulders, and upper back, contributing to thoracic outlet syndrome (TOS), chronic neck pain, shoulder pain, upper back pain, nerve compression, and brachial plexus compression. 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 a scale, elbow locked, and palm up, so you aren't touching the floor. Your arms can typically weigh more than your head. This demonstrates how much weight your shoulder support muscles must suspend throughout the day to maintain healthy posture and normal shoulder mechanics.

Your upper trapezius and levator scapulae muscles suspend the arms. These muscles must maintain a sustained contraction to support the weight of the arms hanging from the center spring. These are also the two primary muscles that suspend the shoulder girdle above the thoracic outlet and thoracic outlet tunnel. When these muscles become fatigued, they allow the shoulder girdle to drop, increasing compression on the brachial plexus, subclavian artery, and subclavian vein, which can contribute to neurogenic thoracic outlet syndrome, venous thoracic outlet syndrome, arterial thoracic outlet syndrome, shoulder pain, arm numbness, hand tingling, chronic neck pain, and nerve compression.

As the shoulder girdle gradually drops because of muscle fatigue, poor posture, or prolonged sustained muscle contraction, the amount of compression placed on the nerves and blood vessels passing through the thoracic outlet can progressively increase. This is one reason why maintaining good posture, healthy shoulder mechanics, and adequate muscle endurance is essential for thoracic outlet syndrome prevention and long-term recovery.

So, if you have muscle superspasms pulling your shoulder down into the thoracic outlet and your levator scapulae, upper trapezius, and supporting shoulder muscles are too weak and fatigued to suspend the shoulder above the thoracic outlet and tunnel, you have effectively doubled the compressive forces on the thoracic outlet, increasing the risk of thoracic outlet syndrome symptoms, brachial plexus compression, blood vessel compression, chronic neck pain, shoulder pain, arm pain, hand tingling, weakness, and chronic musculoskeletal pain.

There is an orthopedic test called the Cyriax test used to determine whether a fatigued trapezius muscle is allowing the shoulder to drop into the thoracic outlet and tunnel. It involves passive elevation of the arms and shoulders from the elbows to remove the weight of the upper extremities from the thoracic outlet. If the thoracic outlet syndrome symptoms, such as arm numbness, hand tingling, shoulder pain, neck pain, or weakness, subside, the test is considered positive. This simple clinical test demonstrates how reducing the downward load on the shoulder girdle can immediately decrease nerve compression and vascular compression within the thoracic outlet.

There are many occupations that require prolonged arm elevation or sustained shoulder contraction, increasing the risk of thoracic outlet syndrome, repetitive strain injuries (RSIs), chronic muscle fatigue, shoulder dysfunction, and postural overload. These include barbers, hairdressers, dentists, dental hygienists, physiotherapists, physical therapists, massage therapists, assembly line workers, switchboard operators, painters, masons, forestry workers, computer operators, office workers, secretaries, musicians, surgeons, and other professionals who spend long periods with their arms unsupported or elevated (4-5). Individuals in these occupations should pay particular attention to ergonomics, posture correction, shoulder strengthening, and regular movement breaks to reduce sustained muscle contraction and lower the risk of developing thoracic outlet syndrome and other repetitive strain disorders.

I have been invited to work on more than 100 concert tours where one or more musicians suffered from chronic neck pain, upper back pain, shoulder pain, repetitive strain injuries, and thoracic outlet syndrome. Professional musicians are particularly vulnerable because of the prolonged static postures required to play their instruments.

My ex-wife, Michelle McGovern, is an accomplished flute player. I remember her six-hour practice sessions with her arms held in one position for extended periods. This prolonged static posture created sustained muscle contraction throughout the neck, shoulders, upper back, and forearms.

It used to be that the severity of thoracic outlet syndrome symptoms was directly related to the amount of time musicians practiced. Not anymore. Today, you must also consider the cumulative effects of computer use, driving, carrying heavy instrument cases, watching television in bed, prolonged smartphone use, texting, and poor posture throughout the day. One violin player developed such severe forearm muscle spasms that she developed pitting edema, demonstrating how prolonged muscle contraction can interfere with normal circulation and lymphatic drainage.

If you are a musician and must practice 6–8 hours per day, there is no escaping muscle fatigue and muscle spasms unless you actively recover between sessions. For those who are not in Chicago and cannot find an experienced practitioner, I recommend using the Vibeassage® or Vibeassage Pro® before and after practice sessions to help reduce muscle tension, improve circulation, decrease muscle tenderness, and support recovery until all areas of tenderness have resolved.

• When you carry a heavy purse, shoulder bag, backpack, briefcase, camera bag, or laptop bag on one shoulder, such as a 10-pound purse on the left shoulder, the upper trapezius, levator scapulae, and scalene muscles on that side must sustain a prolonged contraction to support the additional weight, increasing compression on the thoracic outlet, brachial plexus, and surrounding neurovascular structures.
• Most importantly, your head tilts in the opposite direction to counterbalance the added weight. This compensatory posture creates an additional sustained contraction of the neck muscles, effectively doubling the compressive forces acting on the thoracic outlet, neck, shoulders, upper back, and surrounding nerves and blood vessels, increasing the likelihood of developing thoracic outlet syndrome, chronic neck pain, shoulder pain, arm numbness, tingling hands, headaches, and muscle fatigue.

The best option is to lighten the load and set the object down as soon as possible to minimize sustained muscle contraction and reduce compression on the thoracic outlet. Ask yourself whether you really need to carry every item. For example, you probably don't need to carry a bottle of water in your purse all day. Reducing unnecessary weight is one of the simplest ways to decrease chronic muscle tension, improve posture, and help prevent thoracic outlet syndrome, chronic neck pain, shoulder pain, and repetitive strain injuries.

Sustained Contraction of the Shoulder Muscles

When you reach your arm and hand forward in front of your body beyond the perpendicular position for longer than a few minutes, you engage a sustained contraction of muscles that depress and compress the shoulder down into the thoracic outlet, thoracic tunnel, costoclavicular space, and subpectoral space, increasing the risk of thoracic outlet syndrome (TOS), brachial plexus compression, and subclavian artery and vein compression.

When you reach your arm forward to manipulate an object in front of you, such as a computer keyboard, computer mouse, smartphone, tablet, steering wheel, or handheld device, a series of muscle contractions occur that can cause narrowing of the costoclavicular space, thoracic outlet, thoracic tunnel, and subpectoral (pectoralis minor) space.

• The lower trapezius and latissimus dorsi contract to pull the shoulder girdle downward to stabilize and anchor the shoulder to the chest, providing a solid platform to counterbalance the weight of the shoulder and arm. This prolonged contraction contributes to shoulder depression, thoracic outlet compression, and nerve and blood vessel compression.
• The pectoralis minor, coracobrachialis, and short head of the biceps brachii anchor the scapula to the chest wall to maintain a stable platform during shoulder flexion. Chronic shortening and spasm of these muscles contribute to pectoralis minor syndrome, thoracic outlet syndrome, brachial plexus compression, and narrowing of the subpectoral space.
• The subclavius muscle stabilizes the clavicle to the first rib. During prolonged contraction, it elevates the first rib into the thoracic outlet while simultaneously pulling the clavicle downward, contributing to costoclavicular compression, thoracic outlet syndrome, subclavian artery compression, subclavian vein compression, and brachial plexus compression.

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

• The longer the muscles remain contracted.
• The longer the muscles remain contracted, the greater the muscle spasm, muscle tightness, and muscle shortening.
• The greater the muscle spasm, the more deeply the abnormal movement pattern and muscle contraction reflex become programmed into the nervous system.
• The deeper the reflex becomes programmed, the longer it takes to restore normal movement and muscle function.
• The longer it takes to restore normal movement, the less successful physical therapy, rehabilitation, corrective exercise, stretching, and conservative treatment for thoracic outlet syndrome become.
• The more conservative treatment and physical therapy sessions fail, the greater the likelihood of living with chronic thoracic outlet syndrome, chronic neck pain, chronic shoulder pain, chronic upper back pain, or undergoing thoracic outlet syndrome surgery that may never have been necessary.

Ma'am, please remove your hand from the smartphone, computer mouse, computer keyboard, tablet, or handheld device before somebody gets hurt.

Other muscles, when chronically shortened or constantly contracted, can also contribute to narrowing of the costoclavicular space. The pectoralis minor, short head of the biceps brachii, coracobrachialis, subclavius, and anterior neck muscles work together to pull the clavicle downward into the thoracic outlet and thoracic tunnel, increasing compression of the brachial plexus, subclavian artery, and subclavian vein. These muscles commonly remain in a prolonged state of contraction during activities requiring the arms to be held in front of the body, including computer work, smartphone use, gaming, driving, office work, and repetitive reaching activities.

Costoclavicular Space Compression and Subpectoral Space Compression

Narrowing of the subpectoral (pectoralis minor) space commonly results from shortening, tightness, and chronic spasm of the pectoralis minor muscle (30). The hypercontracted pectoralis minor, subclavius, coracobrachialis, and short head of the biceps brachii work together to compress the thoracic outlet, subpectoral space, and costoclavicular space. The swollen, inflamed, and hypercontracted pectoralis minor muscle alone may compress the brachial plexus, subclavian artery, and subclavian vein as they pass beneath it, producing the signs and symptoms of pectoralis minor syndrome and thoracic outlet syndrome.

A large percentage of people spend hours every day using smartphones, mobile phones, tablets, laptop computers, desktop computers, video game controllers, and other handheld electronic devices. These activities are recognized risk factors for repetitive strain injuries, neck pain, shoulder pain, upper back pain, thoracic outlet syndrome, pectoralis minor syndrome, forward head posture, rounded shoulders, and other musculoskeletal disorders.

Place your hand on the opposite side of your chest just below your collarbone. Now raise the arm on that side until your hand is at eye level, as though you are looking at your smartphone, tablet, or computer screen. You should feel a firm muscle contraction beneath your hand. This is your pectoralis minor muscle, one of the primary muscles responsible for thoracic outlet compression.

These muscles contract to lock the shoulder to the chest wall, creating a stable platform that allows you to support your approximately 10-pound arm away from your body's center of gravity. The farther the arm moves from the body, the greater the mechanical load placed on the shoulder. Your brain interprets this prolonged muscle activity as a normal movement pattern, reinforcing the abnormal muscle contraction associated with thoracic outlet syndrome and repetitive strain injuries.

This prolonged contraction can also shift or lock ribs three, four, and five, leading to pain between the shoulder blades, rib pain, chest pain, upper back pain, mid-back pain, pain around the sternum (breastbone), difficulty taking a deep breath, shortness of breath, and symptoms that mimic a heart attack. Many people seek emergency medical care believing they are having a heart attack, only to discover their heart is normal.

The Most Hypercontracted Muscle in Thoracic Outlet Syndrome: The Subclavius Muscle

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

Insertion: The subclavius inserts on the inferior surface of the middle third of the clavicle (collarbone).

Action: The primary action of the subclavius muscle is to depress and stabilize the clavicle (collarbone).

When the subclavius muscle becomes chronically shortened, hypercontracted, or goes into muscle spasm, it pulls the clavicle and shoulder downward and forward while simultaneously elevating the first rib into the thoracic outlet. This combination significantly increases costoclavicular compression, brachial plexus compression, subclavian artery compression, subclavian vein compression, and thoracic outlet syndrome.

The subclavius muscle is the only muscle capable of contributing to compression of the interscalene triangle, costoclavicular space, and subpectoral space, making it one of the most important muscles involved in the development of thoracic outlet syndrome.

In my clinical experience, I find severe inflammation, chronic muscle spasm, fibrosis, and hypercontraction of the subclavius muscle in virtually 100 percent of patients with thoracic outlet syndrome, making it one of the most difficult muscles to restore to normal function.

Why isn't the subclavius muscle included in almost every article discussing non-surgical treatment, conservative treatment, physical therapy, rehabilitation, and exercise for thoracic outlet syndrome?

Why aren't doctors cutting this subclavius muscle out in patients with thoracic outlet syndrome (TOS), neurogenic thoracic outlet syndrome, or vascular thoracic outlet syndrome?

You never see it mentioned with respect to doctors injecting it with analgesics, local anesthetics, or trigger point injections as part of the treatment for thoracic outlet syndrome, thoracic outlet compression, costoclavicular syndrome, or compression of the thoracic outlet.

In my many years of examining the muscles in this area, the painful spasms of the subclavius muscle are the most consistent and persistent spasms that pull the collarbone (clavicle) down into the thoracic outlet. Also, subclavius muscle swelling, muscle tightness, and muscle spasm increase the thickness of the muscle, causing narrowing of the costoclavicular space and possible compression of the brachial plexus, subclavian artery, and subclavian vein that pass underneath.

Common activities that stimulate sustained contraction of the subclavius muscle, pectoralis minor muscle, coracobrachialis muscle, and biceps short head muscle include reaching your arm forward or working with your arm extended for prolonged periods. Sustained contraction of these shoulder muscles can produce myofascial trigger points, chronic muscle spasms, and protective muscle contractions that depress the shoulder into the thoracic outlet and thoracic outlet tunnel, causing not only thoracic outlet syndrome symptoms but also symptoms that can mimic angina, heart attack symptoms, chest pain, and other compression syndromes.

If you understand thoracic outlet syndrome, you know much of the current focus is on treatment and surgical resection (removal) of the pectoralis minor muscle. In my opinion, the pectoralis minor is not the primary muscle responsible for thoracic outlet compression or costoclavicular compression in many patients.

If you study the origin, insertion, and action of the biceps short head, coracobrachialis, pectoralis minor, latissimus dorsi, lower trapezius, and subclavius muscle, you will find that each of these muscles can depress the shoulder girdle into the thoracic outlet, reducing the available space for the brachial plexus, subclavian artery, and subclavian vein. In my opinion, the pectoralis minor is simply one of the muscles that is easier to surgically remove while producing less permanent weakness of the shoulder girdle.

I have found that the subclavius muscle is one of the muscles most responsible for compressing the costoclavicular space, producing costoclavicular syndrome, and contributing to thoracic outlet syndrome.

Researchers from the Tokyo Medical and Dental University in Tokyo, Japan, identified an aberrant subclavius muscle connecting the first costal cartilage to the superior border of the scapula during postmortem examinations (cadaver dissections). Normally, the subclavius muscle attaches to the clavicle. They found this anatomical variation in 8.9% of the 124 cadavers examined (6).

The researchers recommended that physicians consider the possible presence of an aberrant subclavius muscle when examining patients with thoracic outlet syndrome, particularly those with venous thoracic outlet syndrome, subclavian vein compression, or other symptoms of venous compression, because the muscle lies directly over the subclavian artery and brachial plexus (6).

Now, don't rush out to get an MRI or other diagnostic imaging looking for an aberrant subclavius muscle, assuming it is the cause of your thoracic outlet syndrome. If the muscle is not in spasm, it is unlikely to compress the subclavian vein, subclavian artery, or brachial plexus, even if it lies directly over these structures. If your doctor performs a thorough thoracic outlet syndrome examination and carefully evaluates the ten muscles capable of compressing the thoracic outlet for muscle spasms and myofascial trigger points, the involved muscle can usually be identified and treated using the treatment approach described in Chapter 13, helping reduce thoracic outlet compression and relieve thoracic outlet syndrome symptoms.

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). Excessive multitasking, prolonged sitting, and repetitive computer use can contribute to poor posture, chronic neck pain, shoulder pain, upper back pain, muscle fatigue, and thoracic outlet syndrome symptoms.

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). Prolonged television viewing, poor sitting posture, and static postures may contribute to chronic neck pain, shoulder pain, upper back pain, muscle tension, poor biomechanics, and thoracic outlet syndrome.

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, smartphones, iPads, tablets, laptops, and other handheld digital devices can be classified as computers.

According to the 2016 Nielsen 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. Excessive screen time, prolonged smartphone use, computer use, and prolonged sitting increase repetitive loading of the neck, shoulders, upper back, arms, forearms, wrists, and hands.

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). As smartphone use continues to increase worldwide, so do posture-related musculoskeletal disorders, repetitive strain injuries, chronic neck pain, and thoracic outlet syndrome symptoms.

This casual use of smartphones and tablets demands way more muscle contractions in the neck, shoulders, arms, forearms, wrists, and hands than the body can take. This is why so many people are developing thoracic outlet syndrome, chronic neck pain, shoulder pain, upper back pain, repetitive strain injuries, myofascial pain syndrome, nerve compression, and poor posture.

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, representing more than 5,000,000,000 mobile phone subscribers as of 2017. Frequent texting, smartphone browsing, prolonged cell phone use, and repetitive thumb movements have become major contributors to repetitive strain injuries and musculoskeletal disorders.

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 developed myofascial pain syndrome in the thumb from excessive cell phone use (9).

Other associated problems diagnosed were thoracic outlet syndrome (51.85 percent), fibromyalgia syndrome (25.93 percent), wrist pain and tendonitis (14.81 percent), thumb pain and tendonitis (7.41 percent) (9), chronic neck pain, shoulder pain, upper back pain, repetitive strain injury, nerve compression syndromes, and poor posture associated with excessive smartphone use.

Children are undergoing surgery more frequently for thoracic outlet syndrome (TOS). If you suspect your child has thoracic outlet syndrome, chronic neck pain, arm numbness, tingling hands, shoulder pain, or symptoms of nerve compression related to excessive smartphone use, poor posture, or prolonged screen time, take the phone away and seek qualified medical evaluation immediately before the condition progresses. Early recognition and treatment may help prevent chronic brachial plexus compression, long-term disability, and the need for surgery.

Another consequence of all these handheld devices is that we have to carry more items with us for hours every day, including smartphones, tablets, laptops, chargers, backpacks, purses, and shoulder bags, all of which can overload the neck, shoulders, upper back, and thoracic outlet, contributing to muscle fatigue, poor posture, shoulder compression, and thoracic outlet syndrome. Modern technology has also contributed to tech neck, prolonged forward head posture, and repetitive strain injuries that increase stress on the cervical spine and shoulder girdle.

The result of a heavier load on the shoulder is earlier fatigue of the upper trapezius muscle, the primary muscle responsible for suspending the shoulder above the thoracic outlet and tunnel. As this muscle fatigues, the shoulder begins to drop, increasing compression of the brachial plexus, subclavian artery, and subclavian vein within the thoracic outlet. Commonly, these patients' neck muscles become so fatigued that they can no longer comfortably support the weight of the head. You often see them leaning against a wall or doorjamb or supporting their head by placing a hand under the chin. These are common signs of postural muscle fatigue, poor shoulder support, and progressive thoracic outlet compression.

Dr. Sharan conducted a study to determine the prevalence of musculoskeletal disorders among Indian schoolchildren who carry backpacks. Results revealed that upper back pain (40 percent), neck pain (27 percent), and shoulder pain (20 percent) were the most common affected body regions, followed by forearm and wrist pain (7 percent) and low back pain (6 percent). Results further revealed that every student participating in the study had pressure marks over the shoulders. More importantly, 54.55 percent of the children were diagnosed with myofascial pain syndrome, while the remainder were diagnosed with thoracic outlet syndrome (10), demonstrating the growing relationship between excessive backpack loading, shoulder compression, poor posture, repetitive strain, and thoracic outlet syndrome. These findings support growing concerns about backpack-related injuries, school backpack weight, and the long-term effects of excessive shoulder loading on the developing musculoskeletal system.

I was honored to be invited to speak to the delegates at Dr. Sharan's medical conference in Bangalore, India, on October 4–5, 2017, regarding thoracic outlet syndrome, biomechanics, and the Human Spring Approach. Dr. Sharan and I agree that the prevalence of thoracic outlet syndrome, repetitive strain injuries, posture-related disorders, and chronic musculoskeletal pain is significantly higher than current estimates suggest. As smartphone use, computer use, and prolonged sitting continue to increase worldwide, these posture-related conditions are likely to become even more common.

Chronic neck muscle fatigue frequently causes individuals to support the weight of their head with their hands under the chin. Patients who regularly adopt this posture often lack sufficient resting muscle tone to support the average 9- to 12-pound head. Supporting the jaw with the hand while leaning to one side can overstretch the ligaments of the jaw, contribute to temporomandibular joint (TMJ) dysfunction, jaw subluxation, painful jaw joint misalignment, chronic neck pain, poor posture, and additional biomechanical stress throughout the cervical spine and thoracic outlet. Over time, this habit can increase brachial plexus compression, contribute to thoracic outlet syndrome symptoms, and create a chain reaction of postural compensation affecting the neck, shoulders, upper back, and jaw.

This can lead to temporomandibular joint (TMJ) dysfunction, temporomandibular disorder (TMD), jaw pain, jaw clicking, and chronic jaw pain. 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 TMJ disorders effectively. It would be rare to have one where you live. In other words, keep your hands off your jaw!

The inflammation from chronic neck pain, TMJ syndrome, temporomandibular joint inflammation, and other chronic inflammatory 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 chronic inflammation, premature aging, skin aging, and an inflammatory condition making you feel and look older than you really are!

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), repetitive strain, repetitive stress injury (RSI), and ergonomic overloading, which are characteristic of chronic musculoskeletal pain, work-related musculoskeletal disorders (WMSDs), and thoracic outlet syndrome in the workplace.

Direct US workers' compensation costs total $51.1 billion, averaging more than one billion dollars per week (12). Muscle soreness, musculoskeletal pain, and work-related pain accounted for 12 percent of the total cases (12).

Musculoskeletal disorders (MSDs), often referred to as ergonomic injuries, occupational injuries, or repetitive strain injuries, accounted for 33 percent of all workplace injuries and illnesses requiring time away from work in 2011 (12).

For all occupations, low back pain, back injury, and lumbar musculoskeletal disorders 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, shoulder pain, and shoulder muscle injury 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 work, computer use, and office work are in line with these findings, since they indicate a higher loading of the hand, wrist, and forearm muscles (wrist extensors) than of the neck, shoulder, and upper trapezius muscles (13-15).

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

Neck and Upper Extremity Problems—Workplace Stressors—Causes

One category of risk factors for neck pain, upper back pain, shoulder pain, arm pain, hand pain, and thoracic outlet syndrome is workplace stress. Workplace stressors include high work demands, high mental processing, high memory demands, performing multiple tasks simultaneously, time pressure, low decision authority, prolonged computer work, and working too hard for too little pay (16–18).

First, muscle activity might be affected indirectly through a changed work style due to these stressors, for example, increased work pace, high forces on the keyboard and mouse, prolonged computer use, 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, muscle tension, muscle guarding, and muscle overactivity, which in turn might lead to muscle injury, overuse injuries, thoracic outlet syndrome, myofascial pain syndrome, and brain patterning. Remember, any activity repeated consistently creates fixed patterns in the brain, whether this involves athletic movements, dance or gymnastics movements, repetitive occupational activities, or stressful input during work, daily activities, or 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, 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, prolonged computer use, and more awkward and sustained postures), which can lead to muscle fatigue, neck fatigue, shoulder fatigue, work-related musculoskeletal disorders, thoracic outlet syndrome, and eventually chronic musculoskeletal pain (18–19).

Doctors think that continuously increased muscular activity can lead to muscle fatigue, muscle overuse, and eventually musculoskeletal disorders. Mental stress combined with excessive activity of the muscles of the hands, wrists, forearms, shoulders, and neck can lead to a higher risk for repetitive strain injuries, myofascial pain syndrome, neck pain, shoulder pain, and thoracic outlet syndrome (20).

The Keyboard and the Mouse

When we leave our arms in a sustained posture at an angled position on a desk for long periods of time, it can cause chronic muscle spasms, muscle hypertonicity, protective muscle guarding, and muscle tension, leading to thoracic outlet compression, brachial plexus compression, vascular compression, and ultimately thoracic outlet syndrome.

Muscles affected: trapezius, upper trapezius, pectoralis minor, levator scapulae, biceps short head, coracobrachialis, anterior scalene muscles, middle scalene muscles, sternocleidomastoid, and the muscles that stabilize the shoulder blade.

When you leave your arms resting at an angled position on a desk for long periods, fairly soon you start to feel a burning shoulder pain, neck pain, shoulder tension, muscle tightness, and upper back pain. We all have experienced this when we work with our computer keyboard, computer mouse, laptop computer, tablet, smartphone, handheld devices, or other digital devices.

Repetitive Strain Injury—Keyboards

Work-related upper extremity disorders, repetitive strain injuries (RSI), repetitive stress injuries, and computer-related musculoskeletal 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, coracobrachialis muscle, and the long and short head of the biceps muscle, contributing to thoracic outlet syndrome, nerve compression, brachial plexus compression, shoulder pain, arm pain, and repetitive strain injury.
• You have the activity of the fingers when you type, putting stress on the muscles located in the forearm, increasing the risk of forearm pain, wrist pain, hand pain, tendon strain, carpal tunnel syndrome, cubital tunnel syndrome, median nerve compression, and repetitive stress injury.
• 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, leading to forward head posture, neck pain, upper back pain, shoulder pain, muscle tension, cervical strain, and thoracic outlet syndrome symptoms.
• You have the constant mental stress that affects your shoulders, abdominal muscles, and neck muscles—which is where many of us store our mental stress—leading to muscle tightness, chronic muscle tension, stress-related muscle spasms, scalene muscle tightness, and compression of the thoracic outlet.

The result can be a complete lockdown of the entire upper half of your body, leading to chronic neck pain, chronic shoulder pain, upper back pain, arm numbness, tingling hands, nerve compression syndromes, and thoracic outlet syndrome.

Mouse Use Duration

Studies have indicated that it is the amount of time that you hold the mouse in one position that is most strongly associated with the incidence of hand pain, wrist pain, forearm pain, arm pain, repetitive strain injury (RSI), repetitive stress injury, and thoracic outlet syndrome symptoms rather than the amount of time you are using a computer keyboard (21).

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 scalene muscles, upper trapezius muscles, levator scapulae muscles, pectoralis minor muscle, and the muscles that suspend the shoulder, dragging the shoulder into the thoracic outlet at the same time, increasing the risk of brachial plexus compression, nerve compression, thoracic outlet syndrome, neck pain, shoulder pain, and upper extremity disorders. 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, median nerve compression, repetitive strain injury, and work-related upper extremity disorders, 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 simply 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 workplace injuries, repetitive stress injuries, musculoskeletal disorders, chronic pain, and lost work time by introducing more variety into their workers' schedules.

Computer Use Duration

Another study showed an increased risk for developing severe hand pain, wrist pain, repetitive strain injury, work-related musculoskeletal disorders, and upper extremity 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 pain, wrist pain, hand pain, forearm pain, repetitive strain injury, and cumulative trauma disorders (23).

So, you are more at risk for carpal tunnel syndrome, cubital tunnel syndrome, forearm pain, elbow pain, wrist pain, hand pain, and repetitive strain injuries than for neck and shoulder conditions when you work long hours (24) (23) (22).

Monitor Position and Visual Stressors

Your position in front of a monitor, including monitor height, determines whether you can get your head, neck, and spine into a perfect perpendicular position to lessen the strain on your body's Integrated Spring-Mass Model, Human Spring mechanism, posture, cervical spine, thoracic outlet, and spinal biomechanics.

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 computing, 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 proper posture, reduced neck strain, reduced shoulder strain, improved spinal alignment, and minimal stress on my Human Spring mechanism 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 biomechanics, running biomechanics, gait analysis, posture, movement patterns, chronic pain, thoracic outlet syndrome, and the Integrated Spring-Mass Model.

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, cervical spine, thoracic outlet, neck muscles, shoulder muscles, and posture, which can lead to thoracic outlet syndrome, chronic neck pain, upper back pain, shoulder pain, brachial plexus compression, and other compression syndromes. 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, chronic neck pain, upper back pain, shoulder pain, arm pain, arm numbness, tingling hands, poor posture, computer-related pain, repetitive strain injury, and thoracic outlet syndrome symptoms. 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, forward head posture syndrome, computer posture syndrome, repetitive strain injury, chronic neck pain, and nerve compression. 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 training, strength training, and weight training 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 muscle recovery and muscle repair, for approximately 60–90 seconds between sets.

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

Performing excessive repetitions, repetitive movements, and repetitive overuse can and does cause muscle damage, repetitive strain injuries, and overuse injuries. You know from the last chapter that muscle damage causes inflammation, and that inflammation triggers the nociceptors (pain receptors) to send an alarm to the brain. The alarm triggers a protective muscle contraction, protective muscle spasm, or muscle guarding of the area, and soon it can become a chronic muscle spasm or sustained muscle 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-treatment, self-care, and thoracic outlet syndrome treatment approach I outline in Chapter 13, "What Works and Why?" as a routine to reduce inflammation, prevent repetitive strain injuries, and help prevent the development of chronic thoracic outlet syndrome later.

2. Repetitive Strained Motions on Muscles, Tendons, Ligaments, and Bones

Oftentimes I catch patients, workers, and athletes performing repetitive movements, repetitive strain motions, poor lifting mechanics, and poor movement patterns that strain the muscles. Movements that cause strain with the first repetition happen because we do not know the optimum joint alignment, body mechanics, posture, and biomechanics 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 lifting technique, exercise technique, movement mechanics, posture correction, shoulder mechanics, neck mechanics, and biomechanics for lifting with the arms, back, chest, neck, and shoulder muscles.

3. Single Overloading Strain on Muscles, Tendons, Ligaments, and Bones

Auto Accidents and Sports Injuries

Research suggests that thoracic outlet syndrome (TOS) most frequently occurs following a single episode of neck trauma, cervical spine trauma, or 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), automobile accident, or car accident.

Motor vehicle accidents resulting in whiplash injuries, whiplash-associated disorders (WAD), and cervical acceleration-deceleration injuries are the most common causes of neck injuries, cervical spine injuries, and whiplash neck injuries, with approximately 1,000,000 occurring each year in the United States (26).

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

Quite often, injured car accident victims had stopped for a red traffic light when another vehicle struck them from behind. A force like this hyperextends the neck and stretches the anterior scalene muscle, middle scalene muscle, and scalene muscles. These muscles stretch, bleed, hypertrophy, scar, and shorten. This process further narrows the already crowded triangular tunnel through which the brachial plexus, subclavian artery, subclavian vein, and neurovascular bundle pass (26).

Injuries like this, especially a blow or jerking injury to the neck or shoulder region, can cause a chronic muscle spasm, chronic neck pain, chronic shoulder pain, and thoracic outlet syndrome, which might precipitate the syndrome (28). This can occur even with relatively minor impacts during car accidents (29). According to statistics, persistent chronic 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 injuries, whiplash-associated disorders (WAD), and cervical spine injuries show a distinct pattern of trigger points, myofascial trigger points, and muscle spasm distribution that differs significantly from other patient groups and healthy subjects. The trauma might cause scalene muscle injury, resulting in swelling of the anterior scalene muscle, middle scalene muscle, and neck muscles. This often appears as swelling in the front of the neck. In lean individuals, you should be able to see the outline of these 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 whether you can identify the outline of the neck muscles, collarbone (clavicle), and shoulder structures.

If these structures are obscured, then perhaps you have neck inflammation, muscle inflammation, soft tissue swelling, or scalene muscle inflammation due to injury of the scalene muscles and other muscles of the neck. For some of you, it might require looking at older photographs to determine whether the swelling was present before the accident.

In an auto accident injury like this, it is normal for scar tissue, fibrosis, and muscle adhesions to form in the scalene muscles (30), which could result in less flexible, stiffened muscle tissue surrounding the brachial plexus, subclavian artery, and subclavian vein as they pass between these muscles. One study demonstrated significantly increased scalene muscle scarring in patients with thoracic outlet syndrome compared with those without the condition (30).

Why do auto accidents cause chronic musculoskeletal pain, chronic neck pain, chronic shoulder pain, chronic upper back pain, and chronic thoracic outlet syndrome in so many people? You experience similar impact forces during tackles in contact sports such as football, which should produce similar strain on the neck, upper back, and shoulders. Athletes often recover from 20–50 impacts each week, while another person may sustain a single impact and develop chronic pain for years.

The reason they tolerate these impacts better is because trained athletes develop greater spring strength, muscular resilience, shoulder stability, neck strength, and postural strength. They also improve resting muscle tone, spring stiffness, impact absorption, shock absorption, and biomechanical efficiency to protect themselves from these impacts. Their training prepares them for collision forces. Think about it—how many of you perform shoulder shrug exercises, trapezius strengthening, levator scapulae strengthening, neck strengthening exercises, and upper body strengthening to reduce the risk of shoulder compression on the brachial plexus, subclavian artery, and subclavian vein within the thoracic outlet?

I will teach you this thoracic outlet syndrome exercise program, strengthening program, and spring 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 contribute to thoracic outlet syndrome by allowing the shoulder to sag into the thoracic outlet, in addition to stress and strain on the upper back and rib cage, is large breasts (breast hypertrophy), breast implants, or large muscular arms (31).

Wearing a properly fitted support bra with wide shoulder straps, crossed-back support straps, and improved breast support may decrease pressure, improve posture, and reduce strain on these tissues (31).

Breast reduction surgery (reduction mammoplasty) has been recommended for carefully selected patients with breast hypertrophy–related thoracic outlet syndrome (31–33).

Thoracic outlet syndrome surgery, thoracic outlet decompression surgery, or surgical decompression should only be considered for patients with true neurological deficits, such as muscle weakness, hand weakness, muscle wasting, or atrophy of the intrinsic muscles of the hand (31).

Mental Stress

There's significant scientific evidence that mental stress, psychological stress, and chronic emotional stress can trigger systemic inflammation and increase inflammatory markers in the body. Studies have measured blood inflammation biomarkers before and after stressful situations and found significant increases in inflammatory cytokines, demonstrating that acute stress and chronic stress can promote inflammation (35).

Inflammation is also strongly linked to depression, anxiety disorders, mood disorders, chronic fatigue, and many age-related diseases, including heart disease, stroke, Alzheimer's disease, Parkinson's disease, and certain cancers. Chronic low-grade inflammation is now recognized as an important contributor to many chronic medical conditions.

I've presented lectures on the inflammation-depression connection, stress-induced inflammation, and the relationship between chronic inflammation and mental health at medical conferences in Melbourne, Australia; Bangkok, Thailand; and Kuala Lumpur, Malaysia. I reviewed more than 3,000 scientific studies while developing these presentations. Many experts in Alzheimer's disease, Parkinson's disease, neurological disorders, and brain health attended these conferences.

When I discussed how abnormal biomechanics, poor posture, musculoskeletal dysfunction, mental stress, anxiety, and chronic muscle tension can contribute to elevated systemic inflammation, my presentations were well received. Several experts commented that they had never considered how musculoskeletal inflammation might contribute to depression, anxiety, Alzheimer's disease, Parkinson's disease, and other neurodegenerative disorders. Many returned to their research with a broader understanding of the relationship between movement, inflammation, and brain health.

Mental/Psychogenic

Research consistently shows that high job stress, workplace stress, mental stress, psychological stress, and other psychogenic factors are associated with upper extremity pain, neck pain, shoulder pain, arm pain, and thoracic outlet syndrome symptoms. Numerous studies also demonstrate that increased job demands, occupational stress, and work-related stress contribute to the development of these painful conditions (36).

In addition, muscle tension, muscle activity, and muscle guarding may increase directly in response to mental stress without any change in posture, body position, or movement patterns (37–39). Increased psychological stress can activate the nervous system, causing involuntary muscle contractions that increase compression, pain, and inflammation.

One study demonstrated that arm stiffness became more common during periods of increased mental stress (36). This suggests that forearm muscle contractions, muscle tightness, and muscle spasms may result not only from repetitive physical activity but also from emotional stress, anxiety, mental tension, and other psychological stressors.

Now let's identify the lifestyle risk factors, daily habits, and activities of daily living that increase the risk of thoracic outlet syndrome, neck pain, shoulder pain, nerve compression, and chronic musculoskeletal pain, and develop a practical plan to eliminate them.

How You Can Abide by the Laws of Gravity

Sitting Rules

• Never touch your back to the back of the chair to help maintain good posture and reduce neck pain, back pain, and thoracic outlet syndrome.
• Give your recliner to someone you don't like.
• Relax and allow your reflexes to determine a stress-free, strain-free, balanced posture.
• Keep your body segments either perpendicular or horizontal to gravity, with your joints maintained near 90-degree angles for proper posture and body alignment.
• Keep your feet flat on the floor or on a footrest if they do not comfortably reach the floor.
• Rest your arms on the armrests to reduce shoulder compression, lift your shoulders off your chest, and decrease thoracic outlet compression.
• Make sure your chair provides a level sitting surface.
• Do not cross your legs at the knees or ankles.
• Get up, walk, and restore circulation every 25 minutes to reduce muscle stiffness, inflammation, and poor posture.
• Never twist your back against the chair.
• Distribute your body weight evenly over both hips.

Correct Driving Position

• Press the accelerator and brake using your foot rather than moving your entire leg.
• Do not work in your car.
• Do not recline your seat excessively.
• Do not lean against the armrests, which may contribute to shoulder compression and poor posture.

Sleeping

• Choose a firm mattress that supports proper spinal alignment.
• Remove the television from the bedroom to improve sleep quality.
• Sleep with a properly fitted pillow.
• Check your pillow thickness every two weeks. Photograph yourself lying on the pillow to ensure your head remains level and your cervical spine stays in a neutral position.
• Add a folded towel if your pillow becomes too thin.
• Avoid sleeping on your stomach, which may increase neck pain, shoulder pain, and thoracic outlet syndrome symptoms.

Standing

• Wear shoes with extended medial heel stabilizers for improved posture and body alignment.
• Avoid prolonged standing.
• Stand on the balls of your feet when appropriate to encourage better body mechanics.
• Avoid shifting your weight onto one leg.
• Set heavy objects down as soon as possible to reduce muscle strain and shoulder compression.

Desk/Computer Work

• Avoid working directly on a laptop whenever possible.
• Connect your laptop to a full-size monitor positioned at eye level to improve computer ergonomics, workstation ergonomics, and neck posture.
• When finished using the keyboard or mouse, remove your hands and rest your arms on the chair armrests to reduce shoulder tension, neck muscle strain, and thoracic outlet compression.

Stress and Inflammation

• Have your inflammation levels and inflammatory biomarkers tested.
• Identify and eliminate lifestyle factors that contribute to chronic inflammation.
• Reduce the major sources of inflammation affecting your body.
• Practice regular deep breathing, stress reduction, and relaxation techniques to help lower stress-induced inflammation and improve overall health.

Important!

Accelerated aging is characterized by chronic, higher-than-normal levels of inflammation, termed inflammaging or chronic low-grade inflammation. Inflammaging is a highly significant risk factor for brain fog, chronic fatigue, depression, anxiety, cognitive decline, atherosclerosis (hardening of the arteries), cardiovascular disease, neurodegenerative disease, and many other age-related diseases.

So if your muscles around your head and neck are soaking in inflammation, it's easy to understand why you may experience brain fog, chronic fatigue, low energy, anxiety, mood changes, or depression. Read Anthony Fields' book, How I Got My Wiggle Back, to learn how he overcame chronic fatigue syndrome, fibromyalgia, chronic pain, systemic inflammation, and even 20 years of clinical depression by focusing on reducing chronic inflammation.

United States Department of Labor Occupational Safety and Health Administration (OSHA) Recommended Working Positions for Computer Ergonomics and Office Workstations (40)

• Hands, wrists, and forearms are straight, in-line, and roughly parallel to the floor.
• Head is level, or bent slightly forward, facing forward, 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 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 upright 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 recommendations for office ergonomics, workstation ergonomics, sitting posture, and computer workstation setup were developed by people—and people can make mistakes. Here is where I agree with OSHA's ergonomic recommendations and where I disagree, and why.

• Hands, wrists, and forearms — I agree.
• Head and torso — I disagree. If your head and upper body are bent slightly forward, the neck muscles, upper back muscles, trapezius muscles, levator scapulae muscles, and cervical extensor muscles remain in constant contraction to prevent your head from falling forward. This prolonged forward head posture contributes to neck pain, shoulder pain, muscle fatigue, muscle spasms, headaches, thoracic outlet syndrome, and poor posture. Instead, stack your head directly over your neck and relax. Remember: "Stack and Relax."
• Shoulders and upper arms — I disagree. Your arms should not hang freely because this increases fatigue in the trapezius muscles, levator scapulae muscles, neck muscles, and shoulder muscles. Rest your forearms on properly adjusted armrests to reduce muscle fatigue, shoulder tension, neck strain, and upper back pain.
• Elbows — I disagree. The elbows should be positioned at exactly 90 degrees, with the forearms resting slightly above the desktop to promote neutral shoulder posture, proper upper-extremity biomechanics, and reduced nerve compression.
• Feet — I agree.
• Back — I disagree. Your back should never depend on external support. Your core muscles, abdominal muscles, and postural stabilizing muscles are designed to support your spine naturally and help maintain healthy posture, spinal alignment, and normal biomechanics.
• Thighs and hips — I agree.
• Knees and feet — I disagree. All body segments should remain either horizontal or perpendicular whenever possible and should avoid prolonged angled positions that increase muscle tension, joint stress, nerve compression, poor biomechanics, and postural fatigue.

If OSHA wants to challenge me on my opinions, I can prove with surface electromyography (surface EMG) testing that their OSHA computer workstation ergonomics and OSHA sitting posture recommendations lead to sustained muscle contractions, resulting in sustained strain on the muscles, ligaments, tendons, joints, and bones. I'd love to conduct a scientific study with OSHA to objectively demonstrate these findings.

If you go to the OSHA website listed below and review the Computer Workstations eTool and computer workstation ergonomics guidelines, you will see four examples of body posture changes that OSHA considers neutral working positions.

1. Upright Sitting – In this photo OSHA says it is acceptable to lean back against the backrest. This causes the body to lean backward out of a true neutral spine position and neutral sitting posture. In this position, the 9–12-pound human head is held in a sustained forward-angled position, forcing the anterior cervical muscles, anterior scalene muscles, middle scalene muscles, and other deep neck flexor muscles to remain in a sustained contraction. Prolonged sustained muscle contraction can contribute to neck muscle strain, forward head posture, poor posture, chronic neck pain, and cervical muscle fatigue. Never sit this way.

Sitting in this position could contribute to and exacerbate thoracic outlet syndrome (TOS), neurogenic thoracic outlet syndrome, brachial plexus compression, and thoracic outlet compression syndrome.

1. Standing – Standing for prolonged periods can place sustained strain on the tibialis posterior, tibialis anterior, peroneus longus, and peroneus brevis muscles, which I refer to as the arch spring suspension muscles. This constant loading of the foot arch, medial longitudinal arch, and foot spring mechanism can also stretch and strain the foot ligaments, resulting in collapse of the arch, abnormal foot biomechanics, altered gait mechanics, and abnormal walking mechanics.

Conditions associated with prolonged standing include plantar fasciitis, plantar fasciopathy, ankle pain, chronic ankle pain, knee pain, patellofemoral pain syndrome, chondromalacia patella, iliotibial band syndrome (IT band syndrome), hip pain, lower back pain, low back pain, varicose veins, foot pain, and other workplace musculoskeletal disorders.

1. Declined Sitting – In this position the legs are not horizontal and perpendicular to the body. If the nervous system senses you may slide forward, the gluteal muscles, hip stabilizers, and postural muscles must remain in a constant contraction to prevent sliding.

Sitting for prolonged periods in this position can contribute to lower back pain, low back pain, hip pain, gluteal muscle fatigue, pelvic instability, lumbar muscle strain, and chronic sitting-related pain.

1. Reclined Sitting – This is the absolute worst sitting position if your goal is to prevent neck strain, neck pain, forward head posture, scalene muscle spasm, thoracic outlet syndrome, neurogenic thoracic outlet syndrome, or worsening of thoracic outlet syndrome symptoms.

Again, in this position the 9–12-pound human head is held in a sustained forward-angled position, forcing the anterior cervical muscles, anterior scalene muscles, middle scalene muscles, and other neck stabilizing muscles into continuous contraction. Never sit this way at work, at home, or anywhere for prolonged periods. If you do, you may continue to reinforce the muscle tension and compression associated with thoracic outlet syndrome, brachial plexus compression, chronic neck pain, and shoulder pain, regardless of how many treatments you receive.

OSHA should delete this article and apologize for misguiding the public regarding what it considers proper workplace ergonomics, healthy sitting posture, and safe computer workstation positioning.

If you are a workplace safety director, occupational health manager, ergonomics coordinator, human resources director, or corporate wellness manager and would like me to present a fun and informative workshop on workplace ergonomics, injury prevention, office ergonomics, musculoskeletal injury prevention, posture correction, and preventing workplace injuries, please contact us at teamdoctors@aol.com.

Let's Spring to Action™ on Workplace Injury Prevention!

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 it is acceptable to lean back against the backrest. However, this causes the body to lean backward out of a position that is perpendicular to gravity. In this position, the 9- to 12-pound head is held in a sustained angled posture, forcing the anterior cervical muscles and the anterior and middle scalene muscles to remain in a prolonged isometric contraction. This sustained muscle contraction increases muscle fatigue, muscle tension, and compression around the thoracic outlet. Never sit this way.

Sitting in this position can cause or significantly worsen thoracic outlet syndrome (TOS) by increasing brachial plexus compression, reducing normal blood flow through the thoracic outlet, and contributing to chronic neck pain, shoulder pain, arm numbness, tingling of the hands, poor posture, and repetitive strain injuries. Maintaining a neutral sitting posture with the body aligned perpendicular to gravity is essential for healthy biomechanics and long-term thoracic outlet syndrome recovery.

2. Standing

Standing for prolonged periods places continuous strain on the tibialis posterior, tibialis anterior, peroneus longus, and peroneus brevis muscles, which I refer to as the arch spring suspension muscles. This constant strain on the arch of the foot can stretch and overload the ligaments of the foot, leading to a drop-and-lock of the arch joints and abnormal foot biomechanics during walking.

Conditions associated with prolonged standing include plantar fasciitis, foot pain, ankle pain, knee pain, patellofemoral pain syndrome (chondromalacia patella), iliotibial band syndrome, hip pain, lower back pain, varicose veins, leg fatigue, and other musculoskeletal disorders. Prolonged standing without adequate movement or recovery also contributes to muscle fatigue, reduced circulation, poor posture, and abnormal lower-extremity biomechanics that may affect the entire kinetic chain.

3. Declined Sitting

In this position the legs are not horizontal or perpendicular to gravity. If the body senses that you could slide forward, the gluteal muscles must contract continuously to prevent this from happening. These sustained isometric contractions increase muscle fatigue and unnecessary stress on the hips and lower back.

Sitting for prolonged periods in this position can contribute to lower back pain, hip pain, pelvic muscle tension, poor sitting posture, and altered spinal biomechanics. Over time, prolonged poor sitting posture may also influence the alignment of the spine, increasing abnormal muscle tension throughout the body and contributing to chronic musculoskeletal pain.

4. Reclined Sitting

This position is the worst sitting posture if your goal is to prevent neck strain, chronic neck pain, scalene muscle spasms, thoracic outlet syndrome, or the worsening of existing thoracic outlet syndrome symptoms.

Again, in this position the 9- to 12-pound head is held in a sustained angled posture, forcing the anterior cervical muscles and the anterior and middle scalene muscles to remain in a prolonged isometric contraction. This sustained contraction increases muscle fatigue, trigger points, muscle spasms, and compression of the brachial plexus, subclavian artery, and subclavian vein within the thoracic outlet.

Never sit this way at work, at home, in a recliner, or anywhere else. If you continue to spend hours each day in this posture, you will continue to overload the muscles that suspend your head and shoulders. As a result, you are unlikely to reverse thoracic outlet syndrome, regardless of how many treatments, exercises, medications, or therapies you receive. Correcting your sitting posture, improving ergonomics, and maintaining proper body alignment relative to gravity are fundamental principles of successful thoracic outlet syndrome treatment and long-term recovery.

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!