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Key Takeaway

Thoracic Outlet Syndrome is not just a neck or shoulder problem. It is a compression problem in a vital corridor that can affect nerves, blood vessels, and quality of life.

Chapter 10: What Treatment Doesn’t Work and Why?

Chapter 10

What Treatment Doesn’t Work and Why?

Human judges can show mercy. But against the laws of nature, there is no appeal.

—Arthur C. Clarke

These are the possible consequences of myofascial pain syndrome, if left untreated. Where are you in this journey?

  • Myofascial pain syndrome that causes neck pain, upper back pain, and shoulder pain.
  • When myofascial pain syndrome compresses the outlet, it’s called thoracic outlet syndrome.
  • When thoracic outlet syndrome leads to a clot, it’s called Paget-Schroetter syndrome.
  • When Paget-Schroetter syndrome leads to a clot that gets lodged in an artery in the lung, it’s called a pulmonary embolism.
  • When a pulmonary embolism causes cellular death, it’s called a pulmonary infarction.
  • When a pulmonary infarction happens, it can cause death.

Proper management of thoracic outlets requires an understanding of the causes of the condition (1).

Management of these complex diagnoses requires an individualized approach to the patient and his or her particular signs, symptoms, and overall general health. For every doctor you see, you usually get a different approach. However, the approach that will help you get to maximum medical improvement is the approach that addresses the cause of thoracic outlet syndrome and that is compression As I mentioned, I read more than 2,400 scientific papers in the U.S. National Library of Medicine, part of the National Institutes of Health, and made a list of every single approach to treating thoracic outlet syndrome. Of the 16 different approaches to treatment, not one can, by itself remove the cause of compression. That certainly is a bold statement and seems impossible to be true, but I will prove it to you in this chapter.

The most likely cause of your compression is muscle tension or spasms. Now, I can shorten this chapter by just asking one question. Which treatments reprogram the nervous system to shut off the muscle spasms that are compressing the outlet? That is what you want to know, right? There is more to this.

What are the five requirements to reverse thoracic outlet syndrome in the long term?

  1. The spasms in the 10 muscles that are compressing the outlet must be released.
  2. The “joint play” must be reestablished in the joints of the spine and extremities.
  3. The inflammation and lactic acid must be completely flushed out of the tissue.
  4. Your activities of daily living must not exacerbate the condition.
  5. The muscles that maintain a wide thoracic outlet and tunnel must be strengthened.

Let’s look at how effective each of the 16 treatment approaches is for each of the six requirements and see if these different treatment approaches can be combined to reverse your thoracic outlet syndrome and prevent it from returning.

So, the question is, “Do any of the following 16 standard-of-care treatments by themselves accomplish all six requirements for long-term correction of thoracic outlet syndrome?”

  1. Painkillers for symptom reduction
  2. Medication: analgesic drug therapy, antidepressants, anticonvulsants, others
  3. Nonsteroidal anti-inflammatory drugs (NSAIDs)
  4. Scalene injection (Botox)
  5. Scalene injection (bupivacaine)
  6. Ultrasound, hot packs, and muscle stimulation
  7. Traction
  8. Nerve gliding
  9. Different bra for breast hypertrophy
  10. Breast reduction—reduction mammoplasty
  11. Stretching and/or stretching exercises
  12. General Massage
  13. First rib adjustments alone
  14. Strengthening with exercise
  15. Correction of the ergonomics of the workstation
  16. Ergonomic corrections

You will see some of these treatment modalities listed in Chapter 13, “What Works and Why,” where I go into what treatment works and why. What I am stressing is that you cannot do three of the six requirements and still reach complete healing at your maximum medical improvement. You must do all six.

1. Gentle Stretching and/or Stretching Exercises

Stretching the neck like this causes tension in the scalene muscles, which lift the ribs up even higher into the thoracic outlet. If your doctor or therapist is doing this tell them to stop!

Stretching

When in doubt, stretch it out. No!

You can’t read an article about treating thoracic outlet syndrome without the author recommending stretching of the neck side to side. This is a warning. Stretching of the neck side to side is one of the worst things you can do if you have a thoracic outlet syndrome or even a stiff neck.

Never stretch the neck like this!

First, let’s get this straight. The neck is not tight because the muscle is shorter. The scalene muscles are soaking in inflammation and in a painful spasm. This spasm is a muscle contraction that is lifting the first and second ribs up into the outlet and compressing the discs in the neck.

So, when you lean your head to the side and stretch you are essentially yanking the ribs higher into the thoracic outlet, making your condition worse.

Sometimes gentle stretching produces a release pop or crack of the lower neck. Because you have to bend your neck to the side using your 10–12-pound head as a fulcrum to pull the ribs up on that side to get the click, it then allows the only bones that can be released—the first rib and the lower neck vertebrae. The bones are popping up into the outlet.

I know how you feel. I felt it too. If you could only get that bone at the base of the neck to pop, you would feel better. The problem is that the first and second ribs are already stuck in an elevated position causing a compression of the blood vessels and nerves to be compressed from underneath.

Stretching to the side elevates them more. The logical strategy is to adjust the ribs down out of the outlet and not up.

Once you start self-manipulating, you can’t seem to stop the urge to keep cracking the neck in this manner. Soon, you’re doing it twice a day, then three or four times a day, then eight or nine times a day. This is because with every pop you stretch the ligaments that hold the bones together as a strong stable joint are stretched a little more each time beyond their elastic limit. Pretty soon your ligaments are too stretched and your spine is hypermobile and can even be considered unstable.

The self-adjustments are addictive and usually you don’t feel an instantaneous pain so you don’t think there is a consequence. Inflammation and painful muscle spasm stiffness is commonly delayed 4–24 hours after straining of the muscles and joints. The pain from stretching of the scalene muscles usually doesn’t occur until about four hours later, after the inflammation has had time to accumulate. When you start feeling the symptoms of numbness or shooting pain screaming down your arm and hand then you will stop.

You should only stretch when you know the super contractions of all 10 muscles have been released and when all inflammation has been flushed out of the area. I have some excellent stretches in Chapter 14, “Spring Training,” that I recommend.

Stretching Exercises

Some therapists recommend conservative treatment. Focusing on stretching exercises for the neck and shoulder will help to focus on scalenes and the shoulder muscles (1) (2). In my opinion, stretching over-contracted and highly inflamed muscle is contraindicated to relaxing it. In fact, excessive stretching of the tight neural and soft tissue structures unnecessarily irritates the patient's symptoms and therefore is not recommended (4).

2. General Massage

A general Swedish massage will not help relieve your thoracic outlet.

Structural massage is different. It involves myofascial or neuromotor techniques that are intended to focus on particularly tense contracted muscles or adhesions that a therapist perceives are the cause of the abnormal changes in the body’s engineering. This is not general massage. This approach involves additional training to be able to do effectively. I teach you how to do your own structural massage in Chapter 13, “What Works and Why.”

3. Traction

Mechanical traction is a technique of stretching or distracting the spine. Patients lie on a table with a harness system attached to their back or neck. The harness system is connected to a machine that applies a pull to create a traction force on the spinal segments. I never use this therapy in our offi ce.

You might think if you have compression forces on the outlet that traction would be good to separate the neck, shoulder, and chest. That is what your doctor and therapist thought too. However, the brain is trying to protect you by contracting the muscles and you are straining them. You are going against the nervous system.

4. Hot Packs, Ultrasound, and Muscle Stimulation

Hot packs have been recommended to help facilitate effective stretching of the scalene and pectoralis minor muscles (5). They warm the area; however, they are only temporary. In fact, one of the leading cause of malpractice in chiropractic practices is burns with hot packs. I have never used a hot pack in my entire career as a doctor. Never use a heating pad on your neck.

Ultrasound is only used for a particular area to help reduce inflammation (6). Honestly, when I used this with patients, I never had one patient tell me they had less pain after an application of therapeutic ultrasound. The common statement they made when it was being used was, “What am I supposed to feel, because I’m not feeling anything?”

This therapy cannot be used where you need it on the front of the neck for the scalenes because it’s too near the carotid sinus. Also, you can’t put it over bones. In my opinion, ultrasound is a worthless therapy for thoracic outlet syndrome, because it only targets a limited area. The human body needs to be modeled like a bag of hot water. Drugs and other chemicals, inflammation, etc., are like a tea bag in your bag of hot water. These substances work for an equal distribution of chemical like when the tea seeps out of the bag to become equally distributed in the glass.

When you use ultrasound over a limited area of inflammation, even if the therapy reduced inflammation over that area it would seep back into the area and affect the tissues once again. There’s really no long-term benefit to this therapy. Frankly, I don’t even see a short-term benefit to this therapy.

Muscle stimulation, functional electrical stimulation, and transcutaneous electrical nerve stimulation (TENS) are different methods of applying electrical current to modify the degree of muscle tension.

  • Transcutaneous Electrical Nerve Stimulation (TENS)—used primarily for pain relief
  • Interferential Current (IFC)—used primarily for pain relief
  • High-Voltage Pulsed Current (HVPC)—used for wound care and sometimes for pain relief
  • Neuromuscular Electrical Stimulation (NMES)—used for muscle strengthening You might think that electrically stimulating muscles could both relax muscle super contractions and even strengthen muscles that are supposed to be suspending the shoulder over the thoracic outlet and tunnel.

The problem is that you cannot effectively stimulate the exact 10 specific muscles that either directly or indirectly compress the outlet and tunnel. Because the pectoralis minor and subclavius muscles are deep under the pectoralis major muscles, you cannot even reach them with electrical muscle stimulation.

Also, electrical muscle stimulation is contraindicated when applied over three of the spasmed 10 muscles of the outlet like the pectoralis minor and/or scalenes. For instance, you should never electrically stimulate the thoracic area (chest) of anyone with arrhythmia, congestive heart failure, recent myocardial infarction, and other heart conditions. That means you must have a complete evaluation of your cardiovascular system to ensure you are not at risk.

The carotid artery is located along the side of your neck, running alongside your scalene muscles. The carotid sinus is an area in the carotid artery around the midpoint of your neck that has many sensitive receptors and nerve endings, which monitor blood pressure. The carotid sinus is sensitive to any form of stimulation and, as a result, overstimulation can affect heart rate, the amount of blood reaching the brain, and blood pressure. This is known as carotid sinus hypersensitivity (CSH).

You should never apply electrical stimulation of any kind through the carotid sinus area, as it might cause a rise in blood pressure and slow the heart rate. In severe cases, a loss of consciousness, convulsions, and seizures might occur when a buildup of pressure occurs in these arteries.

Both therapeutic ultrasound and electrical currents cannot be used over metal implants, like screws and plates used to fuse neck vertebrae for a herniated disc. We all know metal is an excellent conductor of electricity. Ultrasound would heat that metal so fast and hot, you would be burned severely from the inside.

If your insurance policy has a limit on what you can spend on treating your thoracic outlet syndrome, spending time and money on direct, hands-on, deep tissue on the muscles that compress the outlet and twist the body into a state of chronic pain is a better option. Be sure you find a therapist who will spend quality one-on-one time with you. Don’t see an assistant for muscle stimulation treatment that cannot be applied to all 10 muscles equally.

About eight years ago, I decided all electrical therapies, such as TENS, interferential current (IFC), and therapeutic ultrasound, were a waste of the patient’s money and time.

5. Scalene Injection

I found through reading the studies that medical doctors use scalene injections to treat thoracic outlet syndrome. Some use scalene injections as a method of diagnosing thoracic outlet syndrome when patients present with typical patterns of pain and paresthesia. They claim it helps to identify the relative contribution of thoracic outlet syndrome when symptoms overlap with another disease (7). Two studies determined the scalene injection helped support the diagnosis of thoracic outlet syndrome but the relief of symptoms was short lived (8–9).

Doctors think that, if the scalene injection reduces the symptoms of thoracic outlet syndrome, then it would confirm the clinical diagnosis that the scalene muscle somehow contributed to the rest of outlet syndrome (4), if, in fact, there were other diseases or conditions that overlapped. So temporary relief after scalene injection might support the diagnosis of thoracic outlet syndrome, but the relief is short-lived (5–6).

There are two problems with this approach to diagnosis and treatment.

The first flaw in this approach to diagnosis is that the scalene muscle is not the only muscle that causes compression of the nerves and the blood vessels. The scalene muscles are just the muscles that lift the ribs that compress from the floor up narrowing the interscalene triangle.

I have never seen a patient with thoracic outlet syndrome with only spasms in the scalene muscles in 30 years, and my hands are all up in these muscles checking every one, one inch at a time. I always see about the same degree of muscle tension or spasm in the other muscles of the shoulder, such as:

  1. Anterior scalene muscle
  2. Middle scalene muscle
  3. Posterior scalene muscle
  4. Subclavius muscle
  5. Biceps short head muscle
  6. Coracobrachialis muscle
  7. Pectoralis minor muscle
  8. Anterior cervical (neck) muscles
  9. Latissimus dorsi muscle
  10. Lower trapezius muscle If you got temporary relief from just an injection of the scalene muscles and your surgeon decided that was enough for him to recommend scalenectomy (surgical removal of the scalene muscles) and rib resection (surgical removal of the first rib), after the surgery was over, the wounds healed, and the painkillers wore off, the outlet would still be compressed by the other six muscles, and you would still have about the same degree of thoracic outlet compression.

Unfortunately, for many of you, this incomplete and ineffective approach to determining if this surgical procedure was medically necessary won’t be your final set up for surgery. Your next set up for surgery might be to do a second surgery to surgically remove your pectoralis minor muscle.

6. Scalene Injection (Botox)

Recently, doctors have been injecting the anterior and middle scalenes with botulinum toxin (Botox) for temporary relief of pain and spasms resulting from compression of the nerves and blood vessels in the thoracic outlet. Botox is injected into the tight or spastic scalene muscles.

Botox is a drug that blocks signals from the nerves to the muscles. The injected muscle can no longer contract, which causes the wrinkles to relax and soften. The same thing happens when you inject Botox into the scalenes. Your scalene muscles no longer contract.

Botulinum toxin can cause prolonged muscle relaxation through inhibition of acetylcholine release (11). Acetylcholine release can seep into tissues and some scientists think it seeps into spindle cells, causing them to trigger spasms in the adjacent muscles. Doctors think this is also an advantage.

Botox does nothing for inflammation.

You might think this will help your thoracic outlet syndrome, because it paralyzes the muscles that are compressing the body. The neurotoxin paralyzes the muscle for three to four months. You might think this is good, because it will reduce the compression of the outlet in this area for long-term relief. That’s not the whole story!

The problem is that your scalene muscles, or any other muscles injected with this neurotoxin, won’t contract for months. Remember, when you break your arm, the cast is left on for about nine weeks. This leads to severe atrophy of the muscles of the arm, which is noticeable when the cast is removed. Imagine the amount of atrophy these injections will cause in your scalene muscles, or other muscles, when these muscles don’t have normal contractions for four to six months or sixteen to twenty-four weeks!

Also, after the drug wears off, you will end up with severe atrophy of the muscle, which will require months of rehabilitation to rebuild the strength.

Are Botox injections effective? Here are three studies that say they’re not.

  • In a double-blind, randomized, controlled trial conducted at Canada’s University of British Columbia Division of Physical Medicine and Rehabilitation, the effect of toxin-type injections to the scalene muscles on patients with thoracic outlet syndromes were studied in six-week, three-month, and six-month increments. The study concluded that Botox injections to the scalene muscles did not result in clinically or statistically significant improvements in pain, paresthesia, or function in this population of subjects with TOS (12).
  • Another important study, conducted by the Washington State Department of Labor and Industries, University of Washington, Department of Environmental and Occupational Health Sciences; Department of Neurology; Department of Health Services found “Evidence does not support the use of scalene blocks, botulinum toxin therapy, or vascular studies to diagnose NTOS” (13).

Some doctors think there is an advantage to using Botox over hands-on treatments, because it’s fast and provides a longer sustained period of pain relief. These are the reasons why I would never recommend botulinum toxin therapy to anyone with thoracic outlet syndrome.

  1. The purpose of the therapy to the muscles is to reduce the muscle spasm or super contraction. It is not to completely shut off the nerve supply to the muscle for up to six months! Did you ever see what someone’s arm looks like after removing a cast that has immobilized the arm for nine weeks? There is such significant atrophy and weakness in the muscles that there is a noticeable difference in the size of the casted arm versus the normal arm. Imagine how weak your neck muscles would be after the nerve supply was shut down for up to six months (25 weeks or more)!
  2. There are 10 muscles that either directly or indirectly contribute to the compression of the thoracic outlet area. So, because they only inject the scalenes, you already know this treatment approach is incomplete. What if they injected all 10 muscles? Doctors know that if they inject all 10 muscles that compress the outlet, that it would be as if your neck and shoulder were almost paralyzed.

So, assuming your Botox helped you, which three studies predict it won’t, after the Botox has worn off in six months, you must now go through a long and arduous active rehabilitation program to rebuild the strength in the muscles that were paralyzed by the neurotoxin.

You already have enough work to redevelop the strength in the muscles that support the thoracic outlet so the shoulder doesn’t fall into the blood vessels and nerves. Deadening nerves making muscles even weaker will make your active rehabilitation an incredibly daunting task. Please do not make your life more difficult.

If you had a muscle cramp in your calf, would you ask your doctor to inject that? Of course not! Don’t go this route. It is not well-thought-out, and it’s a fragmented and irrational approach to long-term improvement. When muscles don’t contract for months, they don’t pull against the bone to stimulate the bone growth that prevents osteoporosis.

The decision to treat a patient with Botox should be undertaken carefully, as there are other potential complications with this injection, such as muscle weakness, difficulty swallowing, and a neurological disorder affecting the voice muscles in the larynx (voice box) making talking difficult.

Also, Botox does not accomplish the same result as deep tissue to reduce muscle contraction. When muscles are in a spasm, they are constantly contracted. If a muscle is contracted, it cannot contract anymore. That is why it is weak. If we do deep tissue on the muscles that are contracting 24 hours a day, they will relax. The more muscles are relaxed now, they can contract once again. That means every time we relax a muscle spasm, it gets stronger with each application because more muscle fibers of that muscle can contract now.

So deep tissue relaxes muscle spasms and increases strength of the muscle, and Botox completely turns off muscle contraction for six months causing immediate weakness and severe atrophy that will be extremely difficult to rehabilitate. In 2007, I attended a gala party at the Hôtel de Paris Monte-Carlo for the Anti-Aging Medicine World Congress, Monte Carlo, Principality of Monaco. Sitting next to me was a beautiful young woman. I noticed a strange hairstyle with a strand of hair covering her right eye. I asked her who did her style.

She said “I did it! My husband, the doctor, shot me with Botox for my jaw pain and it paralyzed the muscles that close my eye. Now I can’t close my eye for weeks.” I felt sorry for her.

Botox injections are not cheap. If you think that the scalene muscles are an integral part of what is compressing your thoracic outlet, then instead of injections, which range from $300–$5,000 per injection, you could have 2 to 30 hours of deep tissue to the scalenes and the surrounding muscles that compress the outlet, to determine if this deep tissue treatment would relieve the pressure on the outlet with natural means.

7. Nerve Gliding

Nerve gliding—Dr. Ahmad Wehbe describes the series of nerve gliding that can be employed to safely reduce tension on the nerves of the brachial plexus, when performing activities of daily living that demand arm and neck movements (14).

I haven’t employed these nerve-gliding exercises, because I just don’t understand how nerve gliding in a severely compressed thoracic outlet and tunnel could provide relief from the compression. Why glide nerves through an outlet that is still compressed?

If you spent the time decompressing the outlet, once the outlet is decompressed, one treatment of nerve gliding should be enough to release the nerve from its adhesions.

8. Different Bra for Breast Hypertrophy

Some women with breast hypertrophy (large breasts) might benefit from a bra that better supports their breasts. I would highly recommend this as a part of the treatment, but obviously once the muscle super contractions have got a lockdown on your thoracic outlet and tunnel.

9. Breast Reduction—Reduction Mammoplasty

For some female patients, it is obvious that the size and the weight of their breasts contribute a great deal to the exacerbation of thoracic outlet syndrome. Therefore, breast reduction is considered and needs to be discussed with your doctor. It is never the only reason for developing thoracic outlet syndrome, so a combined treatment approach is always recommended.

10. First Rib Adjustments Alone

First rib adjustments are medically necessary to adjust the first and second ribs down out of the outlet.

If you don’t get your first ribs adjusted, you have to hope that after the muscle tension is reduced in all three of your scalene muscles that the rib slides down out of the outlet on its own.

If the ribs have been elevated for a long time, this is almost impossible, because there are most likely adhesions that have glued the ribs in this elevated position. Movements of joint play are independent of the action of muscles.

Joint play is the natural healthy movement of the joint that allows full, unrestricted range of motion of the joint. Natural motion of a joint is a rolling or gliding motion. A dislocation is called a luxation.

Chiropractors and therapists call these slight misalignments with a reduction in joint play or joint spring, subluxations.

Joint mobility is difficult to assess by many hands-on healers. It requires an attuned sense of touch.

Not all healers have a refined sense of touch. In fact, many try, but just don’t have it, and they give up and just use gadgets and therapies instead.

Super contractions of the scalene muscles shift the ribs out of their natural position, affecting the natural joint play and causing compression of the blood vessels and nerves as they pass through the outlet. That is why surgeons cut the first ribs out. The reason they cut them out is because they haven’t been taught and do not have the skill set to adjust the ribs down out of the thoracic outlet. With a lot of bony misalignments, there are muscles you can exercise to move bones where they belong by improving resting tone through training. In this case, there are no muscles you can train to pull the ribs down from their elevated position.

First rib adjustments alone have been recommended as a treatment for thoracic outlet syndrome. In most cases, the first rib adjustment is required for complete relief. I adjust the first and second ribs and, frankly, all the ribs on every patient with thoracic outlet syndrome.

The majority of patients don’t know if they have had a good adjustment. An effective adjustment is where you can feel the ribs physically move under your hand out of the thoracic outlet. This adjustment isn’t easy, because you have to be able to gently manipulate the ribs through a thick, powerful, trapezius muscles. It takes a fine art and a lot of confidence and experience to do it correctly. When I adjust your first and second rib, you will feel the ribs move. The first few times you are adjusted there is a loud audible release and some substantial movement is felt. After subsequent adjustments, the sound and amount of movement felt is far less. After the adjustment, the most patients laugh out loud and exclaim “wow” and say they feel a big noticeable improvement right after the release.

Rib adjustments are mostly performed by chiropractors. However, just because you go to a chiropractor doesn’t mean he or she can do an effective first rib adjustment. The level of talent in giving first rib adjustments is varied. Before I went into practice, I studied and sampled at least 50 or more chiropractors’ first rib adjustments to see which one would be best for me.

How many have you sampled before you found an effective one?

Shoulder Joint Adjustments

Also, when super contractions in the subclavius muscle, the pectoralis minor muscle, the coracobrachialis muscle, and biceps short head muscle drag the shoulder down into the outlet, it can cause a shift of the collarbone, scapula (wing bone), and humerus bone to an abnormal position. The shifting of these bones in their joint space demands they be manipulated into their normal gliding motion to reestablish normal movement.

You cannot release the thoracic outlet area by just releasing the spasms in the 10 muscles, without addressing the abnormal joint shift or stiffening of joint play in the shoulder. The act of reestablishing joint play in the joints of the ribs and shoulder area is an art form that takes years to refine. Many patients with TOS call me frustrated in their quest to find a chiropractor who can give an effective rib adjustment. Only a handful has mentioned any luck finding someone in their area to effectively release the reduced joint play in the shoulder joints.

11. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

12. Medication: Analgesic Drug Therapy, Antidepressants, Anticonvulsants, Others

13. Painkillers for Symptom Reduction

As mentioned in previous chapters, inflammatory chemicals can stimulate the nociceptor nerves, causing an alarm signal to be communicated to the brain that there is something wrong. The brain then responds reflexively with muscle contractions (spasms) to try to protect you in some way. This contributes directly to the compression of the thoracic outlet. Obviously, this inflammation must not only be flushed out of the area muscles, but the entire body, to ensure the reflex that retriggers the super contractions. When you go to any doctors, they typically ask, “Do you want something for your pain?” They also address the inflammation with a medication. They have their choice between nonopioid analgesics (nonsteroidal anti-inflammatory drugs [NSAIDs], acetaminophen) and opioid analgesics.

Nonopioid Analgesics (NSAIDs)

NSAIDs commonly are used in patients with mild to moderately severe pain. Did you know that the use of some NSAIDs is associated with an increases incidence of cardiovascular adverse events (such as myocardial infarction, stroke, or thrombosis), which can be fatal? The risk might increase with duration of use.

So, your blood flow is restricted by the compression of the artery and vein, and the doctor recommends a medication that comes with an increased risk of a clot that could really complicate matters. The minimal temporary benefit does not exceed the big risk.

Opioid Analgesics

When it comes to chronic and/or severe pain, opioid painkillers, including morphine and morphine- like drugs, such as oxycodone, hydrocodone, and codeine, are among the most powerful tools in a doctor’s arsenal. They are also among the most addictive and potentially dangerous.

These powerful and addictive opioid painkillers do not turn off the reflex in the brain for the muscle spasms that are causing the compression of the thoracic outlet. That means you will more than likely be on these drugs forever, eventually developing an addiction to them. Also, the longer you take them, the more you develop a tolerance for them. In 2000, the US Congress declared that January 1, 2001, would start the Decade of Pain Control and Research. Medical boards across the country encouraged physicians to assess and treat pain in all patients (15). They did not encourage physicians to assess and treat the cause of pain in patients, just pain.

The use of painkillers quadrupled between 1999 and 2010 (15). The problem is they did not start the Decade of the Cause of Pain Research at the same time. That is why we know no little about the cause of pain since then.

It’s also why prescription drug overdoses now claim more lives than heroin and cocaine, combined.

I have found that these drugs are not effective for nerve pain, so how are they good for symptoms such as numbness and tingling in the arms and hands caused by restricted blood flow in and out of the arms? The symptoms of thoracic outlet syndrome are not manifested the same way as back or knee pain. The symptoms are caused by pinching of a nerve and a lack of blood in the arms. Pain medication does nothing for the symptoms of numbness and tingling.

Also, if you have had severe chronic pain, you understand. Not even these powerful opioid painkillers can reduce the symptoms of the nerve pain. For relief of pinched nerve pain, doctors commonly prescribe tramadol. Tramadol has major side effects and is extremely addictive.

The side effects may include seizures, increased risk of serotonin syndrome, decreased alertness, and drug addiction (16). On August 18, 2014, the DEA placed the substance Tramadol into schedule IV of the Controlled Substances Act (17). That means if you have Tramadol and you give yours to someone or sell it, you could face criminal charges and jail time. That should give you enough evidence that this drug is dangerous.

Recognized risk factors for tramadol overdose include depression, addiction, and seizures. Long- term use of high doses of tramadol might be associated with physical dependence and withdrawal syndrome. In most cases, tramadol withdrawal will set in 12–20 hours after the last dose, but this can vary. Tramadol withdrawal lasts longer than that of other opioids; seven days or more of acute withdrawal symptoms can occur, as opposed to typically three or four days for other codeine analogues. I once had a patient taking eight tramadol and three over-the-counter pain relievers every four hours.

He did not realize he was taking more than 20 pills a day. He said this helped his nerve pain go from a 10/10 to a 9/10 pain. So, he had kidney and liver damage and put himself at risk for overdose and death to get only a 10 percent reduction in pain.

Understanding that he was at a high risk of overdose or death, not from the thoracic outlet syndrome but from the drugs he was taking for the TOS, I treated him from 8:00 p.m. to 12:00 midnight the first day. Thankfully, we were able to reduce his pain by 85 percent that night, allowing him to immediately get off all drugs the next morning.

I have helped many patients get off opioid painkillers by ending the cycle of chronic pain. If patients have no pain or less pain, there is no longer a reason to take these medications. If we have to, we get them into a drug treatment program.

These drugs are not candy, and if you are treating them like that, then you need to get into a drug treatment program. Getting off opioids is no joke. The discontinuation of these powerful drugs leads to intense withdrawal symptoms, which includes drug cravings, anxiety, restlessness, vomiting, extreme sweating, and racing heart.

Professionally administered withdrawal is usually not as effective as you think. It’s true that most patients with moderate-to-severe opioid use disorder will relapse after supervised treatment. You hear about it with celebrities. Most patients will need maintenance pharmacotherapy with methadone, buprenorphine, or naltrexone to prevent relapse.

You could lose your friends, your family, your job, and your life, if you get addicted to these drugs.

Don’t use these drugs to ease the pain while you think about doing something about what to do to eliminate this condition. Get on it now!

Antidepressants

Doctors might put you on antidepressants. Who wouldn’t be depressed if they had constant pain?

Especially if your doctors don’t know what causes what you have and can’t offer you any treatment that offers long-term improvement. These drugs include tricyclic antidepressants; selective serotonin reuptake inhibitors (SSRI); and antidepressants, such as paroxetine (Paxil); fluoxetine (Prozac); sertraline (Zoloft); nefazodone (Serzone); and venlafaxine (Effexor). When you try to get off these drugs, you have SSRI discontinuation syndrome, also known as SSRI withdrawal syndrome, or SSRI cessation syndrome. Withdrawal can be broken into two phases: (1)

immediate symptoms, occurring within six weeks of discontinuation, and (2) persistent symptoms, occurring months or years after discontinuation.

Symptoms are described as “brain zaps,” “brain shocks,” “brain shivers,” “brain pulse-waves,” “head shocks,” “pulses,” “flickers,” or “cranial zings.” Common responses to dose reduction or cessation include dizziness, electric shock-like sensations, sweating, nausea, insomnia, tremors, confusion, nightmares, and vertigo.

Doctors even routinely prescribe anticonvulsive drugs, such as clonazepam, topiramate, gabapentin, lamotrigine, tiagabine, and zonisamide. These drugs have been tried for relief of the nerve pain in treatment of TOS. Muscle relaxants are also a popular drug for muscle spasms, such as metaxalone (Skelaxin), cyclobenzaprine (Flexeril), benzodiazepines, and tizanidine.

Metaxalone’s exact mechanism of action is not known, but it might be due to general central nervous system depression. Cyclobenzaprine is supposed to decrease pain in the first two weeks, peaking in the first few days, but has no proven benefit after two weeks. Then what?

Here’s the bottom line: painkillers are useless to reverse the brain-patterned spasms that cause your TOS pain. They are dangerous too. Muscle relaxants have not been shown to reverse the specific spasms of TOS and are poison to the body. I never use them or recommend them. Anti-inflammatories are not going to reverse the compression on your outlet.

The typical cost for outpatient addiction treatment is $10,000. Residential alcohol and drug rehab range from $20,000 to $32,000, depending on the level of services needed. Additional services, such as counseling, other issues, and prescriptions, are charged separately when needed.

  1. Your activities of daily living must not exacerbate the condition.
  2. Correction of the Ergonomics of the Workstation

15. Ergonomic Corrections

Ergonomic corrections do help reduce thoracic outlet syndrome. Even if I treated you for 100 days for 100 hours, you would not improve if you did not follow the laws of gravity with respect to your body’s orientation to gravity. Because poor posture (holding the arm and head in a sustained contraction due to ergonomic issues) is one of the causes of thoracic outlet syndrome ergonomics is a must! I had an attorney tell me that he had 40 percent relief, just from following the recommendations I gave him for ergonomic considerations.

However, just correcting the ergonomics won’t put an end to your TOS. There are six criteria that must be met to completely eliminate thoracic outlet syndrome once and for all. I mention these in Chapter 13.

  1. The muscles that suspend the shoulder over the thoracic outlet and tunnel must be strengthened to open and preserve adequate space in the thoracic outlet and tunnel.
  2. Strengthening with Exercise Exercises add more loads to an already compressed neck, upper back, chest, and shoulder area. Why would you want to compress the body, when it is already compressed more than it should be? Therapists who initiate active rehab of lifting or stretching before all compressive spasms are released put you at great risk of injury, because you are adding additional compression to an already compressed outlet. When muscles are in a super contracted state, they compress the region and cause abnormal movements of the joints. This can lead to additional stress and strain picked up by the strain gauges and the spindle cells, which can lead to a worsening of your condition or a new injury.

The abnormal movement of the joints affects the natural glide and rotation needed for healthy joint play. Putting additional pressure on the area with resistance exercises can cause further compression of the outlet and wear and tear of the joints that can increase inflammation.

Therapists often recommend exercises as a treatment for a compressed neck, upper back, shoulder, and thoracic outlet. Many therapists and doctors just think exercise and stretching will fix everything.

They don’t realize that exercise is contraindicated with an active thoracic outlet syndrome.

You should not lift weights when you have TOS, because the area is already significantly compressed, and more external forces could cause the discs of the neck to herniate or the outlet to close down, causing a complete compression of the artery or vein, leading to a blood clot. This could cause the blood clot, called an embolus, to release. If the embolus travels to the lung, it can cause a stroke, which might necessitate emergency surgery.

If your thoracic outlet symptoms are much better, you might decide to go to the gym to start working out again. Next thing you know, your arm feels heavy, and your veins look more prominent on one side. You notice your arm swelling and starting to turn blue. That is when you call 911 and get to the hospital immediately for clot-buster treatment or surgery.

According to the Centers for Disease Control and Prevention, the precise number of people affected by DVT/PE is unknown, although as many as 900,000 people could be affected (1 to 2 per 1,000) each year in the United States. The CDC estimates that 60,000–100,000 Americans die of DVT/PE (also called venous thromboembolism). Sudden death is the first symptom in about one-quarter (25 percent) of people who have a pulmonary embolism (18).This means you don’t even get a chance to dial 911. You die on the spot. If you live through a pulmonary embolism, 10 to 30 percent of people will die within one month of diagnosis.

So, is it risky to just live with thoracic outlet syndrome? Absolutely!

First release the compression, then it is safer to exercise. Also, the human spring must be trained as a human spring. This means you have to include spring training or exercises that strengthen the human spring through drills that involve impacts. In the state you are in, impacts would seem like they are more of a thud than a spring. Obviously, this is down the line after treatment, but it is what we will be springing at for long-term human spring health.

Conclusion

We’ve gone systematically through the six requirements that must be satisfied to effectively reverse the causes of thoracic outlet syndrome. We’ve also discussed the sixteen different treatment approaches listed in the U.S. National Library of Medicine, part of the National Institutes of Health, and found them ineffective by themselves for long-term relief of thoracic outlet syndrome.

Unfortunately, you have been led to believe that these treatment approaches are effective for thoracic outlet syndrome, otherwise why would they be recommended? So, after seeing a few physical therapists, a chiropractor or two, you are probably thinking that you have tried everything, and there is no other alternative.

Now, you can see why it is common to have failure of a carefully supervised physical therapy program that leads to surgery that was never medically necessary.

Spring ahead and learn how and why surgery is recommended for thoracic outlet syndrome, and if it is an effective treatment approach for long-term relief.

Frequently Asked Questions

Why doesn't treatment work for thoracic outlet syndrome (TOS)?

Treatment for thoracic outlet syndrome (TOS) often fails because it focuses on relieving symptoms rather than correcting the underlying biomechanical cause of nerve or vascular compression. If poor posture, sustained muscle contraction, abnormal Human Spring biomechanics, first rib dysfunction, muscle tightness, fascial restrictions, or repetitive aggravating activities are not corrected, thoracic outlet syndrome (TOS) usually persists or returns.

Successful treatment requires restoring the normal relationship between the neck, shoulders, clavicle, first rib, and surrounding soft tissues rather than treating only the painful area. Throughout this book, you will learn why correcting the underlying biomechanical causes is the key to successfully treating thoracic outlet syndrome (TOS).

Why am I getting worse with thoracic outlet syndrome (TOS)?

Thoracic outlet syndrome (TOS) often becomes worse when the underlying causes of compression continue despite treatment. Poor posture, prolonged computer or cell phone use, sustained muscle contraction, inflammation, repetitive overhead activities, and abnormal Human Spring biomechanics may continue to increase compression of the brachial plexus, subclavian artery, and subclavian vein.

Many patients unknowingly continue the very habits that caused their thoracic outlet syndrome (TOS) in the first place. Throughout this book, you will learn how identifying and eliminating these aggravating factors is essential for long-term recovery from thoracic outlet syndrome (TOS).

What treatments fail for thoracic outlet syndrome (TOS)?

Treatments for thoracic outlet syndrome (TOS) often fail when they focus only on symptoms without correcting the underlying cause of compression. Stretching alone, strengthening alone, medication alone, injections alone, massage alone, or surgery performed without addressing abnormal Human Spring biomechanics may fail to provide lasting improvement for many patients with thoracic outlet syndrome (TOS).

Successful treatment requires correcting posture, restoring normal movement, reducing muscle and fascial restrictions, and eliminating the mechanical source of compression. Throughout this book, you will learn why addressing the root cause produces better long-term results than treating symptoms alone in thoracic outlet syndrome (TOS).

Why do some patients fail physical therapy for thoracic outlet syndrome (TOS)?

Some patients fail physical therapy for thoracic outlet syndrome (TOS) because treatment begins with stretching or strengthening before the thoracic outlet has been adequately opened. If muscle guarding, fascial restrictions, first rib dysfunction, inflammation, and abnormal Human Spring biomechanics remain untreated, exercise may simply reinforce abnormal movement patterns and continue compressing the brachial plexus.

Physical therapy is most successful after the mechanical restrictions causing thoracic outlet syndrome (TOS) have been addressed. Throughout this book, you will learn why restoring biomechanics before rehabilitation exercises greatly improves recovery from thoracic outlet syndrome (TOS).

Is stretching the scalene muscles always helpful for thoracic outlet syndrome (TOS)?

No. Stretching the scalene muscles is not always helpful for thoracic outlet syndrome (TOS) because stretching a muscle that is already inflamed, guarding, or protecting an unstable biomechanical system may increase irritation rather than relieve it.

If the underlying cause of thoracic outlet syndrome (TOS) has not been corrected, aggressive stretching may increase nerve irritation or worsen symptoms. Stretching should only be introduced after the source of compression and abnormal Human Spring biomechanics have been properly addressed.

Throughout this book, you will learn when stretching the scalene muscles is beneficial and when it may delay recovery from thoracic outlet syndrome (TOS).

Is stretching the pectoralis minor always helpful for thoracic outlet syndrome (TOS)?

No. Stretching the pectoralis minor is not always helpful for thoracic outlet syndrome (TOS) because a tight muscle is often a protective response to underlying biomechanical dysfunction rather than the primary cause of compression.

Stretching the pectoralis minor before correcting posture, muscle guarding, inflammation, and abnormal Human Spring biomechanics may temporarily increase symptoms or fail to produce lasting improvement. The underlying cause of the shortened muscle must be corrected before stretching becomes effective.

Throughout this book, you will learn when stretching the pectoralis minor helps recovery and when it may prolong thoracic outlet syndrome (TOS) symptoms.

Can the wrong exercises make thoracic outlet syndrome (TOS) worse?

Yes. The wrong exercises can make thoracic outlet syndrome (TOS) worse by increasing sustained muscle contraction, narrowing the thoracic outlet, and increasing compression of the brachial plexus, subclavian artery, and subclavian vein.

Heavy lifting, repetitive overhead exercises, aggressive stretching, and strengthening performed before restoring Human Spring biomechanics may aggravate symptoms rather than improve them. Exercise should begin only after the source of compression has been corrected and normal movement has been restored.

Throughout this book, you will learn how selecting the correct exercises is essential for recovering from thoracic outlet syndrome (TOS).

Can massage make thoracic outlet syndrome (TOS) worse?

Yes. Massage can make thoracic outlet syndrome (TOS) worse if it is excessively aggressive, performed directly over irritated nerves, or applied before the underlying biomechanical cause of compression has been corrected.

Temporary symptom relief may occur, but massage alone cannot eliminate abnormal Human Spring biomechanics, first rib dysfunction, poor posture, or sustained muscle guarding. The effectiveness of massage depends on the timing, technique, and whether it is part of a comprehensive treatment program for thoracic outlet syndrome (TOS).

Throughout this book, you will learn when massage helps recovery and when it may actually aggravate thoracic outlet syndrome (TOS).

Can exercise make thoracic outlet syndrome (TOS) worse?

Yes. Exercise can make thoracic outlet syndrome (TOS) worse if it is started before the thoracic outlet has been adequately opened and normal biomechanics have been restored.

Increasing muscle activity and blood flow through a narrowed thoracic outlet may increase compression of the brachial plexus, subclavian artery, and subclavian vein, worsening pain, numbness, tingling, and weakness. Exercise should follow correction of posture, muscle guarding, and Human Spring biomechanics, not precede it.

Throughout this book, you will learn why the sequence of treatment is critical for successful recovery from thoracic outlet syndrome (TOS).

What mistakes delay recovery from thoracic outlet syndrome (TOS)?

Many mistakes delay recovery from thoracic outlet syndrome (TOS), including continuing poor posture, prolonged computer and cell phone use, ignoring aggravating activities, exercising too early, failing to correct biomechanics, and treating symptoms instead of the underlying cause. Continuing sustained muscle contraction around the thoracic outlet prevents the brachial plexus, subclavian artery, and subclavian vein from recovering.

Recovery requires eliminating the daily habits that continue to create compression. Throughout this book, you will learn how avoiding these common mistakes dramatically improves recovery from thoracic outlet syndrome (TOS).

What common treatment mistakes should patients avoid with thoracic outlet syndrome (TOS)?

Patients with thoracic outlet syndrome (TOS) should avoid beginning aggressive stretching, strengthening, or heavy exercise before the source of compression has been corrected. They should also avoid prolonged poor posture, excessive cell phone and computer use, exercising through pain, ignoring inflammation, and relying on treatments that address symptoms without correcting Human Spring biomechanics.

These common mistakes frequently prolong thoracic outlet syndrome (TOS) and increase the risk of persistent symptoms or recurrence. Throughout this book, you will learn how avoiding these treatment mistakes allows thoracic outlet syndrome (TOS) to heal more quickly and completely.

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6. Crosby C.A., Webbe M.A. Conservative treatment of thoracic outlet syndrome. Hand Clin. 2004 Feb;20(1):43-9, vi. https://www.ncbi.nlm.nih.gov/pubmed/15005383

7. Lee GW, Kwon YH, Jeong JH, Kim JW. The efficacy of scalene injection in thoracic outlet syndrome. J Korean Neurosurg Soc. 2011 Jul;50(1):36-9. doi: 10.3340/jkns.2011.50.1.36. Epub 2011 Jul 31. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3159878/

8. Atasoy E. History of thoracic outlet syndrome. Hand Clin. 2004;20:15–16. http://www.ncbi.nlm.nih.gov/pubmed/15005378

9. Jordan SE, Machleder HI. Diagnosis of thoracic outlet syndrome using electrophysiologically guided anterior scalene blocks. Ann Vasc Surg. 1998;12:260–264. http://www.ncbi.nlm.nih.gov/pubmed/9588513

10. Hameroff SR, Crago BR, Blitt CD, Womble J, Kanel J. Comparison of bupivacaine, etidocaine, and saline for trigger- point therapy. Anesth Analg. 1981 Oct;60(10):752-5. http://www.ncbi.nlm.nih.gov/pubmed/7027827

11. Zhou JY1, Wang D. An update on botulinum toxin a injections of trigger points for myofascial pain. Curr Pain Headache Rep. 2014 Jan;18(1):386. doi: 10.1007/s11916-013-0386-z. http://www.ncbi.nlm.nih.gov/pubmed/24338700

12. Finlayson HC1, O’Connor RJ, Brasher PM, Travlos A. Botulinum toxin injection for management of thoracic outlet syndrome: a double-blind, randomized, controlled trial. Pain. 2011 Sep;152(9):2023-8. doi: 10.1016/j. pain.2011.04.027. Epub 2011 May 31. https://www.ncbi.nlm.nih.gov/pubmed/21628084

13. (Franklin GM1. Work-Related Neurogenic Thoracic Outlet Syndrome: Diagnosis and Treatment. Phys Med Rehabil Clin N Am. 2015 Aug;26(3):551-61. doi: 10.1016/j.pmr.2015.04.004. Epub 2015 Jun 19. https://www.ncbi.nlm.nih.gov/pubmed/26231965 13. Povlsen B1, Hansson T, Povlsen SD. Treatment for thoracic outlet syndrome. Cochrane Database Syst Rev. 2014 Nov 26;(11):CD007218. doi: 10.1002/14651858.CD007218.pub3. https://www.ncbi.nlm.nih.gov/pubmed/25427003

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Glossary

Browse important terms used in this chapter. Select a letter or search by keyword.

A Activities of Daily Living (ADLs)
Routine daily activities such as working, driving, sleeping, computer use, lifting, and personal care. The chapter emphasizes that aggravating daily activities must be corrected to achieve long-term recovery from thoracic outlet syndrome.
A Accessory Joint Motion
Also called joint play, these small passive movements occur naturally within healthy joints and are necessary for normal movement and biomechanics.
A Acetaminophen
A non-opioid analgesic medication commonly prescribed for pain relief. The chapter notes that acetaminophen may reduce pain symptoms but does not address the underlying compression causing thoracic outlet syndrome.
A Acetylcholine
A neurotransmitter released at the neuromuscular junction that stimulates muscle contraction. The chapter discusses how botulinum toxin blocks acetylcholine release to temporarily paralyze muscles.
A Active Rehabilitation
A rehabilitation approach involving exercises, strengthening, and movement training designed to restore function. The chapter recommends delaying active rehabilitation until thoracic outlet compression has first been reduced.
A Accessory Motion
See Accessory Joint Motion. These passive gliding and rolling movements are required for normal joint mechanics.
A Analgesics
Medications used to reduce pain. Analgesics relieve symptoms but do not eliminate the muscular and biomechanical causes of thoracic outlet syndrome.
A Anterior Cervical Muscles
The muscles located on the front of the neck. These muscles are included among the ten muscles identified by the author as contributing to thoracic outlet compression.
A Anterior Scalene Muscle
One of the primary muscles contributing to thoracic outlet compression. Chronic contraction elevates the first rib and narrows the interscalene triangle.
A Arthrokinematics
The small rolling, gliding, and spinning movements occurring between joint surfaces during normal motion. The chapter emphasizes restoring normal arthrokinematics before strengthening exercises begin.
B Baroreceptors
Pressure-sensitive receptors located within the carotid sinus that continuously monitor blood pressure. Excessive electrical stimulation over this region may alter heart rate and blood pressure.
B Biceps Short Head Muscle
One of the ten muscles identified as contributing to thoracic outlet compression. Chronic contraction may pull the shoulder girdle into an abnormal position.
B Botulinum Toxin
A neurotoxin that blocks acetylcholine release at the neuromuscular junction, producing temporary muscle paralysis. It is commonly known by the trade name Botox®.
B Botox®
The commercial name for botulinum toxin. Botox injections temporarily weaken the scalene muscles but, according to the chapter, do not correct the underlying biomechanical causes of thoracic outlet syndrome.
B Brachial Plexus Compression
Mechanical compression of the brachial plexus causing pain, numbness, tingling, weakness, and neurological symptoms in the upper extremity. The chapter identifies reducing brachial plexus compression as a primary treatment goal.
B Breast Hypertrophy
Excessively large breasts that may contribute to downward shoulder loading and thoracic outlet compression. Proper support or reduction mammoplasty may be appropriate in selected patients.
B Breast Reduction (Reduction Mammoplasty)
A surgical procedure to reduce breast size. The chapter explains that breast reduction may reduce mechanical loading in selected patients but should not be viewed as the sole treatment for thoracic outlet syndrome.
B Bupivacaine Injection
A local anesthetic injection into the scalene muscles used diagnostically or therapeutically. The chapter notes that symptom relief is generally temporary.
C Carotid Artery
A major artery supplying blood to the brain. The chapter warns against applying electrical stimulation over the carotid artery because of nearby baroreceptors.
C Carotid Sinus
A specialized enlargement of the carotid artery containing pressure receptors that regulate blood pressure. Electrical stimulation over the carotid sinus may produce serious cardiovascular complications.
C Carotid Sinus Hypersensitivity (CSH)
An exaggerated response of the carotid sinus that may produce slowing of the heart, altered blood pressure, dizziness, syncope, or reduced cerebral blood flow.
C Cervical Traction
A treatment applying longitudinal pulling forces to the cervical spine. The chapter argues that cervical traction may increase strain on already contracted protective muscles in thoracic outlet syndrome.
C Chiropractic Adjustment
A manual therapy procedure intended to restore normal joint motion and biomechanics. The chapter emphasizes first rib and shoulder adjustments as important components of treatment.
C Chronic Muscle Guarding
Persistent protective muscle contraction initiated by the nervous system following injury or inflammation. Chronic muscle guarding is described as a major contributor to thoracic outlet compression.
C Compression Neuropathy
A disorder caused by mechanical compression of a peripheral nerve. Thoracic outlet syndrome is presented as one form of compression neuropathy.
C Conservative Treatment
Non-surgical management including manual therapy, first rib mobilization, posture correction, ergonomic changes, and rehabilitation. The chapter evaluates numerous conservative treatment approaches individually and in combination.
C Coracobrachialis Muscle
One of the ten muscles identified by the author as contributing to thoracic outlet compression. Chronic contraction may alter shoulder mechanics and compress the neurovascular bundle.
C Costoclavicular Space
The anatomical space between the clavicle and first rib through which portions of the brachial plexus and subclavian vessels pass. Narrowing contributes to thoracic outlet syndrome.
D Deep Tissue Massage
A focused manual therapy technique directed at chronically contracted muscles, myofascial adhesions, and soft tissue restrictions. The chapter distinguishes deep tissue massage from general relaxation massage because it targets the specific muscles responsible for thoracic outlet compression.
D Deep Tissue Therapy
An intensive manual therapy approach designed to reduce chronic muscle spasms, restore normal biomechanics, improve joint mobility, and decompress the thoracic outlet. The chapter presents deep tissue therapy as a foundational component of long-term recovery.
D Deep Vein Thrombosis (DVT)
Formation of a blood clot within a deep vein. The chapter discusses upper-extremity DVT as a potential complication of venous thoracic outlet syndrome that may progress to pulmonary embolism.
D Drug Tolerance
A physiological adaptation in which progressively larger doses of a medication are required to achieve the same therapeutic effect. The chapter discusses drug tolerance as a consequence of prolonged opioid use.
D Dynamic Movement Drills
Controlled movement exercises performed later in rehabilitation to restore normal Human Spring function, athletic performance, and resilience after thoracic outlet compression has been corrected.
E Electrical Muscle Stimulation (EMS)
The application of electrical current to stimulate muscles or nerves. The chapter argues that electrical stimulation cannot effectively reach all ten muscles responsible for thoracic outlet compression and therefore has limited value as a standalone treatment.
E Ergonomic Corrections
Changes made to workstations, posture, equipment, and daily movement patterns to reduce repetitive mechanical stress contributing to thoracic outlet syndrome.
E Exercise Rehabilitation
A structured progression of strengthening, mobility, and functional exercises performed after thoracic outlet compression has been relieved. The chapter cautions against beginning exercise rehabilitation too early.
F First Rib Adjustment
A manual manipulation designed to move an elevated first rib downward out of the thoracic outlet. The chapter considers first rib adjustment an essential component of restoring normal biomechanics.
F First Rib Dysfunction
Abnormal positioning or restricted motion of the first rib that contributes to narrowing of the thoracic outlet and compression of neurovascular structures.
F First Rib Manipulation
A manual therapy procedure intended to restore normal first rib alignment, joint play, and mobility.
F First Rib Mobilization
A gentle manual technique used to restore normal first rib movement and reduce thoracic outlet compression.
F Functional Electrical Stimulation (FES)
A form of electrical stimulation used to activate muscles through externally applied electrical current. The chapter notes that FES has limited usefulness because the deep compressive muscles of the thoracic outlet cannot all be reached effectively.
F Functional Recovery
The restoration of normal movement, strength, coordination, and daily activity after successful treatment. The chapter emphasizes that true functional recovery requires correcting the underlying biomechanical causes of thoracic outlet syndrome.
F Functional Spring Exercises
Exercises designed to restore the body's natural spring-like biomechanics through progressive impact loading and elastic recoil training after adequate decompression has occurred.
G General Massage
A relaxation-oriented massage, such as Swedish massage, intended primarily to reduce stress and promote relaxation. The chapter states that general massage alone does not relieve thoracic outlet compression.
G Gentle Stretching
Low-force stretching commonly recommended for musculoskeletal disorders. The chapter cautions that even gentle stretching may worsen thoracic outlet syndrome when significant muscle spasm and compression remain present.
G Gravity
The constant downward force acting on the body. The chapter emphasizes that successful long-term recovery requires restoring posture and movement so the body remains mechanically aligned with gravity.
G Guarding Reflex
A protective neurological response in which muscles contract automatically to protect injured tissues. Persistent guarding reflexes contribute to chronic thoracic outlet compression until the underlying cause is corrected.
H Heating Pad
A device used to apply superficial heat to the body. The chapter advises against using heating pads on the neck because of the potential to increase inflammation or cause burns.
H High-Voltage Pulsed Current (HVPC)
A form of electrical stimulation primarily used for wound healing and, in some cases, pain relief. The chapter lists HVPC among electrical therapies that do not adequately address thoracic outlet compression.
H Hot Packs
Moist or dry heat applications used to warm soft tissues before stretching. The chapter states that hot packs provide only temporary warming and do not correct the underlying causes of thoracic outlet syndrome.
H Human Spring
The integrated biomechanical system of muscles, joints, ligaments, fascia, tendons, and connective tissues that stores, releases, and transfers energy throughout the body. The chapter emphasizes restoring Human Spring function before strengthening and impact training.
H Human Spring Stretching Program
A structured stretching program introduced only after muscle spasms have been reduced, inflammation has resolved, and thoracic outlet compression has been relieved.
I Impact Training
A later-stage rehabilitation strategy using controlled impact loading to restore normal elastic recoil, resilience, and Human Spring biomechanics.
I Inflammation
The body's biological response to injury characterized by swelling, inflammatory chemicals, cytokines, metabolic waste accumulation, and pain. The chapter identifies inflammation as a major contributor to protective muscle spasms and thoracic outlet compression.
I Inflammatory Cytokines
Chemical messengers released during inflammation that stimulate pain receptors and trigger protective muscle guarding.
I Interferential Current (IFC)
A form of electrical stimulation primarily intended for pain relief. The chapter concludes that IFC cannot adequately reach all muscles responsible for thoracic outlet compression.
J Joint Mobility
The normal ability of a joint to move freely through its passive and active range. Restoring joint mobility is one of the five requirements for long-term correction of thoracic outlet syndrome.
J Joint Play
The small passive gliding movements that occur naturally within healthy joints. The chapter stresses that restoring joint play is essential before strengthening exercises begin.
J Joint Spring
The elastic resistance felt during passive joint movement. Loss of joint spring indicates restricted motion and altered biomechanics.
K Kidney Damage
Impairment of kidney function that may occur from excessive long-term medication use. The chapter presents kidney damage as a possible consequence of chronic overuse of pain medications.
L Lactic Acid
A metabolic byproduct produced during muscle activity. The chapter lists removal of lactic acid and other metabolic waste products as one of the essential requirements for long-term recovery from thoracic outlet syndrome.
L Latissimus Dorsi Muscle
One of the ten muscles identified as contributing to thoracic outlet compression. Chronic contraction may alter shoulder position and upper-quarter biomechanics.
L Ligamentous Instability
Excessive looseness of supporting ligaments caused by repeated overstretching. The chapter warns that repeated self-manipulation of the neck may contribute to cervical instability.
L Lower Trapezius Muscle
One of the ten muscles identified as contributing to thoracic outlet compression. Dysfunction of the lower trapezius affects shoulder stabilization and upper-quarter biomechanics.
L Luxation
A complete dislocation of a joint in which the articulating surfaces lose normal contact. The chapter contrasts luxation with smaller restrictions of joint play addressed through manual therapy.
M Manual Therapy
Hands-on treatment techniques used to restore normal muscle tone, joint mobility, rib movement, fascial mobility, and biomechanics. The chapter identifies manual therapy as a key component of effective conservative treatment.
M Maximum Medical Improvement (MMI)
The point at which a patient has recovered as completely as reasonably possible with available treatment. The chapter emphasizes that MMI requires correcting the underlying causes of thoracic outlet compression rather than simply relieving symptoms.
M Mechanical Cause of Pain
The underlying biomechanical source responsible for producing chronic pain. The chapter distinguishes treatment of the mechanical cause from treatment of pain symptoms alone.
M Metabolic Waste
Inflammatory byproducts that accumulate within chronically contracted muscles. Removal of metabolic waste is identified as one of the essential requirements for long-term recovery.
M Muscle Atrophy
Loss of muscle size and strength resulting from disuse or denervation. The chapter identifies muscle atrophy as a significant drawback of prolonged Botox-induced paralysis.
M Muscle Guarding
Protective muscle contraction initiated by the nervous system following injury or inflammation. Persistent muscle guarding contributes directly to thoracic outlet compression.
M Muscle Hypertonicity
Abnormally increased resting muscle tension. The chapter discusses reducing muscle hypertonicity as a major treatment goal.
M Muscle Relaxants
Prescription medications intended to reduce muscle spasm or muscle tone. The chapter concludes that muscle relaxants do not reverse the specific compression patterns responsible for thoracic outlet syndrome.
M Muscle Re-education
A rehabilitation process that retrains muscles to contract and function normally following injury or prolonged dysfunction.
M Muscle Spasm
An involuntary sustained muscle contraction. Chronic muscle spasms involving the ten compressive muscles are presented as the primary biomechanical cause of thoracic outlet syndrome.
M Myofascial Adhesions
Fibrous restrictions developing between muscles and fascia that limit normal tissue movement. Structural manual therapy is directed toward releasing these adhesions.
M Myofascial Massage
A specialized form of massage targeting fascia, muscle adhesions, and biomechanical dysfunction rather than general relaxation.
M Myofascial Release
A manual therapy technique designed to restore normal fascial mobility, reduce adhesions, and decrease compression within the thoracic outlet.
M Myofascial Therapy
Hands-on treatment focused on reducing muscle tension, fascial restrictions, and abnormal biomechanics.
N Nerve Compression
Mechanical pressure on a peripheral nerve producing pain, numbness, tingling, weakness, or altered sensation. Thoracic outlet syndrome is presented as a dynamic nerve compression disorder.
N Nerve Gliding
Also called nerve flossing, a therapeutic exercise intended to improve mobility of peripheral nerves by gently moving them through surrounding tissues. The chapter questions its usefulness before thoracic outlet decompression has been achieved.
N Nerve Flossing
Another term for nerve gliding, involving controlled movements intended to mobilize peripheral nerves.
N Neuromotor Therapy
A specialized manual therapy approach directed toward correcting abnormal muscle tone, movement patterns, and biomechanics.
N Neuromuscular Electrical Stimulation (NMES)
Electrical stimulation used primarily for muscle strengthening, muscle re-education, and neuromuscular rehabilitation. The chapter concludes that NMES alone cannot effectively address thoracic outlet compression.
N Neuromuscular Junction
The specialized connection between a motor nerve and muscle fiber where acetylcholine stimulates muscle contraction. Botox blocks transmission at this junction.
N Neurovascular Bundle
The combined brachial plexus, subclavian artery, and subclavian vein that pass through the thoracic outlet. Successful treatment requires relieving compression of this bundle.
N Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
A class of medications commonly prescribed to reduce pain and inflammation. The chapter notes that NSAIDs reduce symptoms but do not correct the underlying biomechanical compression responsible for thoracic outlet syndrome.
N Non-Surgical Treatment
Conservative management emphasizing manual therapy, first rib mobilization, postural correction, ergonomic changes, and rehabilitation before considering surgery.
O Opioid Analgesics
Powerful prescription pain medications such as morphine, oxycodone, hydrocodone, and codeine used for severe pain. The chapter emphasizes that opioids do not correct the underlying causes of thoracic outlet syndrome and carry substantial risks of addiction and dependence.
O Opioid Dependence
A physiological adaptation resulting from prolonged opioid use in which the body requires continued medication to prevent withdrawal symptoms.
O Opioid Withdrawal Syndrome
A collection of physical and psychological symptoms that occur after abrupt reduction or discontinuation of opioids, including anxiety, sweating, vomiting, drug cravings, and restlessness.
O Orthopedic Rehabilitation
A rehabilitation program focused on restoring normal joint mechanics, muscle function, biomechanics, and movement patterns following musculoskeletal injury.
O Overhead Activity
Activities requiring prolonged elevation of the arms above shoulder level. The chapter identifies repetitive overhead activity as an important aggravating factor in thoracic outlet syndrome.
P Painkillers
Medications prescribed to reduce pain symptoms. The chapter emphasizes that painkillers do not address the underlying muscle spasms, biomechanical dysfunction, or neurovascular compression responsible for thoracic outlet syndrome.
P Paresthesia
An abnormal sensation such as tingling, burning, numbness, or pins-and-needles caused by nerve compression.
P Pectoralis Minor Muscle
One of the ten muscles identified as contributing to thoracic outlet compression. Chronic contraction narrows the subpectoral space and contributes to brachial plexus and vascular compression.
P Physical Rehabilitation
A structured program designed to restore strength, function, posture, and movement after successful decompression of the thoracic outlet.
P Plyometric Training
A form of exercise using rapid stretch-shortening cycles to improve elastic recoil, power, and Human Spring function during advanced rehabilitation.
P Postural Correction
Modification of body alignment to reduce abnormal loading of the thoracic outlet. The chapter identifies postural correction as an important but incomplete treatment when used by itself.
P Protective Muscle Guarding
Automatic muscle contraction initiated by the nervous system to protect injured tissues. Persistent protective guarding contributes directly to chronic thoracic outlet compression.
P Protective Muscle Reflex
An involuntary neurological response that contracts muscles to protect painful or injured tissues. Persistent reflex activation maintains chronic muscle tension and compression.
R Reactive Drills
Progressive rehabilitation exercises that train rapid muscular responses, elastic recoil, coordination, and Human Spring function after thoracic outlet compression has been corrected.
R Reduction Mammoplasty
The medical term for breast reduction surgery, performed to decrease breast size and weight. In selected patients, it may reduce mechanical loading on the thoracic outlet but does not eliminate the underlying biomechanical causes of thoracic outlet syndrome.
R Rehabilitation Exercises
Exercises prescribed to restore movement, strength, coordination, posture, and function. The chapter emphasizes that rehabilitation exercises should begin only after compression has been relieved.
R Resistance Training
Exercise performed against external resistance to increase muscular strength. The chapter warns that resistance training performed before thoracic outlet decompression may worsen compression.
R Respiratory Failure
Failure of the lungs to provide adequate oxygenation or ventilation. Respiratory failure is presented as a potential consequence of pulmonary infarction following pulmonary embolism.
R Root Cause
The underlying biomechanical or physiological factor responsible for producing thoracic outlet syndrome. The chapter repeatedly emphasizes treating the root cause rather than merely reducing symptoms.
S Scalene Injection
Injection of local anesthetic or botulinum toxin into the scalene muscles for diagnostic or therapeutic purposes. The chapter concludes that symptom relief is typically temporary and incomplete.
S Scalene Muscle
One of the three paired neck muscles that attach to the first and second ribs. Chronic contraction elevates the ribs, narrows the thoracic outlet, and contributes to neurovascular compression.
S Scalenectomy
A surgical procedure involving removal of one or more scalene muscles to reduce thoracic outlet compression. The chapter argues that scalenectomy alone may leave compression from the remaining muscles untreated.
S Self-Myofascial Release
A self-treatment technique using manual pressure or specialized tools to reduce muscle tension, fascial restrictions, and soft tissue adhesions.
S Shoulder Biomechanics
The coordinated movement and alignment of the clavicle, scapula, humerus, ribs, and surrounding muscles. Restoring normal shoulder biomechanics is identified as an essential component of recovery.
S Soft Tissue Mobilization
A manual therapy technique used to improve mobility of muscles, fascia, ligaments, and connective tissue by reducing adhesions and restoring normal tissue movement.
S Spinal Traction
Mechanical separation of spinal structures through externally applied traction forces. The chapter questions its usefulness for thoracic outlet syndrome because it may increase protective muscle guarding.
S Spring Training
The author's rehabilitation program emphasizing restoration of Human Spring function through progressive biomechanical training, elastic recoil exercises, and impact conditioning.
S Structural Massage
A specialized form of massage focusing on muscle adhesions, fascial restrictions, biomechanics, and movement dysfunction rather than general relaxation.
S Subclavian Artery
The major artery supplying blood to the upper extremity. Compression of the subclavian artery contributes to arterial thoracic outlet syndrome.
S Subclavian Vein
The primary vein draining blood from the upper extremity. Compression contributes to venous thoracic outlet syndrome and increases the risk of thrombosis.
S Subclavius Muscle
One of the ten muscles identified as contributing to thoracic outlet compression. Dysfunction of the subclavius alters clavicular mechanics and narrows the thoracic outlet.
S Subluxation
A slight alteration in joint alignment accompanied by reduced joint play and mobility. The chapter distinguishes subluxation from complete joint dislocation (luxation).
S Supportive Bra
A properly fitted bra designed to improve breast support, reduce shoulder loading, and decrease mechanical stress on the thoracic outlet in selected patients.
S Swedish Massage
A relaxation-oriented massage technique emphasizing gentle soft tissue work. The chapter contrasts Swedish massage with structural deep tissue therapy for thoracic outlet syndrome.
T Therapeutic Ultrasound
A physical therapy modality using high-frequency sound waves to treat localized tissues. The chapter concludes that therapeutic ultrasound has little long-term value for thoracic outlet syndrome because it cannot adequately address widespread muscular compression.
T Thoracic Outlet Syndrome (TOS)
A dynamic neurovascular compression disorder involving the brachial plexus, subclavian artery, or subclavian vein. Chapter 10 evaluates why many conventional treatments fail to correct its underlying causes.
T Thoracic Tunnel
The author's term describing the anatomical passage through which neurovascular structures travel from the neck into the upper extremity. Maintaining an open thoracic tunnel is presented as a major rehabilitation goal.
T Transcutaneous Electrical Nerve Stimulation (TENS)
A form of electrical stimulation used primarily for pain relief. The chapter argues that TENS provides symptomatic relief without correcting the biomechanical causes of thoracic outlet syndrome.
T Tramadol
A prescription opioid-like analgesic commonly used for chronic nerve pain. The chapter discusses tramadol's limited effectiveness for compression neuropathies and highlights its risks of dependence, withdrawal, seizures, and addiction.
U Upper Body Loading
Application of resistance or weight through the shoulders, neck, or upper extremities during exercise. The chapter advises avoiding upper body loading until thoracic outlet compression has been adequately relieved.
V Vascular Compression
Mechanical narrowing of arteries or veins producing impaired circulation. One of the primary goals of treatment is elimination of vascular compression by restoring normal biomechanics.
V Venous Thoracic Outlet Syndrome (VTOS)
Compression of the subclavian vein causing impaired venous drainage, swelling, congestion, and increased risk of thrombosis.
V Venous Thromboembolism (VTE)
A condition encompassing both deep vein thrombosis (DVT) and pulmonary embolism (PE). The chapter discusses VTE as a potentially life-threatening consequence of untreated vascular compression.
W Weight Training
Resistance exercise using free weights or machines to improve muscular strength. The chapter recommends postponing weight training until thoracic outlet compression has been corrected.
W Workstation Ergonomics
The design and arrangement of a work environment to minimize biomechanical stress. Correct workstation ergonomics help reduce repetitive aggravation of thoracic outlet syndrome but are not sufficient as a standalone treatment. No major glossary terms beginning with X appear in Chapter 10. No major glossary terms beginning with Y appear in Chapter 10. No major glossary terms beginning with Z appear in Chapter 10.
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