What Treatment Doesn’t Work and Why?

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

• Myofascial pain syndrome that causes chronic neck pain, upper back pain, shoulder pain, and muscle spasms.
• When myofascial pain syndrome compresses the thoracic outlet, it's called thoracic outlet syndrome (TOS) or neurogenic thoracic outlet syndrome.
• When thoracic outlet syndrome (TOS) leads to a blood clot, it's called Paget-Schroetter syndrome, also known as effort thrombosis or venous thoracic outlet syndrome.
• When Paget-Schroetter syndrome leads to a blood clot that becomes lodged in an artery in the lung, it's called a pulmonary embolism (PE).
• When a pulmonary embolism causes lung tissue death, it's called a pulmonary infarction.
• When a pulmonary infarction occurs, it can result in respiratory failure and death.

Proper management of thoracic outlet syndrome (TOS) requires an understanding of the causes of thoracic outlet syndrome (1), especially the underlying compression of nerves and blood vessels.

Management of these complex diagnoses requires an individualized approach to the patient and his or her particular signs and symptoms, medical history, and overall health. For every doctor you see, you usually get a different diagnosis and treatment approach. However, the approach most likely to help you achieve maximum medical improvement (MMI) is the one that addresses the root cause of thoracic outlet syndrome—compression of the brachial plexus, subclavian artery, and/or subclavian vein.

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 (NIH), and made a list of every published approach to treating thoracic outlet syndrome. Of the 16 conservative and surgical treatment approaches, not one can, by itself, remove the underlying cause of thoracic outlet syndrome—compression. That certainly is a bold statement and may seem impossible to be true, but I will prove it to you in this chapter.

The most likely cause of your thoracic outlet compression is chronic muscle tension, muscle spasms, or protective muscle guarding. Now, I can shorten this chapter by asking one simple question: Which thoracic outlet syndrome treatments actually reprogram the nervous system to stop the muscle spasms that are compressing the thoracic outlet? That is what you really want to know, right? There is more to this.

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

• The muscle spasms in the 10 muscles compressing the thoracic outlet must be released to reduce nerve compression and blood vessel compression.
• Normal joint play, joint mobility, and spinal biomechanics must be reestablished in the spine, ribs, shoulder, and upper extremities.
• Inflammation, lactic acid, metabolic waste, and inflammatory byproducts must be completely flushed from the tissues.
• Your activities of daily living, posture, workstation ergonomics, and movement patterns must no longer aggravate the thoracic outlet syndrome.
• The muscles that maintain a wide thoracic outlet, open thoracic tunnel, and proper shoulder biomechanics must be strengthened to help prevent the compression from returning

What Treatment Doesn't Work and Why?

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 (TOS) 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?"

• Painkillers and pain medication for symptom reduction
• Analgesics, antidepressants, anticonvulsants, and other prescription medications
• Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain and inflammation
• Scalene Botox injection (botulinum toxin)
• Scalene injection (bupivacaine)
• Therapeutic ultrasound, hot packs, and electrical muscle stimulation
• Cervical traction and spinal traction
• Nerve gliding (nerve flossing) exercises
• Supportive bras and bra modifications for breast hypertrophy
• Breast reduction surgery (reduction mammoplasty)
• Stretching, scalene stretches, and pectoralis minor stretching
• Massage therapy, deep tissue massage, and myofascial massage
• First rib adjustments, first rib mobilization, and first rib manipulation alone
• Strengthening exercises, rehabilitation exercises, and physical therapy exercises
• Workstation ergonomic assessment, computer workstation modifications
• Ergonomic corrections and posture correction

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 (MMI). You must do all six.

1. Gentle Stretching and/or Stretching Exercises for Thoracic Outlet Syndrome

Stretching for Thoracic Outlet Syndrome

When in doubt, stretch it out. No!

You can't read an article about thoracic outlet syndrome treatment, thoracic outlet syndrome exercises, or thoracic outlet syndrome physical therapy without the author recommending neck stretching, side-to-side neck stretching, or stretching exercises for thoracic outlet syndrome. This is a warning. Stretching the neck side to side is one of the worst things you can do if you have thoracic outlet syndrome (TOS), neurogenic thoracic outlet syndrome, or even a stiff neck.

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 muscle spasm. This spasm is a muscle contraction that lifts the first rib and second rib into the thoracic outlet, causing thoracic outlet compression, brachial plexus compression, blood vessel compression, nerve compression, and compression of the cervical discs in the neck.

So, when you lean your head to the side and stretch, you are essentially yanking the first rib and second rib higher into the thoracic outlet, increasing thoracic outlet compression, brachial plexus compression, and compression of the nerves and blood vessels, making your thoracic outlet syndrome symptoms 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 upward on that side to get the click, it allows the only bones that can be released—the first rib and the lower cervical vertebrae. The bones are actually popping farther up into the thoracic outlet, increasing compression of the brachial plexus, subclavian artery, and subclavian vein.

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 rib and second rib are already stuck in an elevated position, causing thoracic outlet compression and compression of the blood vessels and nerves from underneath. Side bending and neck stretching elevate them even more. The logical strategy is to adjust the ribs down out of the thoracic outlet and not farther up into the outlet.

Once you start self-manipulating your neck, you can't seem to stop the urge to keep cracking it 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 stabilize the cervical spine. These supporting ligaments are stretched a little more each time beyond their elastic limit. Pretty soon your ligaments become excessively stretched, your cervical spine becomes hypermobile, and it may even become cervically unstable.

These self-adjustments are addictive, and because you usually don't feel immediate pain, you assume there are no consequences. However, inflammation and painful muscle spasms, neck stiffness, and joint inflammation are commonly delayed 4–24 hours after straining the muscles and joints. The pain from stretching the scalene muscles often does not occur until several hours later, after the inflammation has had time to accumulate.

When you begin experiencing arm numbness, hand numbness, tingling in the fingers, shooting arm pain, radiating nerve pain, or thoracic outlet syndrome symptoms traveling down your arm and into your hand, you will finally stop.

You should only perform stretching exercises after the abnormal muscle contractions, protective muscle spasms, and excessive tension in all ten muscles have been released and after the inflammation has been reduced and flushed from the area. I recommend the thoracic outlet syndrome stretches, postural stretching exercises, and Human Spring stretching program presented in Chapter 14, "Spring Training."

Stretching Exercises

Some therapists recommend conservative treatment that focuses on stretching exercises for the neck and shoulder. These neck stretching exercises and shoulder stretching exercises are intended to target the scalene muscles, pectoralis muscles, and other shoulder muscles (2) (1). In my opinion, stretching over-contracted, inflamed muscles, and compressed soft tissues is contraindicated. In fact, excessive stretching of the tight neural tissues, connective tissues, and soft tissue structures can unnecessarily irritate the patient's symptoms, increase nerve irritation, and aggravate compression-related pain; therefore, it is not recommended (4).

2. General Massage

A general Swedish massage, relaxation massage, or full-body massage will not help relieve your thoracic outlet compression.

Structural massage is different. It involves myofascial therapy, myofascial release, neuromotor therapy, deep tissue therapy, and other manual therapy techniques that are intended to focus on particularly tense muscles, contracted muscles, muscle adhesions, fascial adhesions, and soft tissue restrictions that a therapist perceives are contributing to the abnormal changes in the body's biomechanics and movement mechanics. This is not general massage. This approach requires additional training and advanced manual therapy skills to perform effectively. I teach you how to perform your own structural massage, self-myofascial release, and soft tissue mobilization techniques in Chapter 13, "What Works and Why."

3. Traction

You might think that if you have compression affecting the outlet, then cervical traction, neck traction, or spinal traction would help separate the neck, shoulder, and chest. That is what your doctor and therapist probably thought too. However, your central nervous system and protective muscle reflexes are attempting to protect the area by contracting the muscles, and traction places additional strain on those already tight muscles and protective muscle spasms. Instead of reducing the compression forces, you may be working against your own nervous system, protective reflexes, and the body's natural protective muscle guarding mechanisms.

4. Hot Packs, Ultrasound, and Muscle Stimulation

Hot packs have been recommended to help facilitate effective stretching of the scalene muscles, pectoralis minor muscle, and other tight neck and shoulder muscles (5). They warm the area; however, they are only temporary. In fact, one of the leading causes 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.

Therapeutic ultrasound is only used for a particular area to help reduce localized 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 scalene muscles because it's too near the carotid sinus. Also, you can't put it over bones.

In my opinion, therapeutic ultrasound is a worthless therapy for compression syndromes, because it only targets a limited area. The human body needs to be modeled like a bag of hot water. Drugs and other chemicals, inflammatory chemicals, cytokines, metabolic waste products, and inflammation are like a tea bag in your bag of hot water. These substances work toward an equal distribution of chemicals, like when the tea seeps out of the bag to become equally distributed in the glass.

When you use therapeutic 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.

Electrical muscle stimulation, functional electrical stimulation (FES), neuromuscular electrical stimulation (NMES), and transcutaneous electrical nerve stimulation (TENS) are different methods of applying electrical current to modify the degree of muscle tension, muscle activation, and pain perception.

• 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 healing, wound care, and sometimes for pain relief
• Neuromuscular Electrical Stimulation (NMES)—used for muscle strengthening, muscle re-education, and neuromuscular rehabilitation

You might think that electrically stimulating muscles could both relax chronic muscle spasms, reduce muscle hypertonicity, and even strengthen the muscles that are supposed to be suspending the shoulder over the thoracic outlet and thoracic tunnel.

The problem is that you cannot effectively stimulate the exact 10 specific muscles that either directly or indirectly compress the thoracic outlet, brachial plexus, subclavian artery, and subclavian vein. Because the pectoralis minor and subclavius muscles are deep beneath the pectoralis major muscle, 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, such as the pectoralis minor muscles and/or scalene muscles. For instance, you should never electrically stimulate the thoracic area (chest) of anyone with cardiac arrhythmias, congestive heart failure, recent myocardial infarction, or other cardiovascular diseases. 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 contains numerous pressure receptors (baroreceptors) and sensory nerve endings that continuously monitor blood pressure. The carotid sinus is sensitive to any form of stimulation and, as a result, overstimulation can affect heart rate, blood pressure, and the amount of blood reaching the brain. This condition is known as carotid sinus hypersensitivity (CSH).

You should never apply electrical stimulation, TENS, IFC, or any other form of electrical current through the carotid sinus area, as it might cause changes in blood pressure, slow the heart rate, or reduce blood flow to the brain. In severe cases, loss of consciousness, convulsions, seizures, or syncope might occur when excessive stimulation affects these arteries.

Both therapeutic ultrasound and electrical stimulation therapies cannot be used over metal implants, such as screws and plates used during cervical spine fusion surgery for a herniated cervical disc. We all know metal is an excellent conductor of electricity. Therapeutic ultrasound would heat that metal so rapidly that you could suffer severe internal burns.

If your insurance policy has a limit on what you can spend treating your condition, spending time and money on hands-on therapy, manual therapy, deep tissue therapy, myofascial therapy, and soft tissue mobilization directed at the muscles that compress the thoracic outlet, narrow the thoracic tunnel, 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 electrical muscle stimulation that cannot be applied effectively to all 10 muscles involved in thoracic outlet compression.

About eight years ago, I decided all electrical therapy modalities, including TENS, interferential current (IFC), neuromuscular electrical stimulation (NMES), 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 muscle injections, anterior scalene injections, and local anesthetic injections to treat neurogenic thoracic outlet syndrome. Some use scalene muscle injections as a method of diagnosing thoracic outlet syndrome when patients present with typical patterns of neck pain, shoulder pain, arm pain, arm numbness, hand numbness, tingling, paresthesia, weakness, and nerve compression symptoms. 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 muscle injection helped support the diagnosis of thoracic outlet syndrome, but the relief of neck pain, shoulder pain, arm pain, numbness, tingling, and other compression 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 anterior scalene muscle, middle scalene muscle, or scalene muscle complex somehow contributed to the compression of the brachial plexus, subclavian artery, or subclavian vein causing thoracic outlet syndrome (4), if, in fact, there were other diseases or conditions that overlapped. So temporary relief after scalene muscle 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 muscles are not the only muscles that cause compression of the brachial plexus, nerves, arteries, and veins. The scalene muscles are just the muscles that elevate the first rib and upper ribs, compressing the thoracic outlet, narrowing the interscalene triangle, and contributing to neurovascular compression.

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, muscle spasm, myofascial tightness, or muscle shortening in the other muscles of the shoulder, neck, and chest, such as:

• Anterior scalene muscle
• Middle scalene muscle
• Posterior scalene muscle
• Subclavius muscle
• Biceps short head muscle
• Coracobrachialis muscle
• Pectoralis minor muscle
• Anterior cervical (neck) muscles
• Latissimus dorsi muscle
• 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 first rib resection (surgical removal of the first rib), after the surgery was over, the wounds healed, and the painkillers wore off, the thoracic outlet, costoclavicular space, and interscalene triangle would still be compressed by the other muscles, and you would still have about the same degree of brachial plexus compression, thoracic outlet compression, nerve compression, and vascular 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 (pectoralis minor tenotomy) in an attempt to further reduce brachial plexus compression, subclavian vessel compression, and thoracic outlet compression.

6. Scalene Injection (Botox)

Recently, doctors have been injecting the anterior scalene muscle and middle scalene muscle with botulinum toxin (Botox) for temporary relief of neck pain, muscle spasms, and symptoms resulting from compression of the brachial plexus, compressed nerves, and compressed blood vessels in the thoracic outlet. Botox is injected into the tight, hypertonic, 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, reducing muscle tension, muscle spasm, and muscle guarding.

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

Botox does nothing for inflammation, chronic inflammation, swelling, soft tissue inflammation, or the underlying cause of nerve compression.

You might think this will help, 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 thoracic outlet, brachial plexus, subclavian artery, and subclavian vein 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 muscle atrophy, muscle weakness, and loss of muscle strength in the muscles of the arm, which is noticeable when the cast is removed. Imagine the amount of muscle atrophy, disuse atrophy, and muscle wasting 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 muscle atrophy, neck muscle weakness, and loss of muscular strength, which will require months of physical rehabilitation, strengthening exercises, and muscle reconditioning 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, nerve compression, and brachial plexus compression 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, numbness, tingling, or function in this population of subjects with thoracic outlet syndrome (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 neurogenic thoracic outlet syndrome." (13)

Some doctors think there is an advantage to using Botox over hands-on therapy, manual therapy, and soft tissue treatment, 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.

• The purpose of therapy to the muscles is to reduce muscle spasm, muscle hypertonicity, and protective muscle guarding. 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 muscle atrophy, loss of muscle mass, and muscle weakness that there is a noticeable difference in the size of the casted arm versus the normal arm. Imagine how weak your neck muscles, shoulder stabilizers, and postural muscles would be after the nerve supply was shut down for up to six months (25 weeks or more)!
• There are 10 muscles that either directly or indirectly contribute to the compression of the thoracic outlet area. Because they only inject the anterior scalene and middle scalene muscles, 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, it would be as if your neck, shoulder, and upper quarter musculature 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 physical rehabilitation program, strengthening program, neuromuscular rehabilitation, and progressive exercise program to rebuild the strength in the muscles that were paralyzed by the neurotoxin.

Botox Injections Weaken Muscles Instead of Restoring Function

You already have enough work to redevelop the strength in the muscles that support the thoracic outlet, shoulder girdle, and thoracic outlet anatomy so the shoulder doesn't fall into the brachial plexus, subclavian artery, and subclavian vein. Deadening nerves and making muscles even weaker will make your active rehabilitation, physical therapy, muscle strengthening, and functional recovery an incredibly daunting task. Please do not make your life more difficult.

If you had a muscle cramp, muscle spasm, or calf muscle spasm 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 musculoskeletal rehabilitation, conservative treatment, and functional restoration. When muscles don't contract for months, they no longer pull against the bone to stimulate bone remodeling, bone formation, and the normal processes that help prevent osteoporosis and bone loss.

The decision to treat a patient with Botox injections, botulinum toxin injections, or scalene muscle injections should be undertaken carefully, as there are other potential complications with this injection, including muscle weakness, difficulty swallowing (dysphagia), and neurological complications affecting the laryngeal muscles, voice muscles, and voice box (larynx) that can make speaking difficult.

Deep Tissue Therapy Restores Strength Instead of Creating Weakness

Also, Botox injections do not accomplish the same result as deep tissue therapy, deep tissue massage, manual therapy, or myofascial release in reducing muscle tension, muscle contraction, and muscle spasms. When muscles are in a muscle spasm, they remain continuously contracted. If a muscle is already contracted, it cannot contract any further, which is why it becomes weak.

When we perform deep tissue therapy on muscles that have remained contracted 24 hours a day, they begin to relax. As those muscles relax, they regain the ability to contract normally again. Every time a muscle spasm is reduced, the muscle becomes stronger because more muscle fibers are once again able to participate in normal contraction.

By contrast, Botox injections completely shut down muscle contraction for up to six months, producing immediate muscle weakness, severe muscle atrophy, muscle deconditioning, and loss of functional muscle strength, making rehabilitation far more difficult.

A Real-World Example of Botox Complications

In 2007, I attended a gala party at the Hôtel de Paris Monte-Carlo for the Anti-Aging Medicine World Congress in Monte Carlo, Principality of Monaco. Sitting next to me was a beautiful young woman. I noticed she had styled her hair so that a strand covered her right eye. I asked who had done her hairstyle.

She replied, "I did it! My husband, the doctor, gave me Botox injections for my jaw pain and temporomandibular joint (TMJ) pain, and it paralyzed the muscles that close my eye. Now I can't close my eye for weeks."

I felt genuinely sorry for her.

Deep Tissue Therapy Is a More Logical First Step

Botox injections are expensive. If you believe the scalene muscles, anterior scalene, middle scalene, pectoralis minor, and other neck muscles are contributing to compression of the brachial plexus, subclavian artery, subclavian vein, and thoracic outlet, then rather than spending $300–$5,000 per injection, you could invest in 2–30 hours of deep tissue therapy, deep tissue massage, myofascial release, and manual soft tissue therapy directed at the scalene muscles, pectoralis minor, and the surrounding muscles that compress the outlet.

This conservative treatment allows you to determine whether relieving muscle tension, nerve compression, vascular compression, and pressure on the outlet through natural, non-surgical means improves your symptoms before considering more invasive procedures.

7. Nerve Gliding

Nerve gliding (nerve flossing)—Dr. Ahmad Wehbe describes a series of nerve gliding exercises that can be employed to safely reduce tension on the brachial plexus nerves, peripheral nerves, and upper extremity nerves during activities of daily living, arm movements, and neck movements (14).

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

If you spent the time decompressing the thoracic outlet, opening the thoracic tunnel, and reducing brachial plexus compression, 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 (macromastia, large breasts) might benefit from a supportive bra, posture-support bra, or properly fitted bra that better supports their breasts. I would highly recommend this as a part of the treatment, but obviously only after the scalene muscle super contractions, muscle spasms, and muscle tension have released their lockdown on the thoracic outlet, thoracic tunnel, and neurovascular bundle.

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 compression, brachial plexus compression, vascular compression, and thoracic outlet syndrome. Therefore, breast reduction surgery (reduction mammoplasty) is considered and needs to be discussed with your doctor. It is never the only reason for developing thoracic outlet syndrome, nerve compression, or blood vessel compression, so a combined conservative treatment approach, rehabilitation program, and biomechanical correction are always recommended.

10. First Rib Adjustments Alone

First rib adjustments, first rib mobilization, and first rib manipulation are medically necessary to adjust the first rib and second rib down out of the thoracic outlet, thoracic tunnel, and costoclavicular space. 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 fibrous adhesions, scar tissue adhesions, and connective tissue adhesions that have glued the ribs in this elevated position. Movements of joint play, accessory joint motion, and joint mobility are independent of the action of muscles.

Joint play, also called accessory joint motion, is the natural healthy movement of the joint that allows full, unrestricted range of motion, joint mobility, and normal joint mechanics. 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, joint mobility, or joint spring, subluxations.

Joint mobility, joint play, and accessory motion are 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 anterior scalene, middle scalene, and posterior scalene muscles shift the ribs out of their natural position, affecting the natural joint play, reducing joint mobility, and causing compression of the brachial plexus, subclavian artery, and subclavian vein as they pass through the thoracic outlet. That is why surgeons perform first rib resection and 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 muscle tone, muscle balance, and neuromuscular control 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, first rib dysfunction, and thoracic outlet compression. In most cases, the first rib adjustment is required for complete relief. I adjust the first rib, second rib, 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 one where you can feel the ribs physically move under your hand out of the thoracic outlet, thoracic tunnel, and costoclavicular space. This adjustment isn't easy, because you have to be able to gently manipulate the ribs through the thick, powerful trapezius muscle. It takes a fine art and a great deal of confidence, experience, and refined palpation skills to perform it correctly.

When I adjust your first rib and second rib, you will feel the ribs move. The first few times you are adjusted there is a loud audible release and substantial movement is felt. After subsequent adjustments, the sound and amount of movement felt are far less. After the adjustment, most patients laugh out loud and exclaim, "Wow," because they notice immediate improvements in neck mobility, shoulder mobility, arm symptoms, and overall comfort immediately after the release.

Rib adjustments are most commonly performed by chiropractors, manual therapists, and some physical therapists. However, just because you go to a chiropractor doesn't mean he or she can perform an effective first rib adjustment. The level of skill in performing first rib mobilization and first rib manipulation varies considerably. Before I went into practice, I studied and sampled at least 50 or more chiropractors' first rib adjustment techniques to determine which approach produced the best results.

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 thoracic outlet, it can cause a shift of the clavicle (collarbone), scapula (shoulder blade/wing bone), and humerus (upper arm bone) into an abnormal position. The shifting of these bones within the shoulder joint, acromioclavicular (AC) joint, and sternoclavicular (SC) joint alters normal joint mechanics, joint alignment, and joint play, requiring joint mobilization or joint manipulation to restore normal shoulder biomechanics, range of motion, and pain-free movement.

You cannot release the thoracic outlet area by simply releasing the spasms in the subclavius, pectoralis minor, coracobrachialis, biceps short head, and the other muscles involved without also correcting the abnormal joint alignment, restricted joint play, and shoulder joint dysfunction. Restoring normal joint play, rib mobility, first rib mobility, clavicle mobility, scapular motion, and shoulder biomechanics is an art that takes years to master. Many patients with thoracic outlet syndrome, chronic neck pain, shoulder pain, arm numbness, and hand tingling call me frustrated in their search for a chiropractor skilled in first rib adjustment, first rib mobilization, shoulder joint manipulation, and thoracic outlet rehabilitation. Only a handful have reported finding someone in their area capable of effectively restoring normal shoulder joint mobility, rib motion, and thoracic outlet mechanics.

11. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) for inflammation and pain relief

12. Medication: Analgesic drug therapy, antidepressants, anticonvulsants, and other prescription pain medications

13. Painkillers for symptom reduction and chronic pain management

As mentioned in previous chapters, inflammatory cytokines, pro-inflammatory chemicals, and other inflammatory mediators stimulate the nociceptor pain receptors, causing pain signals to travel to the brain that something is wrong. The brain then responds with protective muscle contractions, muscle guarding, and muscle spasms. These protective reflexes contribute directly to compression of the brachial plexus, compression of the subclavian artery, compression of the subclavian vein, and narrowing of the thoracic outlet. Obviously, this inflammation, metabolic waste, and inflammatory chemicals must not only be removed from the affected muscles but reduced throughout the body to help eliminate the neurological reflexes that continually retrigger these powerful muscle contractions.

When you visit most doctors, they typically ask, "Do you want something for your pain?" They commonly prescribe pain medication or medications designed to reduce inflammation and pain symptoms. Their options generally include nonopioid analgesics, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen, or opioid analgesics for more severe pain.

Nonopioid Analgesics (NSAIDs)

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed for mild to moderate pain, musculoskeletal pain, joint pain, and soft tissue inflammation. Did you know that the use of some NSAIDs has been associated with an increased risk of cardiovascular complications, including heart attack (myocardial infarction), stroke, blood clot formation (thrombosis), and other potentially fatal cardiovascular adverse events? Research suggests that this risk may increase with longer duration of use.

So, your blood flow is already reduced because compression of the subclavian artery and subclavian vein restricts circulation, yet you may be prescribed a medication that carries an increased risk of blood clot formation and thrombosis, potentially making an already compromised circulation problem even worse. In many cases, the temporary reduction in pain symptoms does not outweigh the potential cardiovascular risks.

Opioid Analgesics

When it comes to chronic pain, severe pain, chronic nerve pain, and neuropathic pain, opioid analgesics, including morphine, oxycodone, hydrocodone, and codeine, are among the most powerful prescription pain medications in a doctor's arsenal. They are also among the most addictive and potentially dangerous.

Opioid Pain Medications Do Not Treat the Underlying Cause

These powerful and addictive opioid medications do not turn off the reflexes in the brain that produce muscle spasms, protective muscle guarding, and abnormal muscle tension responsible for nerve compression, blood vessel compression, and compression of the thoracic outlet. That means you will more than likely remain on these prescription opioids indefinitely, eventually developing opioid dependence, opioid addiction, and increasing drug tolerance the longer you take them.

The Decade of Pain Control—But Not the Cause of Pain

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 chronic pain, acute pain, and pain symptoms in all patients (15). They did not encourage physicians to assess and treat the root cause of pain, the underlying cause of chronic pain, or the mechanical cause of pain—only the pain itself.

The use of prescription opioid 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 so little about the root cause of chronic pain, compression syndromes, and musculoskeletal pain disorders today.

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

Opioids Are Poor Treatments for Nerve Compression Symptoms

I have found that these drugs are not effective for nerve pain, neuropathic pain, or compression neuropathy, so how are they good for symptoms such as arm numbness, hand numbness, tingling arms, tingling hands, arm weakness, hand weakness, and poor circulation caused by restricted blood flow, vascular compression, and nerve compression in the arms? The symptoms of thoracic outlet syndrome are not manifested the same way as low back pain, knee pain, or arthritis pain. The symptoms are caused by pinched nerves, brachial plexus compression, compressed blood vessels, and reduced blood flow into and out of the arms. Pain medication does nothing to restore normal nerve function, improve circulation, or relieve the symptoms of numbness, tingling, weakness, and loss of sensation.

Tramadol and Pinched Nerve Pain

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

Serious Side Effects of Tramadol

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 prescription opioid medication is dangerous.

Recognized risk factors for tramadol overdose include depression, opioid addiction, and seizure disorders. Long-term use of high doses of tramadol may be associated with physical dependence, opioid dependence, and withdrawal syndrome. In most cases, tramadol withdrawal will begin 12–20 hours after the last dose, although this can vary. Opioid withdrawal symptoms from tramadol often last longer than those 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.

A Real Patient Example

I once had a patient taking eight tramadol tablets 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, arm pain, and chronic pain go from a 10/10 to a 9/10. So, he developed kidney damage, liver damage, and placed himself at risk for drug overdose, opioid overdose, and death to achieve only a 10 percent reduction in pain.

Understanding that he was at a high risk of opioid overdose or death—not from the thoracic outlet syndrome but from the opioid medications he was taking for the thoracic outlet syndrome—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 discontinue all pain medications the next morning.

Breaking the Cycle of Opioid Dependence

I have helped many patients discontinue opioid painkillers, prescription opioids, and narcotic pain medications by ending the cycle of chronic pain. If patients have no pain or significantly less pain, there is no longer a reason to take these medications. If necessary, we help them enter a drug treatment program or opioid addiction treatment program.

These drugs are not candy, and if you are treating them like that, then you need to enter a drug rehabilitation program or opioid addiction treatment program. Getting off opioids is no joke. The discontinuation of these powerful drugs leads to intense opioid withdrawal symptoms, including drug cravings, anxiety, restlessness, vomiting, excessive sweating, and a racing heart.

Opioid Withdrawal and Relapse

Professionally administered opioid withdrawal treatment is usually not as effective as you might 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 require maintenance pharmacotherapy with methadone, buprenorphine, or naltrexone to reduce the risk of relapse.

Treat the Cause—Not Just the Pain

You could lose your friends, your family, your job, and even your life if you become addicted to these drugs. Don't use opioid pain medications simply to ease the pain while you think about what to do to eliminate the underlying condition. Address the root cause of chronic pain, restore normal nerve function, improve blood flow, reduce nerve compression, and begin correcting the underlying cause now.

Antidepressants

Doctors might put you on antidepressant medications. Who wouldn't be depressed if they had chronic pain, persistent neck pain, shoulder pain, arm pain, and constant discomfort? Especially if your doctors don't know what causes your condition and can't offer you any long-term pain relief or lasting recovery. These drugs include tricyclic antidepressants (TCAs); selective serotonin reuptake inhibitors (SSRIs); and antidepressants such as paroxetine (Paxil), fluoxetine (Prozac), sertraline (Zoloft), nefazodone (Serzone), and venlafaxine (Effexor).

When you try to get off these drugs, you may experience SSRI discontinuation syndrome, also known as SSRI withdrawal syndrome or SSRI cessation syndrome. Withdrawal can be broken into two phases: immediate symptoms, occurring within six weeks of discontinuation, and 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 sensations, sweating, nausea, insomnia, tremors, confusion, nightmares, and vertigo.

Doctors also routinely prescribe anticonvulsant medications, antiepileptic drugs, or nerve pain medications, such as clonazepam, topiramate, gabapentin, lamotrigine, tiagabine, and zonisamide. These drugs have been tried for the treatment of nerve pain, neuropathic pain, chronic nerve pain, and compression-related pain. Muscle relaxants are also commonly prescribed for muscle spasms, including metaxalone (Skelaxin), cyclobenzaprine (Flexeril), benzodiazepines, and tizanidine.

Metaxalone's exact mechanism of action is not known, but it may work through general central nervous system depression. Cyclobenzaprine is intended to decrease acute muscle pain during the first two weeks of use, peaking within the first few days, but has no proven long-term benefit after two weeks. Then what?

Here's the bottom line: painkillers, prescription pain medications, and analgesic drugs are unable to reverse the brain-patterned muscle spasms, abnormal muscle tension, or protective muscle guarding that maintain your pain. They also carry significant risks. Muscle relaxants have not been shown to reverse the specific muscle spasms, muscle tightness, or compression patterns responsible for symptoms and expose the body to unnecessary side effects. I never use them or recommend them. Nonsteroidal anti-inflammatory drugs (NSAIDs) and other anti-inflammatory medications are not going to reverse the compression of nerves and blood vessels or restore normal biomechanics.

The typical cost for outpatient addiction treatment is approximately $10,000. Residential alcohol and drug rehabilitation programs typically range from $20,000 to $32,000, depending on the level of care required. Additional services, including behavioral counseling, mental health therapy, addiction counseling, and prescription medications, are billed separately when needed.

14. Ergonomic Corrections and Daily Activities

• Your activities of daily living, work habits, posture, and movement patterns must not exacerbate the condition.
• Correction of the Ergonomics of the Workstation
• Ergonomic Corrections

Ergonomic corrections, postural correction, and workstation modifications do help reduce symptoms. Even if I treated you for 100 days for 100 hours, you would not improve if you did not follow the laws of gravity, maintain proper body mechanics, and keep your body in harmony with gravity. Because poor posture, forward head posture, rounded shoulders, prolonged computer posture, and sustained muscle contraction caused by poor ergonomics contribute to the condition, ergonomic improvements are essential. I had an attorney tell me that he experienced 40 percent pain relief simply by following the ergonomic recommendations, workstation adjustments, and postural corrections I gave him.

However, simply correcting your workstation ergonomics or posture will not completely eliminate your symptoms. There are six criteria that must be met to completely eliminate the condition once and for all. I discuss these in Chapter 13.

• The muscles that suspend the shoulder, maintain shoulder stability, and preserve the thoracic outlet space must be strengthened to open the thoracic outlet, maintain adequate neurovascular space, preserve the safe passage of nerves and blood vessels, and prevent recurrent compression.

15. 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 rehabilitation, strengthening exercises, resistance training, weightlifting, physical therapy exercises, therapeutic exercise programs, or stretching exercises 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 muscle spindle cells, proprioceptors, strain receptors, and mechanoreceptors, which can lead to a worsening of your condition or a new injury.

The abnormal movement of the joints affects the natural joint glide, joint rotation, joint mobility, arthrokinematics, and normal joint mechanics needed for healthy joint play. Putting additional pressure on the area with resistance exercises, strength training, weight training, resistance bands, or upper-body workouts can cause further compression of the outlet and wear and tear of the joints that can increase inflammation, soft tissue irritation, joint degeneration, and chronic pain.

Therapists often recommend physical therapy exercises, strengthening exercises, stretching programs, rehabilitation exercises, posture exercises, and corrective exercises as treatment for a compressed neck, upper back, shoulder, and thoracic outlet. Many therapists and doctors simply think exercise therapy, rehabilitation, stretching, and strengthening will fix everything. They don't realize that aggressive strengthening, resistance exercise, and upper-body loading are contraindicated with an active thoracic outlet syndrome.

Exercise Risks During Active Compression

You should not lift weights when you have thoracic outlet syndrome because the area is already significantly compressed, and more external forces could cause the cervical discs, intervertebral discs, brachial plexus, subclavian artery, or subclavian vein to become further compressed. This additional compression can contribute to a cervical disc herniation, nerve compression, vascular compression, arterial compression, venous compression, blood clot formation, deep vein thrombosis (DVT), or venous thoracic outlet obstruction. A blood clot, called an embolus, may then travel to the lung and become a pulmonary embolism (PE), creating a life-threatening medical emergency that may require emergency surgery, emergency vascular treatment, or clot-dissolving therapy.

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, your superficial veins become more prominent on one side, and you notice arm swelling, discoloration, bluish skin (cyanosis), venous congestion, or reduced circulation. That is when you call 911 and get to the hospital immediately for clot-buster therapy, emergency vascular treatment, thrombectomy, or surgery.

According to the Centers for Disease Control and Prevention (CDC), the precise number of people affected by deep vein thrombosis (DVT) and pulmonary embolism (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 deep vein thrombosis (DVT), pulmonary embolism (PE), or venous thromboembolism (VTE) each year. 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 survive a pulmonary embolism, 10 to 30 percent of people die within one month of diagnosis.

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

Restore Compression Before Beginning Exercise

First release the compression, then it is safer to begin exercise rehabilitation, strengthening exercises, sports rehabilitation, functional training, and performance training. Also, the Human Spring must be trained as a Human Spring. This means incorporating Human Spring training, spring training, plyometric training, elastic recoil training, impact training, reactive drills, dynamic movement drills, and functional spring exercises that strengthen the Human Spring through controlled impacts.

In the condition you are currently in, impacts would feel more like a thud than a spring. Obviously, this comes later in your recovery after treatment, but it is the long-term goal we will be working toward for long-term Human Spring health, injury prevention, athletic performance, healthy biomechanics, resilience, and lifelong musculoskeletal health.

Conclusion

We've gone systematically through the six requirements that must be be satisfied to effectively reverse the causes of thoracic outlet syndrome. We've also discussed the sixteen different conservative treatment approaches, non-surgical treatment options, rehabilitation methods, physical therapy interventions, chiropractic treatments, exercise therapies, manual therapies, and medical management approaches listed in the U.S. National Library of Medicine, part of the National Institutes of Health (NIH), and found them ineffective when used by themselves for long-term relief of thoracic outlet syndrome.

Unfortunately, you have been led to believe that these conservative treatments, physical therapy programs, rehabilitation protocols, chiropractic adjustments, exercise programs, stretching routines, massage therapy techniques, injections, medications, and surgical recommendations are effective for thoracic outlet syndrome. Otherwise, why would they be recommended? So, after seeing a few physical therapists, a chiropractor or two, and perhaps several medical specialists, you are probably thinking that you have tried everything and there is no other alternative.

Now you can see why it is common to experience failure of a carefully supervised physical therapy program, rehabilitation program, strengthening program, exercise program, or conservative treatment plan, ultimately leading to surgery that was never medically necessary.

Spring ahead and learn why surgery is recommended for thoracic outlet syndrome, when surgery may be considered, why surgery often fails to address the underlying cause of compression, and whether it is truly an effective long-term treatment for lasting pain relief and recovery.