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5 November 2008
Last Full Update: 19 August 2010;
Updated: 19 May 2011 |
Thoracic Outlet Syndrome: Overview |
This page presents a collection of selected, fully referenced excerpts and qualitative links on Thoracic Outlet Syndrome (TOS), with
definitions and descriptions, information on the affected anatomy, diagnostic criteria, pathophysiology, epidemiology, treatment strategies and
procedures, doctor lists, forums, and clinical papers.
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Thoracic outlet syndrome (TOS) is a common condition that is recognized uncommonly because the manifestations are varied and there is no single
definitive test for it. Radiographs, MRIs, and even EMGs cannot make the diagnosis with certainty. Unfortunately many physicians doubt the diagnosis
if the pathology cannot be seen radiographically or measured electrophysiologically.
Conceptually TOS is simple. It is a symptom complex caused by compression of the brachial plexus, or the axillary-subclavian artery or vein as
they exit the chest. The clinical presentation is highly variable, depending on what parts of the brachial plexus are involved and to what extent the
circulatory system is involved. The purely vascular forms of thoracic outlet syndrome are diagnosed easily but are uncommon. Neurologic compression
is more difficult to diagnose. The physician needs to discern which symptoms relate to the brachial plexus, which relate to the major vessels, and which
are totally unrelated. Because the presentation is so varied, each patient represents a challenge in physical diagnosis. Diagnosis is based on the total
clinical picture, which is made up of a meticulous history, a complete physical examination, and a review of medical records.
As experience with this common though complicated disorder has increased, several basic concepts have emerged. Once these concepts are
understood, it is possible to make an exact diagnosis and to plan specific, effective management.
Basic concepts of thoracic outlet syndrome
There is a mechanical predisposition.
People who develop clinical manifestations of TOS have one or more congenital anomalies that
predispose them to develop symptoms. Thoracic outlet syndrome is a mechanical space problem. Because of the invariable underlying congenital
anomalies and often a superimposed injury causing chronic muscle spasm, the space for the major structures of the outlet becomes compromised.
This restriction of space precipitates the symptom complex of TOS. Treatment is directed to correcting the space problems either by
physical therapy, exercise, or surgical decompression. The longer the space problem exists the more damage is done to the structures, particularly to
the nerves of the brachial plexus.
TOS symptoms are primarily neurologic
In 98% of cases the symptoms are neurologic. Fifteen percent may have some concomitant arterial symptoms, but arterial symptoms seldom
exist alone. Symptoms caused by pure venous compression occur in 1.5% of patients and usually present as axillary subclavian vein thrombosis.
Physicians who diagnose only the vascular forms of thoracic outlet syndrome are misdiagnosing the vast majority of patients they see who have this
neurologic condition.
Structural anomalies cause the problem
These abnormalities have been well described. Each has a specific effect and few of them compromise the circulation. For this reason, using
circulatory tests as the basis for specific diagnosis commonly leads to error. Muscle spasm is important and aggravates the structural problems.
Injuries lead to fibrosis, which further aggravates the structural problems.
Accurate diagnosis is based on the total clinical picture
There are no short cuts. A careful, even exhaustive history and physical examination are required, together with selective testing. Knowledge
of other conditions that may belong in the domain of other specialists is required. When a patient presents with thoracic outlet syndrome
symptoms, the goal should be to figure out an accurate diagnosis and not just to determine if thoracic outlet syndrome is present or absent. This
may require a team of physicians and therapists.
Symptoms
TOS occurs in young and middle-aged adults and is three times as frequent in women as in men. Symptoms may develop spontaneously or following
trauma of a type that causes chronic muscle spasm in the neck or shoulder region. [...] [Read More] |
Thoracic Outlet Syndromes
Definition
Thoracic outlet syndromes are a group of disorders that cause pain and abnormal nerve
sensations in the neck, shoulder, arm, and/or hand.
Description
The thoracic outlet is an area at the top of the rib cage, between the neck and the chest. Several anatomical structures pass through this area, including
the esophagus, trachea, and nerves and blood vessels that lead to the arm and neck region. The area contains the first rib; collar bone (clavicle); the
arteries beneath the collar bone (subclavian artery), which supply blood to the arms, a network of nerves leading to the arms (brachial plexus); and the top of
the lungs.
Pain and other symptoms occur when the nerves or blood vessels in this area are compressed. The likelihood of blood vessels or nerves in the thoracic outlet
being compressed increases with increased size of body tissues in this area or with decreased size of the thoracic outlet. The pain of thoracic outlet syndrome
is sometimes confused with the pain of angina that indicates heart problems. The two conditions can be distinguished from each other because the
pain of thoracic outlet syndrome does not appear or increase when walking, while the pain of angina does. Also, the pain of thoracic outlet syndrome usually
increases if the affected arm is raised, which does not happen in cases of angina.
There are three types of thoracic outlet syndromes:
- True neurogenic thoracic outlet syndrome is caused by a compression of the
nerves in the brachial plexus. Abnormal muscle or other tissue causes the problem.
- Arterial thoracic outlet syndrome is caused by compression of the major
artery leading to the arm, usually by a rib.
- Disputed thoracic outlet syndrome describes patients who have chronic pain
in the shoulders and arms and have no other disease or syndrome, but the
underlying cause cannot be accurately determined.
- [Read More]
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What is Thoracic Outlet Syndrome?
TOS is an umbrella term that encompasses three related syndromes that cause pain in the arm, shoulder, and neck: neurogenic TOS (caused by compression of the brachial plexus), vascular TOS
(caused by compression of the subclavian artery or vein) and nonspecific or disputed TOS (in which the pain is from unexplained causes). Occasionally, neurogenic TOS and vascular
TOS co-exist in the same person. Most doctors agree that TOS is caused by compression of the brachial plexus or subclavian vessels as they pass through narrow passageways leading
from the base of the neck to the armpit and arm, but there is considerable disagreement about its diagnosis and treatment. Making the diagnosis of TOS even more difficult is
that a number of disorders feature symptoms similar to those of TOS, including rotator cuff injuries, cervical disc disorders, fibromyalgia, multiple sclerosis, complex regional pain
syndrome, and tumors of the syrinx or spinal cord. Symptoms of TOS vary depending on the type.
Neurogenic TOS has a characteristic sign, called the Gilliatt-Sumner hand, in which there is severe wasting in the fleshy base of the thumb. There may be
numbness along the underside of the hand and forearm, or dull aching pain in the neck, shoulder, and armpit.
Vascular TOS features pallor, a weak or absent pulse in the affected arm, which also may be cool to the touch and appear paler than the unaffected arm. Symptoms may include
numbness, tingling, aching, and heaviness.
Non-specific TOS most prominently features a dull, aching pain in the neck, shoulder, and armpit that gets worse with activity. Non-specific TOS is frequently triggered by
a traumatic event such as a car accident or a work related injury. It also occurs in athletes, including weight lifters, swimmers, tennis players, and baseball pitchers.
TOS is more common in women. The onset of symptoms usually occurs between 20 and 50 years of age. Doctors usually recommend nerve conduction studies, electromyography, or imaging
studies to confirm or rule out a diagnosis of TOS. [...] [Read More] | |
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[...]
Some of the more common provocation tests that can suggest the presence of thoracic outlet syndrome include:
- Adson's maneuver. For this test, you'll be asked to turn your head toward the symptomatic shoulder while you extend your arm, neck and shoulder slightly away from
your body. While you inhale, your doctor will check for a pulse on the wrist of your extended arm. If your pulse is diminished or if your symptoms are reproduced during the maneuver, your
doctor considers this a positive test result, which may indicate thoracic outlet syndrome. Because false-positives often occur, your doctor may repeat the test
on the unaffected side.
- Wright test. From a sitting position and with the help of your doctor, you'll hold your arm up and back (hyperabduction),
rotating it outward, while your doctor checks your pulse to see if it's diminished. As in the Adson's maneuver, your doctor will want to know if your
symptoms are reproduced during the test.
- Roos stress test. From a sitting position, your doctor will ask you to hold both elbows at shoulder height while pushing your shoulders back. You will
then repeatedly open and close your hands for several minutes. If your symptoms are present after the test, or if you feel heaviness and fatigue in your shoulders,
this can indicate the presence of thoracic outlet syndrome.
To confirm the diagnosis of thoracic outlet syndrome, your doctor may also order one or more of the following tests:
- X-ray. Your doctor may order an X-ray of
the affected area, which may reveal an extra rib (cervical rib) and can also rule out other conditions that may be causing your symptoms.
- Magnetic resonance imaging (MRI) scan. MRI is a painless procedure that uses a magnetic field and radio waves to create computerized images of the soft tissues of your body. These images can help your
doctor determine the location and cause of compressions of the brachial plexus nerves or the subclavian artery. The scans may also reveal any congenital
anomalies — such as a fibrous band connecting your spine to your rib or a cervical rib — that may be the cause of your symptoms.
- Electromyography (EMG). This test enables your doctor to see and hear how your muscles and nerves are working. To conduct
the test, a small electrode needle is inserted through your skin and into the muscles near where you're having symptoms. The electrical activity detected by
this electrode is displayed on a monitor and may be heard through a speaker.
- Nerve conduction study. Also called nerve conduction velocity, this test measures the speed of conduction of impulses
through a nerve. Doctors use the test to evaluate possible nerve damage. Small electrodes are placed on your skin over the area being tested, and a tiny
electrical current is sent to the nerves in your thoracic outlet. The electrical signals produced by nerves and muscles are picked up by a computer, and the
information is interpreted by a doctor trained in electrodiagnostic medicine.
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The most reliable test for TOS is the "elevated arm stress test," (EAST) described by Roos. It is
performed by having the patient put both arms in the 90º abduction–external rotation position,
with the shoulders and elbows in the frontal plane of the chest. The patient is then instructed to open
and close the hands slowly over a 3-minute period. Normally the patient can perform this stress test
for 3 minutes with only forearm muscle fatigue and minimal distress. In those with an outlet
syndrome, the test reproduces the usual symptoms: gradual increase of pain in the neck and
shoulder, aching progressing down the arm, and paresthesias developing in the forearm and
fingers. Those with arterial compression develop arm pallor with the arm elevated and reactive
hyperemia when the limb is lowered. Those with venous compression may develop cyanosis and
swelling. Many patients with TOS are unable to complete this test and drop the arms to the lap in
marked distress, which they recognize as reproduction of their usual symptoms. An occasional
patient with carpal tunnel syndrome may get some numbness in the fingers, but this is from compression
of the median nerve during squeezing of the hand and is confined to the first three fingers,
a different response from TOS. A patient with cervical disc syndrome may get pain in the neck
and shoulder from holding the arms elevated but feels minimal distress in the arm or hand.
A patient with orthopedic shoulder problems may experience intolerable symptoms but they are
confined to the shoulder area. The important characteristics of a positive test include reproduction
of usual symptoms that involve the entire extremity. The duration of tolerance of this test
may reflect the severity of the TOS.
Nerve tension tests of the upper extremity have been described that correspond to straight leg raising
as a test for nerve impingement in the lower extremity. Upper limb tension tests have been described that are median, ulnar, or
radial nerve dominant. Although they may be well accepted by physiotherapists and do provide
objective measurements, their role in separating TOS from other upper extremity nerve problems
is not well documented. [...] [Read More]
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Etiology
Trauma
The etiology of neurogenic thoracic outlet syndrome (TOS) is believed to be a combination
of neck trauma plus an anatomic predisposition. The basis for regarding neck trauma as the
primary etiology stems from observations in most of a few thousand patients whose symptoms of
pain in their necks and arms and paresthesia in their hands developed shortly after a motor vehicle
accident. This observation was followed by microscopic studies that demonstrated significant histologic
changes in the scalene muscles of patients with neurogenic TOS. Neck trauma may occur
as a single acute incident or it can develop insidiously following repeated small episodes of
neck strain.
Acute neck trauma
Motor vehicle accidents have a high incidence of whiplash injuries. This is the most common
mechanism causing neurogenic TOS. More than half of the patients the authors see with neurogenic
TOS developed their symptoms following a motor vehicle accident. Other investigators
also have noted a high incidence of neck trauma. Studies of whiplash injuries following motor
vehicle accidents by several authors revealed that more than 30% of these patients developed
symptoms of neurogenic TOS; although most patients responded to conservative therapy, a fair
number went on to surgical decompression of the thoracic outlet.
Repetitive stress and posture
The next most common cause of neurogenic TOS is repetitive stress injury in the work place.
This develops in people who work at keyboards, on telephones, on assembly lines, or who sit in one
position for several hours at a time. The specific cause is repeated small traumata to the neck
muscles over a prolonged period of time either by frequently turning the neck back and forth,
holding a telephone by bending the ear against the shoulder, or poor posture causing muscle
imbalance. In muscle imbalance, some muscles are overused and others underused. TOS attributable
to these causes frequently is associated with cumulative trauma syndrome, which includes
carpal tunnel, pronator tunnel, radial tunnel, and cubital tunnel syndromes together with TOS.
Support for the influence of posture on TOS symptoms comes from a survey of more than 1000
dentists, 98% of whom responded. In this group of dental practitioners, there was a 29%
incidence of pain and paresthesia noted in the upper extremities. In a similar study of dental
hygienists, 26% were noted to have symptoms of carpal tunnel syndrome. This emphasizes the
importance of posture and position in the etiology and treatment of neuropathies caused by muscle
imbalance or overuse. Other etiologies that may play a small role in
causing neurogenic TOS are large, heavy breasts and carrying heavy backpacks. These causes are
uncommon but do occur. [...] [Read More] | |
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Background
Thoracic outlet syndrome (TOS) is a controversial topic in the literature; many proponents support the existence of the condition, but some strongly vocal
opponents doubt the validity of TOS as a medical entity. Even the name itself has been questioned because the actual site of pathology is technically the
thoracic "inlet," not the "outlet." The primary controversy seems to center around the lack of objective criteria for diagnosis and the confusion with
multiple types or clinical presentations.
Since TOS involves proximal neurovascular structures (see image below and Image 1), symptoms often are confused with various
distal compression neuropathies or cervical radiculopathies. In addition, surgical treatment has been known to have devastating complications, which
further fuels debate with the opponents of recognition of this entity. Conservative treatment appears to be the most universally accepted approach,
with even surgeons recommending a prolonged trial before any operative procedure.
Pathophysiology
Thoracic outlet syndrome (TOS) involves compression, injury, or irritation to the neurovascular structures at the root of the neck or upper thoracic region,
bounded by the anterior and middle scalenes; between the clavicle and first rib (with possible enlargement/hypertrophy of the subclavius); or beneath the
pectoralis minor muscle. Some authors define the thoracic outlet as an opening bordered by the first rib laterally, the vertebral column medially, and the
claviculomanubrial complex anteriorly. The syndrome of compression at this site could be primarily neurologic, involving the brachial plexus, most often the
lower trunk or medial cord; alternatively, it could involve compression of the subclavian artery and/or vein.
One proposed classification system has broken TOS into the following 3 categories:
- True neurogenic TOS: The brachial plexus is injured in these cases as documented by electromyography (EMG) and/or nerve conduction studies.
- True vascular TOS: The subclavian artery and/or vein is damaged or thrombosed, as documented by arteriogram or venogram.1,2
- Nonspecific or disputed TOS: Patients have symptoms, but there are no abnormal tests to document the lesion clearly. This category is by far the most
common type of TOS seen in the clinical setting.
Many authors have discovered accessory cervical ribs associated with
TOS3; however, they have noted tough fibrous bands coming off the accessory ribs that are
believed to be more responsible for the pathology. There have even been reports of bony fusion of variant cervical ribs, resulting in bifid ribs with attached
fibrous bands.4 The bands cause tethering of the brachial plexus, which results in traction and,
therefore, symptoms. Other authors report compression or irritation of the neurovascular bundle more distally under the pectoralis minor muscle or from anterior displacement of the humeral head.
Additionally, clavicle fractures can result in plexopathy from expanding hematomas or pseudoaneurysms that compress the plexus, with variable latent
periods following the fracture. Delayed onset of symptoms may suggest exuberant callus from the healing fracture site. Nonunion of the fracture site also can
result in direct compression by the lateral fragment, which is pulled inferiorly.
Trapezius weakness due to spinal accessory nerve injury (following cervical lymph node biopsy) also has been implicated as a cause of TOS. This results in
"droopy shoulder" with secondary compression of the neurovascular bundle, which is particularly aggravated with arm elevation (abduction).5
• Overview • Differential Diagnoses & Workup • Treatment & Medication • Follow-up • Multimedia
References
- de Leon RA, Chang DC, Hassoun HT, et al. Multiple treatment algorithms for successful outcomes in venous thoracic outlet syndrome.
Surgery. May 2009;145(5):500-7. [Medline].
- Davidovic LB, Koncar IB, Pejkic SD, et al. Arterial complications of thoracic outlet syndrome.
Am Surg. Mar 2009;75(3):235-9. [Medline].
- Brewin J, Hill M, Ellis H. The prevalence of cervical ribs in a London population.
Clin Anat. Apr 2009;22(3):331-6. [Medline].
- Cagli K, Ozcakar L, Beyazit M, et al. Thoracic outlet syndrome in an adolescent with bilateral bifid ribs.
Clin Anat. Sep 2006;19(6):558-60. [Medline].
- Al-Shekhlee A, Katirji B. Spinal accessory neuropathy, droopy shoulder, and thoracic outlet syndrome.
Muscle Nerve. Sep 2003;28(3):383-5. [Medline]. | |
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Abstract:
Thoracic outlet syndrome (TOS) is due to compression/irritation of brachial plexus (BP) elements ("neurogenic TOS") and/or
subclavian vessels ("vascular TOS") in their passage from the cervical area toward the axilla. The usual site of entrapment
is the interscalenic triangle. TOS is a source of disagreement among clinicians regarding its incidence, diagnostic criteria
and optimal treatment. Constitutional factors, like a cervical rib, predispose to the development of TOS. The syndrome often
develops during the 3rd or 4th decade, following external factors such as trauma, weight excess, incorrect shoulder posture.
The clinical picture can be varied: pain in the cervical region and arm, paresthesias (medial side of arm predilected) aggravated
by overhead positions of the arms, hand intrinsic muscle deficit/atrophy, easy fatiguability, paleness, coldness of hand.
The clinical examination may be entirely normal or show cervical muscle spasm, tenderness of BP in the supraclavicular area,
radial pulse attenuation and occurence of symptoms upon positional maneuvers, sensory or motor deficit. The diagnosis is based
upon clinical evaluation and absence of other relevant pathology. Therefore, the cervical spine and distal peripheral nerves
are studied by radiological and electrophysiological studies. There is no laboratory test confirming TOS: most of the time,
there is no anatomic variation seen radiologically and electrophysiological testing is normal. The scalene muscle block appears
a helpful diagnostic tool if used with the other clinical data.
Unless there is significant motor deficit or subclavian artery compression, the treatment should be kept conservative as long
as possible, by an individually tailored physical therapy program. In case of neurological deficit or symptoms unresponsive
to medical treatment, the patients will be helped by decompressive operation in the thoracic outlet. Transaxillary first rib
resection (TAR) has been the most popular surgical approach but nowadays, the supraclavicular approach has superseded TAR in
many centers. The anterior approach provides a good access to the BP elements and subclavian artery, allowing their adequate
relief from constrictive/irritative anatomic structures. The posterior subscapular approach is indicated in rare cases of TOS
associated with severe obesity, a large cervical rib or recurrent TOS with residual first rib following TAR. (NerveCenter 4(2), 1999)
[...]
Epidemiology:
TOS commonly develops during the 3rd or 4th decade, more often in women, under the combination of a peculiar cervical anatomy
and of external factors. Some morphotypes predispose to the syndrome: poor muscular development, droop of scapula, obesity
and breast hypertrophy. The patient psychological status may sometimes play an important role in the development of the
syndrome: stress and depression can lead to chronic muscle spasm in the neck region and there to decompensation of a previously
asymptomatic predisposing anatomy. Other precipitating factors are work-related (static work posture). An antecedent of neck or
shoulder trauma is noted in approximately half of the cases. [...] [Read Full Text]
Management plan flowchart for TOS | | |
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Nonsurgical Treatment
Doctors begin treating your pain conservatively, without surgery or other invasive procedures. Your doctor can prescribe some
types of medicine to ease your discomfort. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen, can
relieve pain and inflammation, and muscle relaxants can relieve muscle spasm. Some patients who experience chronic pain, such
as the pain of TOS, end up battling depression. In these cases, anti-depressants can be very helpful.
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Your doctor may recommend some simple ways to help you combat TOS. For example, decrease the tension of the shoulder strap
of your seat belt. Take rest periods to avoid fatigue. Overweight patients should seek help with weight loss, and women with
especially large breasts may benefit from using a strapless long-line bra. Avoid heavy lifting, pulling, or pushing. Rapid
breathing and stress can worsen symptoms. Avoid looking up, bending the neck back, or holding your arms up for long periods
of time. And don't carry a purse or bag on the affected shoulder.
Your doctor may start you on some basic exercises. If you have done them for some time and your symptoms aren't getting much better,
you may need to work with a physical or occupational therapist. In most cases therapy can be very effective. However, therapy may not help much if your
symptoms are so severe that the muscles of the hand or forearm have atrophied (shrunk).
Surgery
Surgery for TOS is usually a last resort. The surgery is directed at removing the source of compression on the nerves of the
brachial plexus. The brachial plexus is the network of nerves that go to the hand and forearm. If there is an extra rib, it
is usually removed. Otherwise, surgery consists of simply releasing the constricting elements and scar tissue around the nerves.
Surgery is usually done through an incision under the arm. The surgery will require a general anesthetic, which will put you to
sleep. You will probably need to spend at least one night in the hospital. [...] [Read More] |
Treatment
Nerves must glide to accommodate joint motion. If a nerve does not glide, it is stretched
and injured. Tension on a nerve should not be part of a nerve gliding program. When attempting
to glide a nerve, it is important to put one side on slack before pulling in the opposite direction.
Nerve gliding exercises are the equivalent of flexor tendon gliding exercises. Nerves, however,
cannot be studied reliably in vivo as tendons were. Nerve gliding exercises therefore are based
on anatomic and surgical observations. Each nerve has a consistent course in the extremity. To
create a manageable exercise program, the authors considered a simplified anatomy.
For example, while designing thoracic outlet syndrome (TOS) exercises, the authors limited our
attention to the "upper" and "lower plexus."
Patients with TOS frequently have multiple
nerve entrapments and may benefit from the other nerve gliding exercises described here. Each nerve
has its own gliding exercise. The patient first assumes the starting position, which
puts one end of the nerve in a slack position. The extremity then is taken through the motion
necessary to reach the end position, which glides the nerve in that direction. The exercise then is
reversed so each nerve is moved proximally and distally.
Simultaneous neck bending and scapular elevation is usually painful in patients with TOS.
Painful exercises should be avoided initially because they may aggravate the patient’s symptoms,
and they will be introduced as soon as feasible.
Nerve gliding is important, especially after injury or surgery. By maintaining normal nerve
excursion, scarring and stretching are minimized. Nerve gliding exercises therefore should be included
in the rehabilitation of any peripheral nerve dysfunction. [...] [Read More] |
The Feldenkrais Method, developed through 40 years of research by Dr. Moshe Feldenkrais, is a revolutionary approach to
understanding human functioning. It utilizes movement and attention as the vehicles for enhancing our natural abilities
to learn, to change and to continue to grow throughout our lives.
Born in Russia, Dr. Feldenkrais emigrated to Israel at the age of 13. After receiving degrees in mechanical and electrical
engineering in, he earned his D.Sc. in Physics at the Sorbonne in Paris, subsequently working a number of years with Joliet-Curie
in early nuclear research.
His interest in movement had deep roots in the martial arts. He studied with Professor Kano, the originator of Judo, and was
one of the first Europeans to earn a Black Belt in the martial art (1936).
His own physical problems led him to a lifelong exploration of ways to improve our movement and functioning in general. His
investigations reflected his various fields of expertise (physics, neurology, martial arts, cybernetics, body mechanics,
and psychology) and resulted in a method that is a unique synthesis of science and aesthetics. It addresses universal human
needs as well as a broad spectrum of individual problems making Feldenkrais work useful to a wide and varied population. [...] [Read more]
[...] In a typical Functional Integration session you lie fully clothed on a low table (similar to a massage table but lower
and wider) while the practitioner touches and moves you in gentle, non-invasive ways. The intent of this touch is to explore
your neuromuscular organization -- your subconscious responses to touch and movement -- and to have a tactile, nonverbal
conversation with your central nervous system about how you organize your body and your movement.
The process is akin to biofeedback, though more subtle and complex. In conventional biofeedback you are "hooked up" to a
sensor measuring some aspect of your physiology that you are normally unaware of, such as the tension in a group of muscle
fibers or the temperature of your fingertip. The biofeedback machine transforms this measurement into something you can
see or hear - lighting a light or sounding a tone when the muscle fibers relax, or when your skin temperature rises. Without
knowing exactly how you do it, you can learn to keep the light lit, or the tone on, thus consciously controlling what are
normally unconscious processes. In this way you can learn to relax habitually tight muscles, or to increase peripheral
blood circulation by warming your fingertip. [...] [Read more]
Feldenkrais Educational Foundation of North America |
Dr. John E. Sarno is Professor of Clinical Rehabilitation Medicine at New York University School of Medicine and attending physician at the Rusk Institute of
Rehabilitation Medicine, New York University Medical Center. Since 1973, he has conducted research and clinical practice on disorders relating to pain, identified
the cause of most common back, neck, shoulder, and limb pain, and has developed a revolutionary treatment program which has helped many to become pain-free.
Dr. Sarno's innovative treatment program is based solely on providing knowledge and understanding of the true source of the pain. The core of this treatment is
a lecture presentation in which Dr. Sarno leads his patients through a process of realization of the relationship between emotions and physical symptoms as well
as the power of awareness as a cure for many common pain syndromes.
Tension Myositis Syndrome [...] was first theorized by Dr. John Sarno at NYU's Rusk Institute. In the late 1970's and early 1980's
he described in detail a theory, involving the connections between emotions, the brain, the limbic system, and the autonomic nervous
system that generates this process [resulting in] painful tissue that causes local pain (trigger points, areas of spasm) and sometimes
distant pain (sciatica,etc.). The cure is educational and psychological and highly effective in most patients.
[S]uccessful TMS treatment must involve both an appreciation and understanding of the physical pain AND the vital connection
to the mind and emotions.
Repetitive Strain Injury (RSI)
Computer Related Repetitive Strain Injury
As more and more work, education and recreation involves computers, everyone needs to be aware of the hazard of Repetitive
Strain Injury to the hands and arms resulting from the use of computer keyboards and mice. This can be a serious and very
painful condition that is far easier to prevent than to cure once contracted, and can occur even in young physically fit
individuals. It is not uncommon for people to have to leave computer-dependent careers as a result, or even to be disabled
and unable to perform tasks such as driving or dressing themselves. [...] [Read more]
Harvard RSI Action is a student group that provides preventative education
about Repetitive Strain Injury (RSI) to the general public and to students at Harvard. They provide a breakdown of Treatment Resources, including
Taubman Techniques, Massage, Osteopathy, Acupuncture, Tai Chi, Alexander Technique/Feldenkrais Method, Yoga, Kinesiology, and more.
In April 2000, the RSI Action group held an information session about Sarno and his work. The info session started off with a summary of Sarno's
theory, and then followed up with a panel in which five Harvard students spoke about being cured of RSI after reading Sarno's book and applying the concepts therein to their lives.  Session handout [Word] |
When confronted with pain, numbness, tingling, stiffness, burning or swelling in the hands and fingers, the universal tendency nowadays is to immediately
apply the label "carpal tunnel syndrome," with very little consideration given to other possible causes.
Few people know that myofascial trigger points (tiny contraction knots) in the scalene muscles of the front of the neck are
almost always involved in causing pain and other abnormal sensations in the hands.
This revelation comes from decades of research by Doctors Janet Travell and David Simons, authors of the widely acclaimed medical textbook, Myofascial Pain and Dysfunction: The Trigger Point Manual.
According to Travell and Simons, the scalenes (seen below) are often the primary source of all the symptoms wrongly blamed on the carpal tunnel. [...]
Although numbness and tingling in the hands are clearly the effects of nerve compression, the problem doesn't often originate in
the carpal tunnel. Doctors Travell and Simons explain that the critical nerve impingement actually occurs at the thoracic outlet.
This is the opening under your collarbone through which the nerves and blood vessels pass on their way to the arm.
Nerve compressions occur at the thoracic outlet when trigger points in the scalene muscles keep the first rib pulled up against
the collarbone. This squeezes the brachial plexus, the thick bundle of nerves that supply the arm and hand, which passes through
this area. Pressure on these nerves due to scalene trigger points is often the only cause of numbness, tingling and weakness in
the hands and fingers. [...]
In The Trigger Point Therapy Workbook , nationally certified massage
therapist Clair Davies simplifies Travell and Simons' extensive research into myofascial pain and makes it accessible
to the layman. His innovative methods of self-applied trigger point massage will relieve carpal tunnel syndrome, aching
pain, numbness, tingling, and burning in your hands when trigger points are the cause. [...] [Visit website]
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The February 2004 issue of Hand Clinics is entirely devoted to TOS.
Thoracic Outlet Syndrome
Guest Editor: M.A. Wehbé
IN THIS ISSUE:
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