Conservative treatment of thoracic outlet syndrome using an orthosis

Digital Biomarkers for the Objective Assessment of Disability in Neurogenic Thoracic Outlet Syndrome

Neurogenic thoracic outlet syndrome (nTOS) is a musculoskeletal disorder in which compression of the brachial plexus between the scalene muscles of the neck and the first rib results in disabling upper extremity pain and paresthesia. Currently there are no objective metrics for assessing the disability of nTOS or for monitoring response to its therapy. We aimed to develop digital biomarkers of upper extremity motor capacity that could objectively measure the disability of nTOS using an upper arm inertial sensor and a 20-s upper extremity task that provokes nTOS symptoms. We found that digital biomarkers of slowness, power, and rigidity statistically differentiated the affected extremities of patients with nTOS from their contralateral extremities (n = 16) and from the extremities of healthy controls (n = 13); speed and power had the highest effect sizes. Digital biomarkers representing slowness, power, and rigidity correlated with patient-reported outcomes collected with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and the visual analog scale of pain (VAS); speed had the highest correlation. Digital biomarkers of exhaustion correlated with failure of physical therapy in treating nTOS; and digital biomarkers of slowness, power, and exhaustion correlated with favorable response to nTOS surgery. In conclusion, sensor-derived digital biomarkers can objectively assess the impairment of motor capacity resultant from nTOS, and correlate with patient-reported symptoms and response to therapy.

Treatment for thoracic outlet syndrome

BACKGROUND

Thoracic outlet syndrome (TOS) is one of the most controversial diagnoses in clinical medicine. Despite many reports of operative and non-operative interventions, rigorous scientific investigation of this syndrome leading to evidence-based management is lacking. This is the first update of a review first published in 2010.

OBJECTIVES

To evaluate the beneficial and adverse effects of the available operative and non-operative interventions for the treatment of TOS a minimum of six months after the intervention.

SEARCH METHODS

On 23 June 2014 we searched the Cochrane Neuromuscular Disease Group Trials Specialized Register, CENTRAL, The Database of Abstracts of Reviews of Effects (DARE), MEDLINE, EMBASE, CINAHL Plus and AMED. We also searched reference lists of the identified trials.

SELECTION CRITERIA

We selected randomized or quasi-randomized studies involving participants with the diagnosis of TOS of any type (neurogenic, vascular, and 'disputed'), without limitations as to language of publication.We accepted studies that examined any intervention aimed at treating TOS.The primary outcome measure was change in pain rating, measured on a validated visual analog or similar scale at least six months after the intervention.The secondary outcomes were change in muscle strength, disability, experiences of paresthesias (numbness and tingling sensations), and adverse effects of the interventions.

DATA COLLECTION AND ANALYSIS

Three authors independently selected the trials to be included and extracted data. Authors rated included studies for risk of bias, according to the methods recommended in the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

This review was complicated by a lack of generally accepted criteria for the diagnosis of TOS and had to rely exclusively on the diagnosis of TOS by the investigators in the reviewed studies. We identified one study comparing natural progression with an active intervention. We found three randomized controlled trials (RCTs), but only two of them had a follow-up of six months or more, which was the minimum required follow-up for inclusion in the review. The first trial that met our requirements involved 55 participants with the 'disputed type' of TOS and compared transaxillary first rib resection (TFRR) with supraclavicular neuroplasty of the brachial plexus (SNBP). The trial had a high risk of bias. TFRR decreased pain more than SNBP. There were no adverse effects in either group. The second trial that met these requirements analyzed 37 people with TOS of any type, comparing treatment with a botulinum toxin (BTX) injection into the scalene muscles with a saline placebo injection. This trial had a low risk of bias. There was no significant effect of treatment with the BTX injection over placebo in terms of pain relief or improvements in disability, but it did significantly improve paresthesias at six months' follow-up. There were no adverse events of the BTX treatment above saline injection.

AUTHORS' CONCLUSIONS

This review was complicated by a lack of generally accepted diagnostic criteria for the diagnosis of TOS. There was very low quality evidence that transaxillary first rib resection decreased pain more than supraclavicular neuroplasty, but no randomized evidence that either is better than no treatment. There is moderate evidence to suggest that treatment with BTX injections yielded no great improvements over placebo injections of saline. There is no evidence from RCTs for the use of other currently used treatments. There is a need for an agreed definition for the diagnosis of TOS, especially the disputed form, agreed outcome measures, and high quality randomized trials that compare the outcome of interventions with no treatment and with each other.

Thoracic outlet syndrome: definition, aetiological factors, diagnosis, management and occupational impact

INTRODUCTION

Thoracic outlet syndrome is a controversial cause of neck and shoulder pain due to complex mechanisms involving muscular dysfunction and nerve compression. Although management of thoracic outlet syndrome must be based on a multidisciplinary approach, physicians and occupational therapist should be familiar with the principles of diagnosis and treatment.

METHOD, RESULTS AND CONCLUSION

The purpose of this article is to review the definitions, diagnosis and management of this syndrome. A particular emphasis was described on the links between the workplace and the individual in the pathogenesis, prevalence in the workforce and the course of this disease.

What's new in the diagnosis and treatment of peripheral nerve entrapment neuropathies

Entrapment neuropathies can be common conditions with the potential to cause significant disability. Correct diagnosis is essential for proper management. This article is a review of recent developments related to diagnosis and treatment of various common and uncommon nerve entrapment disorders. When combined with classical peripheral nerve examination techniques, innovations in imaging modalities have led to more reliable diagnoses. Moreover, innovations in conservative and surgical techniques have been controversial as to their effects on patient outcome, but randomized controlled trials have provided important information regarding common operative techniques. Treatment strategies for painful peripheral neuropathies are also reviewed.

Treatment for thoracic outlet syndrome

BACKGROUND

Thoracic outlet syndrome (TOS) is one of the most controversial clinical entities in medicine. Despite many reports of operative and non-operative interventions, rigorous scientific investigation of this syndrome leading to evidence based management is lacking.

OBJECTIVES

To evaluate the beneficial and adverse effects of the available operative and non-operative interventions for the treatment of thoracic outlet syndrome.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group Trials Specialized Register (July 2009), The Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2009), MEDLINE (January 1966 to June 2009), EMBASE (January 1980 to June 2009), CINAHL (January 1981 to June 2009 ), AMED (January 1985 to June 2009 ) and reference lists of articles.

SELECTION CRITERIA

We selected randomized or quasi-randomized studies in any language of participants with the diagnosis of any type of thoracic outlet syndrome (neurogenic, vascular, and 'disputed'). The primary outcome measure was change in pain rating on a validated visual analog or similar scale at least six months after the intervention. The secondary outcomes were change in muscle strength and adverse effects of the interventions.

DATA COLLECTION AND ANALYSIS

Four authors independently selected the trials to be included and extracted data. The one included study was rated for risk of bias according to the methods recommended in the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

This review was complicated by a lack of generally accepted criteria for the diagnosis of TOS and had to rely exclusively on the diagnosis of TOS by the investigators in the reviewed studies. There were no studies comparing natural progression with any active intervention. In one trial with a high risk of bias involving 55 participants transaxillary first rib resection decreased pain more than supraclavicular neuroplasty of the brachial plexus. There were no adverse effects in either group.

AUTHORS' CONCLUSIONS

This review was complicated by a lack of generally accepted diagnostic criteria for the diagnosis of TOS. There was very low quality evidence that transaxillary first rib resection decreased pain more than supraclavicular neuroplasty but no randomized evidence that either is better than no treatment. There is no randomized evidence to support the use of other currently used treatments. There is a need for an agreed definition for the diagnosis of TOS, especially the disputed form, agreed outcome measures and high quality randomized trials that compare the outcome of interventions with no treatment and with each other.

Compression and stretching of the brachial plexus in thoracic outlet syndrome: correlation between neuroradiographic findings and symptoms and signs produced by provocation manoeuvres

In order to investigate the mechanism of nerve irritation in thoracic outlet syndrome (TOS), we studied 150 patients who presented with symptoms of neurologic TOS between 1985 and 1999. They first performed various provocative physical manoeuvres and then underwent injection of contrast medium into the supraclavicular part of the brachial plexus. Several of the provocative manoeuvres were then repeated and radiographs were again obtained. Based on the neuroradiographs, we identified three subsets of patients; those with only compression (type 1 TOS, n=27, 18%), those with combined compression and stretching (type 2 TOS, n=111, 74%), and those with only stretching (type 3 TOS, n=12, 8%). We were able to correlate the neuroradiological subsets with symptoms elicited by pre-radiographic provocative manoeuvres; in 92 patients (61%) these were elicited by traction manoeuvres. We conclude that stretching is an important factor of nerve irritation in TOS.

Thoracic outlet syndrome

Success in conservative management depends upon an accurate assessment and development of a treatment plan relative to the irritability of the patient's condition. Postural correction and avoidance of irritating positions must begin early in the rehabilitation phase to retrain the patient in symptom-reducing postures. Treatment addressing only the neurovascular structures may produce temporary relief of symptoms, but postural correction cannot be maintained without correction of the associated muscle imbalance in the cervicoscapular region. Long-term success of conservative management depends on patient compliance to a home exercise program and behavior modification at home and at work. Surgical decompression should be reserved for patients who fail to improve with conservative management.

Diagnosis of thoracic outlet syndrome by magnetic stimulation of the brachial plexus

The abductor pollicis brevis (APB) and abductor digiti minimi (ADM) compound muscle action potential (CMAP) latencies, and median and ulnar motor conduction velocities (MCVs), obtained by magnetic stimulation of the brachial plexus, were evaluated for the diagnosis of thoracic outlet syndrome (TOS). These measurements were compared in three groups of limbs: (1) the symptomatic limbs of patients with TOS (symptomatic group), (2) the asymptomatic con-tralateral limbs of these patients (asymptomatic group), and (3) the limbs of healthy control subjects (control group). Although no significant differences were observed in MCVs among the three groups, the APB CMAP latency in the sym-ptomatic group (12.0 +/- 1.2 ms) was significantly prolonged compared with that in the control group (10.4 +/- 0.64 ms; P < 0.01), and the ADM CMAP latency in the symptomatic group (11.0 +/- 0.82 ms) was also significantly prolonged compared with that in the control group (10.1 +/- 0.59 ms; P < 0.01). The possibility is suggested that the evaluation of APB and ADM CMAP latencies by magnetic stimulation of the brachial plexus may be helpful for the diagnosis of TOS.

Long-term functional outcome of neurogenic thoracic outlet syndrome in surgically and conservatively treated patients

PURPOSE

Neurogenic thoracic outlet syndrome (NTOS) in the absence of bony and electrodiagnostic abnormalities, often referred to as disputed NTOS, remains enigmatic. Optimal treatment, especially the role of surgery, is controversial. The long-term functional outcome of a cohort of patients undergoing independent medical examination for disputed NTOS with symptoms sufficiently severe to cause inability to work forms the basis for this report.

METHODS

Patients with disputed NTOS and symptoms sufficiently severe to cause at least temporary inability to work seen for independent medical examinations from 1990-1998 formed the study group. None of the patients were treated by our group. Functional outcome was assessed with information from a standardized telephone interview or patient questionnaire. The patients' ability to return to work and an assessment of their current level of symptoms and symptom progression since the time of onset were determined.

RESULTS

Seventy-nine patients were reevaluated at a mean follow-up of 4.2 years (range, 2-7.5 years) after our initial evaluation. Fifteen patients (19%) underwent first rib resection surgery performed by others, whereas 64 (81%) had no surgery. Patients undergoing surgery had missed more work time than those undergoing conservative management (27.6 +/- 6.0 months vs 14.9 +/- 2.6 months, P <.04). Return to work was achieved in nine patients who were operated on (60%) and in 50 patients who were not operated on (78%) (P = not significant [NS]). Among operated patients, current assessment of symptom severity was severe, moderate, mild, and asymptomatic in 7%, 47%, 40% and 7%, respectively. This distribution did not differ significantly from that observed in nonoperated patients (11%, 55%, 30%, 5%; P = NS). When asked about changes in symptomatic status since onset, 7% of the operated group had complete resolution, 27% had marked improvement, 40% had minimal improvement, 13% had no improvement, and 13% were worse. This did not differ significantly from the change in symptoms reported by the nonoperated group (2%, 30%, 22%, 31%, 16%; P = NS).

CONCLUSION

Most patients with disputed NTOS in this nonrandomized series were able to return to work and demonstrated an improvement of symptoms with long-term follow-up. First rib resection did not improve functional outcome in this group.

Thoracic outlet syndrome in aquatic athletes

Thoracic outlet syndrome is a well-recognized group of symptoms resulting from compression of the subclavian artery and vein, as well as the brachial plexus, within the thoracic outlet. Symptoms are related directly to the structure that is compressed. Diagnosis is difficult because there is no single objective, reliable test; therefore, diagnoses of thoracic outlet syndrome is based primarily on a set of historical and physical findings, supported and corroborated by a host of standard tests. Because aquatic athletes are primarily "overhead" athletes, one may expect a higher incidence of thoracic outlet syndrome in this population. The differential between TOS and "swimmer's shoulder" (multidirectional instability and subacromial impingement) may be difficult. Nonsurgical treatment methods can be helpful in relieving symptoms; in certain recalcitrant cases, however, surgical intervention can provide lasting relief and a return to aquatic athletics.