Abstract: The current study is a prospective evaluation of a supervised physiotherapy program of graduated resisted shoulder elevation exercises in eight patients with thoracic outlet syndrome. All had severe neurovascular symptoms and limited neck movements before treatment. After 3 weeks of intervention, symptoms had significantly improved in all patients, and all achieved a full range of cervical neck and shoulder movement. This study confirms the efficacy of a simple treatment program for patients with thoracic outlet syndrome.
Thoracic outlet obstruction may be caused by a number of abnormalities, including degenerative or bony disorders, trauma to the cervical spine, fibromuscular bands, vascular abnormalities , and spasm of the anterior scalene muscle [1,2]. Symptoms are due to the compression of the brachial plexus and subclavian vasculature and consist of complaints ranging from diffuse arm pain to a sensation of fatigue in the arm frequently aggravated by carrying anything in the ipsilateral hand or doing overhead work, e.g., window cleaning.
Treatment options are physiotherapy, strengthening exercises, re-education for postural change, and, finally, surgical decompression in individuals with well-defined supranumerary bony or fibrotic abnormalities [3-6]. There are numerous repons of the beneficial effects of surgery in appropriately chosen patients; the literature is lacking in data regarding conservative regimens.
The current study is a prospective evaluation of a supervised physiotherapy program of graduated resisted shoulder elevation exercises in patients with symptoms of thoracic outlet syndrome in whom Adson's maneuver was positive.
Eight consecutive patients (six women, two men) with a mean age of 45 years (range: 34 to 59 years ) were evaluated. All were referred to a rheumatology clinic for assessment of neurovascular symptoms in the upper limbs. In each patient, a positive Adson's sign was identified by two independent observers, who were unaware of each other's findings. No patient had a previous history of trauma. All patients had evidence of osteoarthritic changes in the cervical spine, and one patient had bilateral cervical ribs. A program of graduated resisted shoulder elevation exercises was supervised by a physiotherapist over a 3-week period.
A detailed clinical history and examination (including neurologic and locomotor system examination, cervical neck radiographs, chest radiograph, and nerve conduction studies to median and ulnar nerves) were performed in all patients. Normal cervical neck movements were defined as forward flexion (touching chin to chest), extension (the ability to look at the ceiling), lateral flexion (moving chin half way to shoulder), and lateral rotation (chin almost reaching the plane of the shoulder) . Two consecutive blood pressure measurements were obtained in each arm using a standard sphygmomanometer after the patient had been sitting for 5 minutes.
Patients completed a visual analogue scale of symptom severity, which was repeated after 3 weeks of treatment. Symptoms included pain in the hands, pain in the arms, pain in the neck, pins and needles, and weakness in the hands and arms. Patients were asked to mark their impression of the severity of symptoms on a scale of 1 to 10.
Written instructions for the physiotherapy program in addition to supervised exercises in the department three times a week for 3 consecutive weeks were given to ensure compliance. The exercise program is outlined in Table I.
Adson's sign was present in all patients. This test is performed by abducting the arm to 30[degree] and rotating the head through 90[degree] toward the abducted arm during deep inspiration . Entrapment neuropathies were excluded by nerve conduction studies.
Symptoms were present for a median of 3 months (range: 3 weeks to_6 years_) in the eight patients studied. Five patients were housewives, two were farmers, and one was a secretary. Symptoms were bilateral in five, predominantly involving the dominant limb in four. In five patients, pain radiated from the neck or back of the head, down the affected arm, and six patients had symptoms in the hands and fingers. All patients had symptoms in the shoulders and arms.
All patients had pain, seven had paresthesia, and four had weakness of finger and hand movements. In seven, the pain was present continuously. In these seven, it was worse in the mornings in five, at night in six, after housework in three, after carrying and lifting in five, and after prolonged writing (one), knitting (one), or while wearing heavy clothing (three). Four patients frequently woke at night because of pain. All patients were taking regular analgesic medications. In addition, four patients took nonsteroidal anti-inflammatory drugs, and one had started taking oral morphine sulphate 1 week prior to presentation. One patient had rheumatoid arthritis diagnosed 1 year previously. With this exception, no intercurrent illnesses were present.
One or more cervical neck movements were limited in five patients: forward flexion, lateral flexion, and lateral rotation. Internal rotation of the shoulder was limited in four patients. Power was reduced in the affected hand in two patients, and sensation to light touch, pinprick, and temperature was reduced in one. No patient had an entrapment neuropathy. Flexion and extension views of cervical spine radiographs and chest radiographs identified disc space narrowing at L4-5 in one patient, C5-6 in five patients, and C6-7 in four patients and osteophyte formation and bilateral cervical ribs in one patient each. One patient had normal radiographic findings.
Posttreatment: All patients participated in the physiotherapy program, and all improved after 3 weeks. The visual analogue scales for symptoms (Figure 1) demonstrated a significant improvement in all parameters (p < 0.01). After the exercise program, cervical neck and shoulder movements and the results of the neurologic examination were normal in all eight patients. Blood pressure measurements were not significantly different before or after physiotherapy (105/70 4- 44/33 mm Hg versus 117/88 4- 4/14 mm Hg; NS).
In patients with symptomatic spondylosis, there is a loss of flexibility of active or passive neck movements and, in turn, a loss of tone in the shoulder girdle musculature. In other situations, e.g., quadriceps femoris muscle, readily measurable loss of muscle bulk is found in painful conditions of the hip or knee. It is our opinion that the loss of tone in shoulder girdle muscles was an important cause of thoracic outlet syndrome in the cases described and predisposed to neurovascular compression in this instance, although measurements of muscle bulk are obviously much less easily done than in other muscle groups . The specificity of this exercise program, which focused on graduated resisted shoulder elevation exercises to the exclusion of any additional exercises, and the results obtained reinforce this opinion.
It is clear that a wide range of structural and vascular defects may be associated with thoracic outlet syndrome, including prolapsed cervical disc, proximal referral of median and ulnar entrapment symptoms, and cervical ribs [1,2]. However, the great majority of patients presenting at outpatient clinics and to family practitioners have none of these features but complain of persistent symptoms of tiresome brachalgia and painful neck [9,2O].
In all such patients, an initial program of graded unresisted shoulder elevation exercises is appropriate. Furthermore, the requirement for supervision is limited, and, during the 3-week period, much of the work is done by patients in their own home. Although the sample of patients considered for detailed study in this paper had symptoms severe enough to merit referral to a hospital rheumatology clinic, there is no reason why the exercise regimen could not be initiated from general practice once the possibility of serious pathology has been adequately excluded.
A review of the literature highlights the varied treatment programs proposed for thoracic outlet syndrome, from postural advice to surgical intervention [3-6]. Results of treatment programs vary due to poor patient selection, failure of adequate trials of conservative therapy prior to surgical intervention, and different sources of patient referral. Few data are available regarding nonsurgical approachs to treatment as outlined in the current paper.
This study confirms the value and efficacy of a simple treatment program for patients with thoracic outlet syndrome, in whom the possibility of serious pathology has been excluded. Moreover, the program requires limited supervision.
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From the Altnagelvin Hospital (GBT, DW, DJK), Londonderry,
Northern Ireland, and the Royal Victoria Infirmary (RAK),
Newcastle upon Tyne, United Kingdom.
Requests for reprints should be addressed to Rose Anne Kenny,
MD, MRCPI, Royal Victoria Infirmary, Newcastle upon Tyne NEI
4LP, United Kingdom.
Manuscript submitted March 13, 1992, and accepted in revised
form April 23, 1992.