Reviewed by Tyler Tice, PT, DPT, OCS, ATC

Article: 

Physical Therapy Management of Neurogenic Thoracic Outlet Syndrome.

Introduction: 

Neurogenic thoracic outlet syndrome is a difficult condition to treat for many reasons.  The region is complex, including multiple joints, the brachial plexus and the subclavian artery.  The diagnosis of neurogenic thoracic outlet syndrome is still considered a diagnosis of exclusion, and there are often other regions involved such as cervical or thoracic spine dysfunctions that can make it difficult to identify the cause or causes of the problem.

There have been many treatment theories presented that can include postural training to improve diaphragm function, scalene and pectoralis minor releases to open space for the neurovascular bundle, shoulder girdle strengthening to decrease fatigue of the muscles in the region and scapulohumeral rhythm training to improve overall mechanics of motion in the region.  Despite the challenges of physical therapy to treat this condition, it is still recommended before attempting surgical intervention.  In one observational study, as many as 27% of patients receiving physical therapy met their goals without needing to progress to surgical intervention.

Methods:

This article discusses different aspects of treating neurogenic thoracic outlet syndrome such as interviewing, different treatment approaches, assessment techniques, support for patients and psychologically informed care.

Results:

  When interviewing a patient with suspected thoracic outlet syndrome, it is important to pay close attention to provoking and relieving activities as well as specific symptoms as these can be clues to whether the symptoms are caused by aggravated vascular tissue or aggravated nervous tissue.  For example, vascular thoracic outlet syndrome can sometimes present with claudication-like symptoms while neurogenic usually does not.  Some patients may be more sensitive to activities that stretch the neurovascular bundle while others may be more sensitive to activities that compress it.  Understanding this information is essential to recommending exercises and activity modification that can help relieve a patient’s symptoms.  Patient reported outcome measures can be useful for gathering this information.

A detailed physical assessment is necessary to rule out other more common pathologies such as cervical radiculopathy which can present with similar findings.  Since the proposed pathoanatomical cause of thoracic outlet syndrome is compromise of the neurovascular bundle, postural and biomechanical screening is key in understanding what patterns or postures may be contributing to this possible compromise.  To get a clear picture of a patient’s presentation, a biomechanical and postural screen should include but is not limited to cervical motion, thoracic motion and scapulohumeral rhythm.

Functional assessment and reassessment can be a useful tool for creating a plan of care as well as helping patients understand what might be triggering their symptoms.  The author uses upper extremity elevation as an example.  While a patient is raising their arm, the therapist can provide a variety of manual cues or resistance to alter the movement pattern and reassess for symptoms.  This could involve shifting the entire shoulder girdle, retracting the cervical spine or facilitating scapular upward rotation.

For treatment, it is important to keep in mind that the goal is often to change the forces moving through the thoracic outlet region.  Bearing in mind that some patients are irritated by traction and others can be irritated by compression, the therapist must be mindful of what positions they want to train in while continually monitoring the patient’s response.  Manual therapy to the scalenes, pectoralis minor, lower cervical and upper thoracic spine can be beneficial to decrease forces across the region and to modulate pain levels.

Although the goal of therapy is active management of the thoracic outlet region via muscular control, passive modalities such as taping can be used during the initial stages of treatment to help patients manage their pain and decrease their tissues irritability levels so they can respond more favorably to other interventions such as scapular stability training.

Stretching of specific muscles found during physical examination such as the scalenes and pectoralis minor should be done with caution.  Although the shortened length of these muscles may be a contributing factor in thoracic outlet syndrome, performing stretches can increase pressure on the neurovascular bundle, exacerbating symptoms.  Instead, the author recommends lengthening these muscles with manual interventions while the core and neck are relaxed and supported in the supine position.  In this way, there is little to no increased pressure on the neurovascular bundle, but a similar effect can be obtained.

Once a more optimal posture is identified for a patient and they are comfortable in this new position, the course of treatment should shift focus toward building endurance in this new position to help maintain the positive changes discovered during therapy.  Additionally, to get carryover into a patient’s everyday life it is necessary to assess and modify the ergonomics of their work and home environments to prevent future exacerbations.

Although positive neural tension testing is often observed with thoracic outlet syndrome, the author cautions against the use of neural gliding or flossing techniques, as these can increase a patient’s tissue irritability rather than decreasing it.  The author instead suggests exercise that focuses on thoracic flexion and rotation to get a more favorable outcome.

During an episode of care, it is important to bear a patient’s emotional state in mind.  It has been shown that motivational interviewing can be an effective adjunct therapy to help manage a patient’s pain.  The physical therapist is in a unique position to help encourage a more active lifestyle for patients as well as to reinforce helpful though patterns that can help patients reframe their pain to help them manage more effectively.

Discussion/Clinical Utility:

  This article provides a basic framework for both assessing and treating neurogenic thoracic outlet syndrome.  Given that thoracic outlet syndrome is considered a diagnosis of exclusion, it is helpful to have some sort of guideline for assessment and treatment planning.  This article does a good job of demonstrating the nuance of the condition by explaining not just what treatments might be appropriate but also the rationale of when you may choose one treatment over another.

Reference:

Collins E, Orpin M. Physical Therapy Management of Neurogenic Thoracic Outlet Syndrome. Thorac Surg Clin. 2021 Feb;31(1):61-69. doi: 10.1016/j.thorsurg.2020.09.003. PMID: 33220772.

Article:

Post-traumatic stress symptom clusters in acute whiplash associated disorder and their prediction of chronic pain-related disability published in Pain Reports.
DOI: 10.1097/PR9.0000000000000631

Current research shows that Post-traumatic Stress Disorder (PTSD) is related to Whiplash Associated Disorder (WAD) and chronic neck pain. These authors set out to determine which specific PTSD symptoms are more predictive of chronic neck pain in individuals suffering from WAD due to a MVC. The authors examined a sample of 146 individuals with an acute, painful whiplash injury from a MVC. They monitored neck pain symptoms using the Neck Pain Disability Index (NDI), and any potential PTSD symptoms with the Post-traumatic Stress Diagnostic Scale (PDS). These items were assessed at baseline (within 1 month of injury) and again 6 months later. Thirty percent of the participants met the threshold for a PTSD diagnosis, and the remaining 70% had symptoms of PTSD but did not qualify for the full diagnosis.

A confirmatory factor analysis^a was performed to determine separate clusters of symptoms on the PDS that could potentially affect neck pain. The results showed two clusters, one deemed the “re-experience/avoidance” cluster and the other the “hyperarousal/numbing” cluster. The avoidance cluster of symptoms included recurrent recollections, recurrent dreams, reliving trauma, psychological distress, physiological reactivity, avoiding thoughts, behavioral avoidance, hypervigilance, and exaggerated startle response. The hyperarousal cluster symptoms included diminished interest in activities, sense of foreshortened future, difficulty sleeping, difficulty concentrating, detachment from others, restricted affect, irritability and anger.

The results of the study showed that the hyperarousal/numbing cluster was the only cluster of symptoms associated with long-term neck pain1. The authors theorized as to why this might be the case. They discussed how inactivity and sleep deprivation could potentially stem from the hyperarousal symptoms. For example, diminished interest in activity, difficulty concentrating, and irritability could all impact the individual’s ability to work, leading to more inactivity. Additionally, difficulty sleeping is a symptom that could understandably lead to increased pain and decreased levels of activity.

However, the authors noted the apparent “non-specificity” of the hyperarousal cluster’s symptoms– meaning they are a group of symptoms that appear in various mental health disorders and are not necessarily specific to PTSD. In contrast, they labeled the avoidance cluster symptoms as typically “specific” to PTSD and not appearing in many other mental health disorders. Therefore, if the hyperarousal cluster of symptoms are present in a patient, one must be careful not to assume PTSD is present. The symptoms could simply be a result of the physical whiplash injury itself, and not stemming from any psychological trauma. More research is needed to be certain.

In conclusion, symptoms such as diminished interest in activities, difficulty sleeping, difficulty concentrating, detachment, irritability and anger may be present in individuals suffering from neck pain after an injury. These symptoms may stem from psychological trauma accompanying the injury, or could perhaps be normal, expected coping mechanisms for neck pain. Regardless, these particular symptoms are indicative of a longer prognosis of recovery and may warrant consideration for referral to a psychologist.

Footnote:

a. Confirmatory factor analysis: “a technique used to analyze the efficacy of measurement models where the number of factors and their direct relationship is specified” In this case, it was done to determine which particular symptoms have similar elements and are likely to have similar effects on neck pain and dysfunction.

References:

Maujean A, Gullo MJ, Andersen TE, Ravn SL, Sterling M. Post-traumatic stress symptom clusters in acute whiplash associated disorder and their prediction of chronic pain-related disability. Pain Rep. 2017;2(6):e631. Published 2017 Nov 27. doi:10.1097/PR9.0000000000000631

Price LA, Confirmatory factor analysis: foundations and extensions. International Encyclopedia of Education (Fourth Edition), Elsevier. Published 2023. 607-618. doi:10.1016/B978-0-12-818630-5.10016-8.

Article:

Intrinsic and extrinsic factors contributing to running-related lower limb injuries among adolescent runners published in Journal of Sport Sciences. DOI: 10.1080/02640414.2022.2163353

Introduction:

Lower extremity injuries are growing increasingly prevalent in adolescent runners. There is current research available that identifies several risk factors for running related injuries such as increased Q-angle, leg-length discrepancies, the female sex, and being of 11-13 years of age. These factors are difficult or impossible to alter and therefore cannot help inform proper injury prevention training guidelines for adolescent runners. These authors endeavored to determine potentially alterable risk factors for running-related injuries in order to better inform training guidelines for this population.

Methods:

The authors conducted a retrospective cross-sectional study of data from a hospital-based injury prevention clinic. They identified adolescent runners who reported running related injuries on their evaluation forms and collected data points regarding specific risk factors. The authors looked at demographic variables, sport participation, history of  injury, training intensity and frequency, intention to lose weight, BMI, Q-angle, leg length discrepancy, lower extremity range of motion, lower extremity strength, lower extremity muscular endurance, average hours of sleep, total hours of running per week, weight training, and consumption of diet soda drinks.They collected data on 130 adolescents athletes and determined which athletes sustained a lower extremity running-related injury. A statistical analysis was performed to understand if a correlation was present between each individual variable and running-related injuries.

Results:

The results showed an intention to lose weight (p=.01) and the female sex (p=.18) as the highest predictors of running-related injuries in adolescent runners, followed by hip abduction strength (p=.17) and reduced hours of weekday sleep (p=.19).

Discussion:

These results can help to inform injury prevention as three of these four variables are alterable. The authors discuss the prevalence of repetitive stress injuries in adolescent runners and how insufficient diet can contribute to poor recovery. Encouraging young athletes to consume a diet that can sustain their level of activity may be an important step towards injury prevention. Reduced hours of sleep additionally could contribute to poor recovery after exercise and is another alterable factor to help adolescents avoid running-related injuries. Finally, hip abduction strength was an expected risk factor for running-related injuries given the hip musculature’s contribution to proper lower extremity kinematics, stability, and shock absorption. This again, is an easily alterable factor for an injury prevention program.

References:

DeJong Lempke AF, Whitney KE, Collins SE, dHemecourt PA, Meehan WP. Intrinsic and extrinsic factors contributing to running-related lower limb injuries among adolescent runners. Journal of Sports Sciences. 2022;40(22):2468-2474. Accessed August 12, 2024. https://research.ebsco.com/linkprocessor/plink?id=14d4d113-1942-3f62-a0e2-7fc6e8d022a8

Reviewed by Tyler Tice, PT, DPT, OCS, ATC

Article:

Neck Pain:  Revision 2017 Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health from the Orthopaedic Section of the American Physical Therapy Association

Introduction:

The orthopaedic section of the American Physical Therapy Association (APTA) published these clinical practice guidelines in 2017 to give recommendations to clinicians in the differential diagnosis, assessment and treatment of neck pain. 

              These recommendations are designed to fit into the International Classification of Functioning, Disability, and Health (ICF model) that was introduced by the World Health Organization (WHO) to improve clinician’s ability to appropriately treat and communicate with patients by including pathoanatomical, psychosocial and societal factors when assessing a patient’s wants and needs. 

Methods: 

Content experts were appointed by the orthopedic section of the APTA to search the current literature for articles relating to the treatment, assessment and diagnosis of neck pain.  Articles included were taken from PubMed, Cochrane Library, Web of Science, CINAHL, ProQuest Dissertations and Abstracts, PEDro, ProQuest Nursing and Allied Health Sources, and Embase with dates ranging from 2007 to 2016. 

              The chosen articles were then categorized based on level of evidence where I represented the highest quality evidence and V represented expert opinion.  After the evidence was reviewed and ranked, the experts developed and ranked recommendations utilizing the information.  A ranked recommendations were based on strong evidence while F ranked recommendations were based on expert opinion.  These recommendations were further categorized into the following content areas; pathoanatomical features/differential diagnosis, Imaging, Examination, Diagnosis/classification, and interventions.  These recommendations are further divided based on the type of neck pain the patient is presenting with; neck pain with mobility deficits, neck pain with movement coordination impairments, neck pain with headaches, and neck pain with radiating pain.    

Results: 

After reviewing the available literature, the authors made the following recommendations: 

              Clinicians should perform assessments on patients to screen for serious pathology and refer to other providers when necessary. 

              Clinicians should use validated self-reported outcome measures to assess and track patient pain, status, and physical/psychological function throughout an episode of care. 

              Clinicians should use easily reproducible activity limitation and participation restriction measures to assess patient function throughout an episode of care.

              Clinicians should use assessments of body impairments to determine if a patient has one of the following; (1)neck pain with mobility deficits (cervical active range of motion), (2)neck pain with headache (cervical active range of motion, the cervical flexion-rotation test, upper cervical segmental mobility testing), (3)neck pain with radiating pain (neurodynamic testing, spurling’s test, distraction test, the Valsalva test), (4)neck pain with movement coordination impairments (cranial cervical flexion and neck flexor endurance test.)

              To effectively classify patients into one of the 4 neck pain designations, clinicians should use cervical motion limitations, thoracic motion limitations, presence of cervicogenic headache, history of trauma and referred or radiating pain into an upper extremity.

Interventions for neck pain with mobility deficits:

              For patients with acute neck pain clinicians should use thoracic manipulation, a program to improve neck ROM, and scapulothoracic and upper extremity strengthening.  Clinicians may provide cervical manipulations and/or mobilization.

              For patients with subacute neck pain clinicians should use neck and shoulder girdle endurance exercises and may provide thoracic and cervical manipulations/mobilizations.

              For patients with chronic neck pain clinicians should employ a multimodal approach including thoracic and cervical manipulations/mobilizations, mixed exercises for the cervical and scapulothoracic regions, dry needling, laser therapy, and intermittent manual or mechanical traction. 

              Clinicians may provide neck, shoulder girdle and trunk endurance exercises and patient education.  Patients should be encouraged to have an active lifestyle and to address psychosocial factors.

Interventions for neck pain with movement coordination impairments

              For patients with acute neck pain clinicians should educated their patients on returning to normal, nonprovocative pre-accident activities as soon as possible, minimize the use of a cervical collar, and perform postural and mobility exercises to decrease pain and increase range of motion.  Patients should be advised that recovery is expected within the first 2-3 months. 

              Clinicians should employ a multimodal approach including manual interventions and exercise programs.  For patients at low risk of developing chronic symptoms, clinicians may provide a single session consisting of education, a detailed exercise program and TENS treatment.  Clinicians should monitor recovery status for signs of chronicity.

              For patients with chronic neck pain clinicians may provide manual interventions, patient education focused on encouragement and exercise programs that utilize concepts from cognitive behavioral therapy. 

Interventions for neck pain with headaches

              For patients with acute neck pain clinicians should provide active mobility exercises as well as C1/C2 self-sustained natural apophyseal glide (SNAG) exercises. 

              For patients with subacute neck pain clinicians should provide cervical manipulation/mobilization as well as SNAG exercises. 

              For patients with chronic neck pain clinicians should provide cervical or cervicothoracic manipulation/mobilization combined with exercises for range of motion, strength and endurance.

Interventions for neck pain with radiating pain

              For patients with acute neck pain clinicians may provide mobilizing and stabilizing exercises, laser treatments, and short-term use of a cervical collar.

              For patients with chronic neck pain clinicians should employ a multimodal approach including mobilization/manipulation, exercise interventions and mechanical intermittent traction.  Clinicians should encourage participation in occupational and exercise activities. 

Discussion and clinical utility: 

This CPG does and excellent job of providing different intervention approaches based on different patient presentations.  Neck pain is variable and sometimes inconsistent, therefore it is important to adjust interventions based on a patient’s current presentation. 

              It is also important to note the emphasis on educating patients to remain active.  Many of the stated interventions involve increasing range of motion in the apophyseal joints of the cervical and thoracic spine.  The challenge is that when in pain, it can be counterintuitive for patients to continue mobilizing those areas.  Encouraging an active lifestyle is a good way of ensuring that benefits introduced during a therapy session continue to have carry over into a patient’s day to day life.

References

Neck Pain: Revision 2017 Peter R. Blanpied, Anita R. Gross, James M. Elliott, Laurie Lee Devaney, Derek Clewley, David M. Walton, Cheryl Sparks, and Eric K. Robertson Journal of Orthopaedic & Sports Physical Therapy 2017 47:7, A1-A83