General review
Rehabilitation of Patients with Thoracic Outlet Syndrome Christian Aligne, MD, Xavier Barral, MD, S a i n t - C h a m o n d and Saint-Etienne, France
A series of physical therapy protocols is proposed for patients with thoracic outlet syndrome. The anatomic findings dictating certain physical therapeutic approaches are outlined. General principles of physical therapy that stem from these findings are suggested, and a specific protocol for the physical therapy regimen is given. An appropriate physical therapy program for thoracic outlet syndrome patients with symptoms of mild-to-moderate severity can avoid early surgery. Degradation of symptoms or invalidating functional compromise indicates a referral to surgery. Physical therapy cannot replace surgery in severe or complicated forms of thoracic outlet syndrome with vascular or neurologic compromise. (Ann Vasc $urg 1992;6: 381-389). KEY WORDS:
Thoracic outlet syndrome; physical therapy.
Physical therapy and rehabilitation are efficacious in most cases of thoracic outlet syndrome [1-6] and therefore surgical correction is limited to complicated or initially severe forms. Minor involvement, with essentially functional impairment, are typically managed initially by physical therapy. Since Peet's description at the Mayo Clinic in 1956 [7], several authors [8-10] have remarked the role played by mechanisms other than the anatomical anomalies associated or not with hypotonia of the suspensor muscles of the shoulder. This evolution of ideas has led to progressive adaptation of physical therapy protocols which are proposed to patients.
From the Service d'Angiologie, Centre Medical de Chavanne, Saint-Chamond, and the Service de Chirurgie Vasculaire, Centre Hospitalier et Universitaire, SaintEtienne, France. Reprint request: C. Aligne, MD, Service d'Angiologie, Centre MOdical de Chavanne, 42400 Saint-Chamond, France.
ANATOMIC FINDINGS AND DYNAMIC MODIFICATIONS The neurovascular bundle for the upper limb is comprised of the subclavian vessels and the brachial plexus. Before reaching the brachial canal, these elements are grouped together in the superior and medial part of the arm as they traverse the thoraco-cervico-brachial region. At this level, they successively course through three narrow anatomical spaces, which can be responsible for dynamic compressions. Schematically, these anatomic landmarks are comprised of two horizontal scissor-like blades, one below, represented by the first rib, the other above, represented by the clavicle and subclavian muscle. The tendons of the scalenus muscles are inserted on these elements vertically and delineate the three narrow passages in which the neurovascular elements can be compressed. The most medial element is the vein. It is located in the dihedral of the costoclavicular angle. Its principal constraint is the subclavian muscle.
381
382
R E H A B I L I T A T I O N OF PATIENTS WITH THORACIC OUTLET
ANNALS OF VASCULAR SURGERY
The two constraints which can act on the artery muscular static disorders secondary to trauma to are the costoclavicular bone angle and the passage the cervical spine or the clavicle have frequently between the scalenus muscles. Although they can been incriminated [14,15]. On the other hand, although very rare, asymmetact in an isolated fashion, both elements usually contribute concomitantly to compression, This is rical muscular hypertonia of the medial rotators (pectoralis major, teres major, latissimus dorsi) is known as the costoscalenic angle. The brachial plexus, originating from the cervical responsible for muscular static imbalance of the spine, joins the artery in the intrascalenic passage in shoulder [5]. Vertebral static disorders have also which it is submitted to the same constraints as the been mentioned. Posterior rocking of the pelvis can decrease costoclavicular space on the opposite side artery. The third passage is called the coracopectoral by modifying the vertebral curvatures [I0]. tunnel, and it lies lateral to the other two. Its limits are comprised of the inferior aspect of the coracoid process above, the subclavius muscle behind, and the tendon of the pectoralis minor in front. This GENERAL PRINCIPLES OF PHYSICAL tendon, inserted on the coracoid process, acts as a THERAPY pulley and can be responsible for nervous compression in movements of hyperabduction and external These principles stem from the anatomical and rotation of the arm. In the normal subject, certain movements of the dynamic descriptions above. The objectives of shoulder narrow these passages. Even in the ab- physical therapy are to enlarge the costoclavicular sence of associated anomalies, abduction of the arm passage in order to decrease the constraints of is responsible for 30° of axial rotation of the clavi- the neurovascular elements. Three complementary cle. The convexity of the clavicle turns from poste- mechanisms are involved. The freedom of the neurovascular elements in the rior to posteroinferior [ 11]. The clavicle can then be responsible for compression of the neurovascular described anatomical passages is the result of an elements on the superior aspect of the first rib. In harmonious equilibrium between the suspensor abduction of the arm, the neurovascular elements muscles of the scapular girdle, which tend to open are made to describe a bayonet-like course and are the passage, and the scapulothoracic muscles which stretched. The subclavian vein is compressed on act to the contrary. The goal of physical therapy exercises is to the first rib, whereas the arteriovenous elements are compressed against the anterior scalenus muscle or improve the contractility and the baseline tonus of the coracopectoral pulley. In abduction, the entire the muscles called "openers", that is, the middle and superior segments of the trapezius, the levator costoclavicular space narrows. Compression in this setting can be increased by scapulae, and the sternocleidomastoid muscles. positions of the head and neck which put the Concomitantly, retraction must be prevented, while anterior scalenus muscle under tension. Congenital relaxation of muscles called "closers" (anterior and or acquired morphological anomalies can directly or medium scalenus, subclavius, pectoralis minor, and indirectly reduce the different passages even further major) is encouraged. In the rare instance of asymmetrical muscular and lead to compression of the neurovascular elements. The most common example is compression hypertonia predominant on the "closing" muscles provoked by cervical ribs. Congenital or acquired [5,9], overall muscular relaxation is the goal. Abnormal ventilation increases the contraction of morphological anomalies of the first rib, apophysomegaly of C7, fibrous bands with anomalous the scalenus muscles and the compression in the insertion on the pleural apex, and malunions of the different passages. Abdominodiaphragmatic respiration does not and should be encouraged in this clavicle have also been described [12]. Ventilation plays a role as well. Compression is setting. Correction of the vertebral static disorders increased during complete inspiration by accrued is an essential part of rehabilitation. Dorsocervical kyphosis associated with vertebral rotation can be contraction of the scalene muscles. The scapular girdle has a sophisticated articula- responsible for scapular protrusion associated with tion and resembles a triangle of suspension. Bal- lowering of the clavicle. This results in narrowing of anced muscular forces are necessary in order not to the costoclavicular space. Postural exercises with decrease the already small physiologically available correction of abnormal vertebral curvatures and space the neurovascular elements must course posterior thrust of the shoulders is required to restore correct scapular placement [10]. through. Well conducted rehabilitation programs should Progressive descent of the shoulder by muscular hypotonia occurs during the third decade of life [13] therefore entail exercises which act on these three and appears to be one of the fundamental promoting components, if not simultaneously, at least in a factors involved in this pathology. Additionally, complementary fashion.
VOLCME 6 N o - 4 1992
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INDICATIONS There seems to be no consensus as to whether physical therapy or surgical correction is preferable. At the origin of this divergence of views is the high prevalence with which the radial pulse is abolished during dynamic movements. This can occur in up to 30% of the population [13] and explains why the sign is not discriminative. It is always difficult to relate pain of the upper limb to thoracic outlet compression even when clinical tests are positive. Indications for physical therapy are dependent on clinical findings. Initial medical therapy is proposed in mild clinical forms. Indications are best when the patient is managed early, during the year following the onset of symptoms [10]. At this stage, fibrosis and local inflammation are still moderate and the possibilities of rehabilitation are optimal. In these forms, surgical treatment is indicated only when correct medical management fails after three to six months. When a cervical rib is present, several authors propose initial surgery [6,12,15] as arterial and nervous complications are more severe in this setting. Clinically severe or complicated forms require surgical treatment. Indications for surgery include invalidating exertional or positional ischemia, severe digital vasomotor disorders, permanent or intermittent edema associated with functional compromise, intense cervical pain with or without motor disorders, acute upper limb ischemia, poststenotic aneurysms, occlusion of digital arteries, and trophic disorders.
;) ] ii
PROTOCOL Carrying heavy loads and prolonged abduction must be avoided. Sports which entail violent movements of the shoulder or poorly directed musculation of the upper limb must be discouraged. Swimming, and particularly the backstroke, is helpful. Rehabilitation is based on sessions guided by the physical therapist as well as individual work. Rehabilitation sessions are conducted three times per week during the first month, then twice weekly the following month. Six to eight additional sessions are occasionally necessary when improvement of symptoms is slow. Eight to ten sessions per year during a four week period can be of benefit to these patients. Each session is composed of several successive steps:
Fig. 1. Postures.
must be attenuated. Forward thrust of the shoulders is recommended in the sitting and standing positions. With the help of a plumb line or a cross-ruled mirror, the patient learns how to assume a correct corporeal position (Fig. 1). Respiratory physical therapy
Postures
This step is directed toward the correction of vertebral static disorders. The vertebral curvatures
This step emphasizes learning how to obtain and use abdominodiaphagmatic respiration preferentially. Exercises are performed symmetrically with the patient lying on his back and then analytically
R E H A B I L I T A T I O N OF PATIENTS WITH 7tIORACIC OUTLET
384
t
t
ANNALS OF VASCULAR SURGERY
,
a
b
Fig. 2. Abdominodiaphragmatic respiration training: (a) symmetrical, (b) hemithorax by hemithorax. for each half of the thorax with the patient lying on his side (Figs. 2a-2b). Decontraction massages
The goal here is to solicit the cutaneous receptors by pressure and stretching stimulation. Musculoaponevrotic proprioceptive receptors are equally stimulated through deeper stimulations. These exercises must be completed by slow passive mobilization of the neck and scapular girdle. Muscular relaxation maneuvers
This step makes use of the weight of the upper limb. With the patient in the procubitus or lateral decubitus position, isometric muscular contractions are induced by salves followed immediately by total relaxation of the scapular girdle (Figs. 3a-3b). Active strengthening of the scapular suspensor muscles
Ten series of movements are repeated twice, separated by a rest period of approximately one minute. Overall exercises
These are done with the patient in the sitting position, with corrected posture. Two goals are strived for: either shoulder musculation by simultaneous elevation (Fig. 4a) or retropulsion (Fig. 4b) of the shoulder against resistance or cervical musculation. This includes lateral inflection of the head
against resistance, which is applied by the physical therapist using a temporo-occipital hand maneuver (Fig. 4c), associated with retropulsion of the head against resistance, applied with the physical therapist's hand placed on the occiput (Fig. 4d).
Analytic exercises
Sternocleidomastoid muscle exercises: While lying on his back, his head over the end of the table, the patient is asked to perform isometric contractions in flexion, first against gravity and then by combining flexion and rotation to the opposite side (Figs. 5a-5b). Serratus anterior exercises: The patient works on antepulsion of the shoulders, either on his back with his shoulders blocked by a cushion and his arms held up perpendicularly, gripping a horizontal bar in order to work symmetrically (Fig. 6a), or in an orthostatic position, with the arms held horizontally, the back of the patient propped on a hard plane against resistance applied by the physical therapist (Fig. 6b). Sternocleidomastoid and superior head of the trapezius muscle exercises: While lying on his abdomen, the head over the end of the table and the sternum propped up by a cushion, the patient makes isometric contractions against gravity in flexion and then combines flexion and rotation to the opposite side (Fig. 7a). Propped on all four limbs, hands turned in, the patient antepulses his shoulders (Fig. 7b). Superior chief of trapezius, serratus, and angular muscle exercises: Standing in a corner, hands
VOLt:ME 6 N o - 4 1992
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¢
a
b
Fig. 3. Maneuvers leading to overall relaxation of scapular girdle: (a) scapulothoracic muscles, (b) superior heads of trapezius and sternocleidomastoid muscles.
placed on the walls in external rotation, the patient is asked to make antepulsion and elevation movements of the shoulders as if he wanted to fit snugly into the corner (Fig. 8a). The same movements are made with the patient sitting on a chair, his back straight and his hands flat on his knees, which are held apart (Fig. 8b). As soon as the patient understands the movements, he is encouraged to perform a series of exercises chosen from those described on his own. Some of these exercises can be performed with weights to replace the resistance applied by the physical therapist. Weight must be small at the beginning (one kilo) but may be increased progressively to five kilos. All during the musculation exercise period appropriate respiration movements must be encouraged in order to enhance enlargement of the anatomical passages. In practice, this is accomplished during inspiration.
ranges between 66% and 87.5% [4,7,9,10,16] for the indications as defined above. During this follow-up period, there were no acute accidents which required emergency surgical treatment. On the other hand, 10% to 15% of patients were referred to surgery because of worsening of symptoms or invalidating functional compromise occurring during the same interval of time. It is extremely difficult to determine the criteria influencing the quality of outcome because of the absence of statistical analysis in the literature. Nonetheless, patient outcome is better when: (1) he enters a rehabilitation program early [10]; (2) cervical and scapular roentgenograms are normal; (3) symptoms are neurological only [14]; and (4) physical therapy is combined with exercises done at home [9]. On the other hand, poor outcomes can be expected in association with antecedent cervical trauma, noted in approximately 20% of cases [10], and with clinically moderate-to-average severity, combining vascular and neurological involvement [lO].
RESULTS Little has been published by physical therapists recently concerning the treatment of thoracic outlet syndromes. Nonetheless, reported improvement or complete relief of symptoms at four years or more
CONCLUSION The high prevalence of positive dynamic maneuvers contrasts with the small number of patients
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Fig. 5. (a) and (b): Exercises to strengthen sternocleidomastoid musculature.
approach is efficacious in initial neurological forms (satisfactory results in approximately 70% of cases). On the other hand, physical therapy cannot replace surgery in severe forms of thoracic outlet syndrome with vascular compromise.
with associated upper limb pain that can formally be connected to thoracic outlet narrowing. This supports the view of starting specific physical therapy first. This strategy avoids early surgery for which medium-term results are often deceptive. The
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a Fig. 6. (a) and (b): Exercises to strengthen serratus muscle.
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VASCUt.AR SURGERY
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Fig. 7. (a) and (b): Exercises to strengthen sternocleidomastoid and superior head of trapezius muscle.
a Fig. 8. (a) and (b): Exercises to strengthen superior heads of trapezius, serratus, and angular muscles.
b
VOLUME 6 No - 4 1992
REHABILITATION OF PATIENTS WITH THORACIC OUTLET
REFERENCES 9. t. BOUCHET JY, RICHAUD C, FRANCO A. Le syndrome de la traversEe thoraco-brachiale et sa reeducation. Ann Kin~sithOrapie 1984;li:83-88. 2. CRIELAARD JM, REGINSTER JY+ BEAU JEAN M, et al. MEdecine physique et rEEducation dans le traitement des syndromes du defile cervico-scapulo-thoracique+ Acta Belg Med Phys 1986;9:303-308. 3. DASKALAKIS MK. Thoracic outlet compression syndrome: current concepts and surgical experience. Int Surg 1983;68:337-344, 4. HIRSH LF, THANKI A+ The thoracic outlet syndrome: meeting the diagnostic challenge. Postgrad Med 1985;77: 19%203. 5. YOUNG HA, HARDY DG+ Thoracic outlet syndrome. B r J Hosp Med 1983;29:457--461. 6. COCCIA MR, SATIANI B. Thoracic outlet syndrome. Am Farn Phys 1984;29:121-126. 7. PEET RM, HENRIKSEN JD, ANDERSON TP, et al. Thoracic outlet syndrome: evaluation of a therapeutic exercise program. Proc Stqff Meet Mayo Clin 1956:31:281-287. 8. REVEL M, LAILLtER M, MEUNIER C. La kinesitherapie
mill
10. 11. 12.
13. 14.
15. 16,
389
des syndromes de la traversee cervico-scapulaire. Ann Kin~sith~rapie 1981:8:277-285. REVEL M, AMOR B. R~Education des syndromes de la traversee cervico-thoraco-brachiale, Phf~bologie 1983;36: 157-165+ SALLSTROM J+ CELEGIN Z. Physiotherapy in patients with thoracic outlet syndrome. Vasa 1983;12:257-261. KAPANDJI IA+ Physiologie Articulaire. Fascicule 1. Paris: Maloine 1971, pp 50-53. DEVIN R. BRANCHEREAU A. Syndrome de compression du defile costo-claviculaire+ Encycl Med Chir Paris+ Techniques Chirurgicales, Chirurgie Vasculaire, 4.1.10, 43290. TODD TW. The descent of the shoulder after birth: its significance in the production of pressure symptoms of the lowest brachial trunk, Anat Anz 1912~41:385-396. VAYSSAIRAT M, PR1OLLET P. Indications et modalites du traitement medical dans les syndromes du defile thoracobrachial, J Mal Vase 1983;8:87-90, MERCIER C, HUGUET JF+ Les Syndromes Vasculaires de fa Travers~e Thoraco-brachiale. Paris: Masson+ 1976, pp 47-51, 124-129, STALLWORTH JM, HORNE JB. Diagnosis and management of thoracic outlet syndrome. Arch Surg 1984; 119:1149-1151,
Rehabilitation of Patients with Thoracic Outlet Syndrome Christian Aligne, MD, Xavier Barral, MD, S a i n t - C h a m o n d and Saint-Etienne, France
A series of physical therapy protocols is proposed for patients with thoracic outlet syndrome. The anatomic findings dictating certain physical therapeutic approaches are outlined. General principles of physical therapy that stem from these findings are suggested, and a specific protocol for the physical therapy regimen is given. An appropriate physical therapy program for thoracic outlet syndrome patients with symptoms of mild-to-moderate severity can avoid early surgery. Degradation of symptoms or invalidating functional compromise indicates a referral to surgery. Physical therapy cannot replace surgery in severe or complicated forms of thoracic outlet syndrome with vascular or neurologic compromise. (Ann Vasc $urg 1992;6: 381-389). KEY WORDS:
Thoracic outlet syndrome; physical therapy.
Physical therapy and rehabilitation are efficacious in most cases of thoracic outlet syndrome [1-6] and therefore surgical correction is limited to complicated or initially severe forms. Minor involvement, with essentially functional impairment, are typically managed initially by physical therapy. Since Peet's description at the Mayo Clinic in 1956 [7], several authors [8-10] have remarked the role played by mechanisms other than the anatomical anomalies associated or not with hypotonia of the suspensor muscles of the shoulder. This evolution of ideas has led to progressive adaptation of physical therapy protocols which are proposed to patients.
From the Service d'Angiologie, Centre Medical de Chavanne, Saint-Chamond, and the Service de Chirurgie Vasculaire, Centre Hospitalier et Universitaire, SaintEtienne, France. Reprint request: C. Aligne, MD, Service d'Angiologie, Centre MOdical de Chavanne, 42400 Saint-Chamond, France.
ANATOMIC FINDINGS AND DYNAMIC MODIFICATIONS The neurovascular bundle for the upper limb is comprised of the subclavian vessels and the brachial plexus. Before reaching the brachial canal, these elements are grouped together in the superior and medial part of the arm as they traverse the thoraco-cervico-brachial region. At this level, they successively course through three narrow anatomical spaces, which can be responsible for dynamic compressions. Schematically, these anatomic landmarks are comprised of two horizontal scissor-like blades, one below, represented by the first rib, the other above, represented by the clavicle and subclavian muscle. The tendons of the scalenus muscles are inserted on these elements vertically and delineate the three narrow passages in which the neurovascular elements can be compressed. The most medial element is the vein. It is located in the dihedral of the costoclavicular angle. Its principal constraint is the subclavian muscle.
381
382
R E H A B I L I T A T I O N OF PATIENTS WITH THORACIC OUTLET
ANNALS OF VASCULAR SURGERY
The two constraints which can act on the artery muscular static disorders secondary to trauma to are the costoclavicular bone angle and the passage the cervical spine or the clavicle have frequently between the scalenus muscles. Although they can been incriminated [14,15]. On the other hand, although very rare, asymmetact in an isolated fashion, both elements usually contribute concomitantly to compression, This is rical muscular hypertonia of the medial rotators (pectoralis major, teres major, latissimus dorsi) is known as the costoscalenic angle. The brachial plexus, originating from the cervical responsible for muscular static imbalance of the spine, joins the artery in the intrascalenic passage in shoulder [5]. Vertebral static disorders have also which it is submitted to the same constraints as the been mentioned. Posterior rocking of the pelvis can decrease costoclavicular space on the opposite side artery. The third passage is called the coracopectoral by modifying the vertebral curvatures [I0]. tunnel, and it lies lateral to the other two. Its limits are comprised of the inferior aspect of the coracoid process above, the subclavius muscle behind, and the tendon of the pectoralis minor in front. This GENERAL PRINCIPLES OF PHYSICAL tendon, inserted on the coracoid process, acts as a THERAPY pulley and can be responsible for nervous compression in movements of hyperabduction and external These principles stem from the anatomical and rotation of the arm. In the normal subject, certain movements of the dynamic descriptions above. The objectives of shoulder narrow these passages. Even in the ab- physical therapy are to enlarge the costoclavicular sence of associated anomalies, abduction of the arm passage in order to decrease the constraints of is responsible for 30° of axial rotation of the clavi- the neurovascular elements. Three complementary cle. The convexity of the clavicle turns from poste- mechanisms are involved. The freedom of the neurovascular elements in the rior to posteroinferior [ 11]. The clavicle can then be responsible for compression of the neurovascular described anatomical passages is the result of an elements on the superior aspect of the first rib. In harmonious equilibrium between the suspensor abduction of the arm, the neurovascular elements muscles of the scapular girdle, which tend to open are made to describe a bayonet-like course and are the passage, and the scapulothoracic muscles which stretched. The subclavian vein is compressed on act to the contrary. The goal of physical therapy exercises is to the first rib, whereas the arteriovenous elements are compressed against the anterior scalenus muscle or improve the contractility and the baseline tonus of the coracopectoral pulley. In abduction, the entire the muscles called "openers", that is, the middle and superior segments of the trapezius, the levator costoclavicular space narrows. Compression in this setting can be increased by scapulae, and the sternocleidomastoid muscles. positions of the head and neck which put the Concomitantly, retraction must be prevented, while anterior scalenus muscle under tension. Congenital relaxation of muscles called "closers" (anterior and or acquired morphological anomalies can directly or medium scalenus, subclavius, pectoralis minor, and indirectly reduce the different passages even further major) is encouraged. In the rare instance of asymmetrical muscular and lead to compression of the neurovascular elements. The most common example is compression hypertonia predominant on the "closing" muscles provoked by cervical ribs. Congenital or acquired [5,9], overall muscular relaxation is the goal. Abnormal ventilation increases the contraction of morphological anomalies of the first rib, apophysomegaly of C7, fibrous bands with anomalous the scalenus muscles and the compression in the insertion on the pleural apex, and malunions of the different passages. Abdominodiaphragmatic respiration does not and should be encouraged in this clavicle have also been described [12]. Ventilation plays a role as well. Compression is setting. Correction of the vertebral static disorders increased during complete inspiration by accrued is an essential part of rehabilitation. Dorsocervical kyphosis associated with vertebral rotation can be contraction of the scalene muscles. The scapular girdle has a sophisticated articula- responsible for scapular protrusion associated with tion and resembles a triangle of suspension. Bal- lowering of the clavicle. This results in narrowing of anced muscular forces are necessary in order not to the costoclavicular space. Postural exercises with decrease the already small physiologically available correction of abnormal vertebral curvatures and space the neurovascular elements must course posterior thrust of the shoulders is required to restore correct scapular placement [10]. through. Well conducted rehabilitation programs should Progressive descent of the shoulder by muscular hypotonia occurs during the third decade of life [13] therefore entail exercises which act on these three and appears to be one of the fundamental promoting components, if not simultaneously, at least in a factors involved in this pathology. Additionally, complementary fashion.
VOLCME 6 N o - 4 1992
R E H A B I L I T A T I O N OF PATIENTS W177t THORACIC O U ] L E T
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INDICATIONS There seems to be no consensus as to whether physical therapy or surgical correction is preferable. At the origin of this divergence of views is the high prevalence with which the radial pulse is abolished during dynamic movements. This can occur in up to 30% of the population [13] and explains why the sign is not discriminative. It is always difficult to relate pain of the upper limb to thoracic outlet compression even when clinical tests are positive. Indications for physical therapy are dependent on clinical findings. Initial medical therapy is proposed in mild clinical forms. Indications are best when the patient is managed early, during the year following the onset of symptoms [10]. At this stage, fibrosis and local inflammation are still moderate and the possibilities of rehabilitation are optimal. In these forms, surgical treatment is indicated only when correct medical management fails after three to six months. When a cervical rib is present, several authors propose initial surgery [6,12,15] as arterial and nervous complications are more severe in this setting. Clinically severe or complicated forms require surgical treatment. Indications for surgery include invalidating exertional or positional ischemia, severe digital vasomotor disorders, permanent or intermittent edema associated with functional compromise, intense cervical pain with or without motor disorders, acute upper limb ischemia, poststenotic aneurysms, occlusion of digital arteries, and trophic disorders.
;) ] ii
PROTOCOL Carrying heavy loads and prolonged abduction must be avoided. Sports which entail violent movements of the shoulder or poorly directed musculation of the upper limb must be discouraged. Swimming, and particularly the backstroke, is helpful. Rehabilitation is based on sessions guided by the physical therapist as well as individual work. Rehabilitation sessions are conducted three times per week during the first month, then twice weekly the following month. Six to eight additional sessions are occasionally necessary when improvement of symptoms is slow. Eight to ten sessions per year during a four week period can be of benefit to these patients. Each session is composed of several successive steps:
Fig. 1. Postures.
must be attenuated. Forward thrust of the shoulders is recommended in the sitting and standing positions. With the help of a plumb line or a cross-ruled mirror, the patient learns how to assume a correct corporeal position (Fig. 1). Respiratory physical therapy
Postures
This step is directed toward the correction of vertebral static disorders. The vertebral curvatures
This step emphasizes learning how to obtain and use abdominodiaphagmatic respiration preferentially. Exercises are performed symmetrically with the patient lying on his back and then analytically
R E H A B I L I T A T I O N OF PATIENTS WITH 7tIORACIC OUTLET
384
t
t
ANNALS OF VASCULAR SURGERY
,
a
b
Fig. 2. Abdominodiaphragmatic respiration training: (a) symmetrical, (b) hemithorax by hemithorax. for each half of the thorax with the patient lying on his side (Figs. 2a-2b). Decontraction massages
The goal here is to solicit the cutaneous receptors by pressure and stretching stimulation. Musculoaponevrotic proprioceptive receptors are equally stimulated through deeper stimulations. These exercises must be completed by slow passive mobilization of the neck and scapular girdle. Muscular relaxation maneuvers
This step makes use of the weight of the upper limb. With the patient in the procubitus or lateral decubitus position, isometric muscular contractions are induced by salves followed immediately by total relaxation of the scapular girdle (Figs. 3a-3b). Active strengthening of the scapular suspensor muscles
Ten series of movements are repeated twice, separated by a rest period of approximately one minute. Overall exercises
These are done with the patient in the sitting position, with corrected posture. Two goals are strived for: either shoulder musculation by simultaneous elevation (Fig. 4a) or retropulsion (Fig. 4b) of the shoulder against resistance or cervical musculation. This includes lateral inflection of the head
against resistance, which is applied by the physical therapist using a temporo-occipital hand maneuver (Fig. 4c), associated with retropulsion of the head against resistance, applied with the physical therapist's hand placed on the occiput (Fig. 4d).
Analytic exercises
Sternocleidomastoid muscle exercises: While lying on his back, his head over the end of the table, the patient is asked to perform isometric contractions in flexion, first against gravity and then by combining flexion and rotation to the opposite side (Figs. 5a-5b). Serratus anterior exercises: The patient works on antepulsion of the shoulders, either on his back with his shoulders blocked by a cushion and his arms held up perpendicularly, gripping a horizontal bar in order to work symmetrically (Fig. 6a), or in an orthostatic position, with the arms held horizontally, the back of the patient propped on a hard plane against resistance applied by the physical therapist (Fig. 6b). Sternocleidomastoid and superior head of the trapezius muscle exercises: While lying on his abdomen, the head over the end of the table and the sternum propped up by a cushion, the patient makes isometric contractions against gravity in flexion and then combines flexion and rotation to the opposite side (Fig. 7a). Propped on all four limbs, hands turned in, the patient antepulses his shoulders (Fig. 7b). Superior chief of trapezius, serratus, and angular muscle exercises: Standing in a corner, hands
VOLt:ME 6 N o - 4 1992
R E H A B I L I T A T I O N OF PATIENTS W l l T t THORACIC O U 1 Z E T
385
¢
a
b
Fig. 3. Maneuvers leading to overall relaxation of scapular girdle: (a) scapulothoracic muscles, (b) superior heads of trapezius and sternocleidomastoid muscles.
placed on the walls in external rotation, the patient is asked to make antepulsion and elevation movements of the shoulders as if he wanted to fit snugly into the corner (Fig. 8a). The same movements are made with the patient sitting on a chair, his back straight and his hands flat on his knees, which are held apart (Fig. 8b). As soon as the patient understands the movements, he is encouraged to perform a series of exercises chosen from those described on his own. Some of these exercises can be performed with weights to replace the resistance applied by the physical therapist. Weight must be small at the beginning (one kilo) but may be increased progressively to five kilos. All during the musculation exercise period appropriate respiration movements must be encouraged in order to enhance enlargement of the anatomical passages. In practice, this is accomplished during inspiration.
ranges between 66% and 87.5% [4,7,9,10,16] for the indications as defined above. During this follow-up period, there were no acute accidents which required emergency surgical treatment. On the other hand, 10% to 15% of patients were referred to surgery because of worsening of symptoms or invalidating functional compromise occurring during the same interval of time. It is extremely difficult to determine the criteria influencing the quality of outcome because of the absence of statistical analysis in the literature. Nonetheless, patient outcome is better when: (1) he enters a rehabilitation program early [10]; (2) cervical and scapular roentgenograms are normal; (3) symptoms are neurological only [14]; and (4) physical therapy is combined with exercises done at home [9]. On the other hand, poor outcomes can be expected in association with antecedent cervical trauma, noted in approximately 20% of cases [10], and with clinically moderate-to-average severity, combining vascular and neurological involvement [lO].
RESULTS Little has been published by physical therapists recently concerning the treatment of thoracic outlet syndromes. Nonetheless, reported improvement or complete relief of symptoms at four years or more
CONCLUSION The high prevalence of positive dynamic maneuvers contrasts with the small number of patients
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approach is efficacious in initial neurological forms (satisfactory results in approximately 70% of cases). On the other hand, physical therapy cannot replace surgery in severe forms of thoracic outlet syndrome with vascular compromise.
with associated upper limb pain that can formally be connected to thoracic outlet narrowing. This supports the view of starting specific physical therapy first. This strategy avoids early surgery for which medium-term results are often deceptive. The
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388
ANNALS OF
R E t t A B 1 L I T A T I O N O F PA 1TENTS W I T H T H O R A C I C O U T L E T
VASCUt.AR SURGERY
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Fig. 7. (a) and (b): Exercises to strengthen sternocleidomastoid and superior head of trapezius muscle.
a Fig. 8. (a) and (b): Exercises to strengthen superior heads of trapezius, serratus, and angular muscles.
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VOLUME 6 No - 4 1992
REHABILITATION OF PATIENTS WITH THORACIC OUTLET
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