MedifocusHealth

• • cyanosis and swelling (if there is venous involvement)

• Halstead Maneuver - the patient stands with shoulders back and arms down. The test is positive if the radial pulse is obliterated while standing in this position.

• Adson Maneuver - the patient keeps their arms down, turns their head towards the affected side, and breathes deeply. The test is positive if the radial pulse disappears while standing in this position or is weakened during deep inspiration.

There is no consensus regarding provocative maneuvering of the arms as a diagnostic tool for TOS since it has been found that in many individuals without TOS, the same degree of arterial compression occurs when their arms are maneuvered in a similar fashion.

Patients with other neurological conditions, (e.g., CTS or cervical disk disease) may develop various symptoms as a result of individual provocative maneuvers but the patterns are markedly different than those for thoracic outlet syndrome. It is not clear whether the severity of TOS is indicated by how long the patient can tolerate the test. The symptoms which the patient describes following the EAST maneuver are strong indicators for the presence of TOS.

Other Diagnostic Tests

A variety of other diagnostic tests may be used in assessing patients with signs and symptoms of TOS. None of these tests are specific for TOS but are used primarily to rule-out other possible causes of the signs and symptoms that the patient is experiencing. Testing should be done selectively based on the patient's history and physical exam. The tests may include:

• Nerve Testing - there is no specific test to directly measure nerve compression, necessitating indirect measurements to help in the diagnosis of TOS including:

  • provocative tests at compression sites
  • direct pressure on the nerve
  • combination of these two procedures. The combination of tests is considered positive if the symptoms are reproduced along the expected neural pathways
  • palpation of the scalene muscle for tenderness
  • Tinel sign - physician taps each entrapment site a few times. If the test is positive, a tingling feeling is elicited. This test is usually positive at later stages of nerve compression.

  Caution must be taken to test only one entrapment site at a time (e.g., wrist, elbow, or shoulder) since it is important to isolate the site of compression. It is also important to identify multiple compression or entrapment sites. Research has shown that more than 50% of patients with TOS have clinical evidence of carpal or cubital tunnel syndrome. Provocative maneuvers at nerve entrapment sites in the early stage of TOS may elicit symptoms but electrodiagnostic tests and sensory nerve tests will be negative.

• Sensory Testing - there are two types of sensory receptors that relay the message of touch to the brain.

  • quickly adapting receptors respond to moving touch. These receptors are tested by threshold vibration, which is the lowest level of vibration needed to evoke a response from these cells.

  • slowly adapting receptors respond to constant touch and are evaluated by cutaneous pressure threshold (i.e., how much pressure must be exerted before the receptors respond.