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Treatment options for neurogenic thoracic outlet syndrome (TOS) include:

• Conservative therapy
• Drug therapy
• Surgery

Conservative Treatment

Conservative treatment has been found to be increasingly effective resulting in a decreased need for surgical intervention. This trend comes with the realization that often symptoms of TOS are related to muscular involvement secondary to postural changes.

The goals of conservative treatment include:

• Decreasing compression on the brachial plexus

• Correcting muscle imbalance in the cervicoscapular region through:

  • patient education
  • behavior modification
  • appropriate exercises

• Stretching muscles

• Increasing mobility and range of motion of cervical and scapular muscles and strengthening these muscles

Most experts agree that a conservative approach is the first-line treatment in the management of patients with neurogenic TOS unless the patient is experiencing significant neurologic impairment or acute vascular insufficiency due to neurovascular compression in which case surgery may be necessary. Approximately 85% or more of patients with TOS will improve with conservative treatment and only a small percentage of patients actually require surgery.

Patient education plays a crucial role in conservative therapy for thoracic outlet syndrome. The patient must be aware of:

• Positions and postures that relieve or exacerbate pain
• The extent to which their actions can control their symptoms
• Behavior modification to develop healthy posture and careful movement at home, work, and during daily activities
• Obesity can also contribute to the severity of symptoms in TOS and has been associated with poor treatment outcome. Proper diet and exercise with resulting weight loss may not eliminate TOS but will boost the efficacy of other treatments.

Conservative treatments for neurogenic TOS include:

• Physical therapy
• Postural training

Physical Therapy

• Muscle strengthening and lengthening exercises
• Stretching/isometric exercises
• Aerobic exercise for cardiovascular health
• Orthotics to help keep posture upright
• Osteopathic manipulation of the scalene and trapezius muscles
• Extra-supportive bra that crosses at the back to help support posture in women with very large breasts
• Heat treatments with ultrasound
• Transcutaneous Electrical Nerve Stimulation (TENS) to control pain
• Swimming - may be beneficial, however, some authorities recommend avoiding the "backstroke" and "breaststroke"

Physical therapists can also advise patients with TOS regarding arm placement and body support during sleep which are especially important since so much time is spent in bed or sleeping. Helpful measures include:

• Soft neck rolls which immobilize and support the cervical spine
• Refraining from resting the arm elongated above the head
• Some health care professionals recommend the use of cervical supports and pillows but these may cause excessive cervical extension and in some cases, increase pain

Postural Training

The goal of postural training is to correct poor posture such as drooping or sagging shoulders. Proper posture is essential in the treatment of TOS. Compression resulting from poor posture and positioning affects soft tissue and eventually causes hyperextension of the cervical spine due to continued head forward position. Some important aspects of muscular rehabilitation in the cervicoscapular region include:

• Stretching to improve range of motion - Improved range of motion is best achieved through gentle stretching and repetitive motions to gain full cervical movement. This stretches tight muscles of the upper chest that attach to the cervical spine. These muscles include: