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• • scalene muscles
  • pectoralis major and minor
  • upper trapezius
  • levator scapulae

To provide the greatest support and least exacerbation of pain, exercises are typically done on the floor with a pillow or towel roll supporting the cervical spine. Exercise intensifies gradually until full cervical extension is achieved and exercises can be done with no extra support of the head or neck. The patient then progresses to doing these exercises in a sitting position. As the tolerance for exercises increases, more aggressive stretching techniques can be initiated. If exercises are too intense for the level of the patient or if they progress too rapidly, symptoms can worsen.

When carrying out a treatment program for increasing the range of motion in the cervicoscapular area, the patient must be careful not to overstretch nerves (neural stretching) which can result in symptoms in the entire arm.

• Restoring muscle strength - Restoration of muscle strength in the cervicoscapular region proceeds only after patients have achieved pain-free range of motion. Initially strengthening exercises are done with gravity assistance (i.e., minimum resistance) and then progressive resistance is introduced. Among the muscles targeted are the middle/lower trapezius muscles and the serratus anterior muscles.

The objective of muscle strengthening activity is endurance, not power, so progressive stages of exercise are introduced gradually. Stretching and range of motion exercises must be maintained during the strengthening stage.

• Improving muscles involved with respiratory function - Poor posture puts a strain on accessory respiratory muscles, those muscles that are not normally involved directly in inhaling and exhaling. Over time, poor posture causes muscles involved in breathing to shorten resulting in the first rib being pulled out of place and elevated which leads to greater compression on the brachial plexus. Accessory respiratory muscles are then used to assist with respiration and chest expansion which puts an added burden on them.

Breathing exercises that promote proper muscle use while maintaining good posture improve chest expansion during breathing resulting in decreased use of accessory breathing muscles.

Drug Therapy

Drug therapy for controlling pain in neurogenic TOS may be accomplished with:

• Analgesics and non-steroidal anti-inflammatory drugs (NSAID's)- may be used to reduce pain and inflammation

• Muscle relaxants - may be used to control muscle spasms (e.g., metaxalone)

• Antidepressants - may be necessary for TOS patients to treat pain:

  • tricyclic antidepressants (Elavil, Pamelor)
  • selective serotonin reuptake inhibitors (Paxil, Zoloft)

• Anticonvulsants (e.g., clonazepam, gabapentin, topiramate)

• Scalene injections with local anesthetic/steroid solutions - may be used to reduce pain

• Stellate ganglion block - may be given to patients with TOS who also have symptoms of reflex sympathetic dystrophy (RSD)

Surgery

As mentioned above, most patients with thoracic outlet syndrome improve with conservative treatment and only a small percentage will actually require surgery for anatomic decompression. Surgery may be considered as an option in certain situations including:

• Patients who have failed to respond to conservative therapy after a minimum of at least 3 months and continue to have severe pain or neurologic deficits

• Patients with acute vascular problems resulting in reduced blood flow to the area