Lifestyle Modifications and Quality of Life in Thoracic Outlet Syndrome

Symptoms of thoracic outlet syndrome (TOS) can initially be mild and non-specific and patients typically to do not seek medical help until the intensity of the symptoms disturbs their day-to-day well being. The symptoms increase in frequency and severity and begin to affect the patient's job, sleep and general activities. When they do seek help, patients may find that they consult with several physicians who misdiagnose them because the determination of TOS is so difficult to confirm. Patients report that they are often told that their pain is psychosomatic and if an injury causing the TOS is employment related, health care providers dealing with workmen's compensation may minimize the injury and symptoms even further.

All of these difficulties often cause significant frustration and extract a significant psychological toll on patients. Quality of life in general and specific areas such as work and social life are severely compromised in some patients. Some patients develop emotional problems due to the lack of appropriate diagnosis and treatment and some may develop permanent neurological damage of the neural plexus because of the lag time before proper diagnosis. Depression is not uncommon among patients with TOS who may experience significant pain.

Depending on the severity of the individual case, thoracic outlet syndrome can be a lifelong condition which is usually controllable or manageable but is not curable and can have a significant impact not only on the patient but on family and friends as well. The condition affects many aspects of life to varying degrees, depending on the severity of the symptoms and the duration that the patient has suffered, including:

• Daily living activities
• Professional life
• Social life
• Personal life

Thoracic outlet syndrome may create a financial strain on the patient and their family due to reduced income from time lost at work, unemployment, and/or medical expenses which may be needed for patient care. Friends and family may find it beneficial to map out a plan of action with the patient's participation so that a daily routine is established. This reduces stress levels and minimizes unexpected changes of plan. Responsibilities that need to be addressed may include:

• Planning meals
• Cooking
• Cleaning
• Laundry
• Shopping
• Car pools
• Pet care
• Leisure activities (e.g., going to the library, movies)

Once the patient with TOS is correctly diagnosed, education about the condition and participation in treatment are essential. Posture awareness is considered one of the earliest hallmarks of successful rehabilitation. Avoiding postures and positions that exacerbate the symptoms requires concentration and behavior modification. Patients need guidelines for good standing, sitting, and sleeping positions. In addition, patients need to be counseled regarding modifications in the work place regarding physical layout, responsibilities, and any other related needs.

It is important for the patient with TOS to correct poor posture and to work on strengthening muscles in a timely fashion since over-correction or accelerated stretching of contracted muscles can exacerbate symptoms and cause further damage. Optimum range of motion in the thoracoscapular region (approximately mid-upper chest and back) is important in order to maintain correct posture.

Exercise programs are essential vehicles for achieving:

• Increased range of motion
• Retraction of the cervical muscles to correct the head-forward position
• Stretching of the thoracoscapular muscle groups

Poor posture is also related to poor aerobic conditioning due to poor or ineffective use of muscles that that aid in the efficacy of the cardiopulmonary system. Many groups of muscles in the back and chest are involved in breathing and if they are not functioning properly, the respiratory system is compromised in various ways, including:

• Insufficient chest expansion during inspiration
• Inefficient functioning of the cardiopulmonary system while at rest

Aerobic exercise is important for cardiovascular health. The most effective aerobic regimen is to start walking while maintaining proper posture (especially the head and neck) and proper breathing.

Conditioning of the various muscle groups should be addressed by the physician or physical therapist through a coordinated program of physical training and patient education focused on full compliance. Exercise should begin early in treatment but not be overly aggressive. It is important for the health professionals involved in treatment (e.g., physician, physical therapist) to regularly evaluate the patient's progress in order to ensure that proper muscle length and strength is maintained. Ultimately, the success of any treatment program depends on patient compliance to home exercise and behavior modification techniques.

In addition to exercise regimens, supplementary modalities which may ease the pain and loosen muscles include:

• Heat application to the painful muscles
• TENS (transcutaneous electrical nerve stimulation)
• Ultrasound

Equally important is awareness of sleep positions, especially if patients wake up in the morning with stiff neck, headache, and numbness in the arm, symptoms which may result from raising their arm above their heads during sleep. Patients need to be coached and taught how to prevent themselves from lying with arm positions which may be counterproductive to their treatment and advised regarding proper support for the cervical spine during sleep, including cervical pillow supports and other types of equipment.

In summary, there are some basic lifestyle modifications that patients with TOS should consider to control and relieve symptoms of the disorder:

• If you are obese, talk with your doctor about starting a safe and effective weight loss program
• If you do not already have an exercise program, talk with your doctor about developing a program to strengthen your muscles (particularly shoulder muscles)
• If you have poor posture, ask your doctor to suggest a postural training program
• Avoid sitting or standing for extended periods of time andtake frequent "stretching" breaks
• Avoid lifting heavy objects at work or at home
• Ask your doctor about work-site modifications that may be necessary to help you control your TOS symptoms while on the job
• Talk with your employer about implementing your doctor's recommendations for work-site modifications