1. Radiating Pain and TOS Examination and Physiotherapy

2. Muscular radiation Suboccipital muscles: upper neck, behind ears and eyes Splenius capitis & cervicis: Neck, upper neck, lateral side of the neck to ear, top of the head Semispinalis cervicis & capitis: From neck to scapulae, behind ears, back of the head Scalenes: Shoulder, arm, even forearm and hands Sternocleidomastoideus: Laterally from neck, temporal and cheek area, above eyes, forehead Levator scapulae: above scapulae, shoulder Trapezius: Neck and shoulder, Chin, temporal area Paraspinals: spinal area, scapular area, chest area Houglum 2010, 513-517)

3. Radiation from Facet Joints Magee 2014, 161

4. Radiation caused by disc

5. THORACIC OUTLET SYNDROME Examination and Physiotherapy

6. Thoracic Oulet

9. Cadaver VIDEOS Anatomiaa: http://www.youtube.com/watch?v=aLjivfG7fGM http://www.youtube.com/watch?v=aLjivfG7fGM Plexus Brachialis: http://www.youtube.com/watch?v=lfcd7IwgzNs http://www.youtube.com/watch?v=lfcd7IwgzNs Deep neck: http://www.youtube.com/watch?v=bUhmNaRWTh0 http://www.youtube.com/watch?v=bUhmNaRWTh0

10. Etiology Most common in women 20-50 years Provocative factors: static work including use of upper arms, shoulder injuries, whiplash Poor posture and limitation in ROM in cervical and upper thoracic spine and shoulder girdle area

11. Signs and Symptoms PAIN: Pain in shoulder area, radiation to chest area, scapula area and head. Usually shoulder and arm pain included FORCE/STRENGTH: Upper limb usually poweless/weak, weakness is provocated in arms up positions (hair brushing, curtains hanging, doing loundry, working arms up positions i.e. hairdessing) SENSE: Loss of sensation, change in temperature, swelling, may occur MOTOR FUNCTION: Tremor may occur (vapina)

12. Signs and Symptoms?

13. TOS Classification Functional TOS (n. 90-95%) Neurogenic (EMG positive, anomalies provoce) Vascular (e.g. thrombosis of vena subclavia) Neurovascular (neurogenic + neurovascular, yht. noin 5%) Read the articles about conservative and operative treatment!

14. TOS – index? TOS is suspected when: -Symptoms increase arms up position -Supraclavicular area and pectoralis minor palpation painful -ROOS or CRLF test positive

15. Yläaukeaman häiriön vaikutukset Sentizisation of neural tissue effects to function of muscles > protective mechanisms try to prevent extra load in neural tissue Muscle tension limits joint movement and increases load in joints → Irritation of neural tissue may seem like tension neck or joint ROM limitation (cervical spine, shoulder)

18. Neurological Status and Examination 1)Reflexes 2)Dermatomes 3)Myotomes 4)Cervical provocation tests (distraction/compression) 5)Neurodynamic tests (ULTT) 6)Observation, palpation 7)ROM, segmental ROM, translatoric joint play 8)TOS- tests: Roos, Adson, Halsted, CRLF, infra- ja supraclaviculaar space, ”scalenus cage”, costa I mobility

19. Neural symptom Sensation loss - sensory nerves Strength loss – motor nerves Hypo- or hypertonus of reflexes (CNS) Sensitivity changes in neural tissue (palpation) Pain from nerve root or perpheral nerve (tension testing)

20. Neuraalikudoksen osuus? Lateral flexion of the cervical spine produces tension to dura mate and causes a sliding movement in brachial plexus – if shoulder girdle stable > tension C4-8 and T1 roots Lateral flexion increases tension of scalenes (med. & and) anteriorly > brachial plexus tension Depression of the shoulder causes tension in brachial plexus > movement from C4-8 and T1 Abduction of shoulder increases tension especially C5-6 and C5 moves caudally if shoulder is stabilized

21. 6. Observation, palpation ALWAYS start from the assessment of posture and postural control  Posture has a great effect to TOS symptoms  TOS customer seeks for ”relief” from slumped position Spine, scapula, shoulder, clavicle, rib cage

22. 6. Observation, palpation Improve control in spine and shoulder girdle (scapula GH joint), Most often: -Trapezius asymmetry between upper and medial & lower parts, rhomboideus minor & major stiffness/weakness, serratus anterior weakness/inability to activate -Scalenus ant & med, suboccipital muscles, pectoralis minor and costa 1 movement decreased -Neurodynamics, sensitivity in brachial plexus, n. ulnaris and medianus, Tension in nervus ulnaris

23. 6. Observation, palpation Thoracic spine and outlet dysfuntion effects shoulder movements: -Limitation in flexion and abduction, in flexion notice tendency to abduction -No comovement in cervical and thoracic area -Increased load in glenohumeral joint

24. Plapate: Neural sensitivity of brachial plexus, ulnar and median nerve, fossa supraclavicular ja infraclavicular (subclavia) area + test brachial plexus Tinell (Magee 187) 6. Observation, palpation

25. Palpation Sternocleidomastoideus M. scalenes (especially anterior ja medialis) Processus coracoideus > m. pectoralis minor, coracobrachialis, biceps short head

26. 7. ROM, segmental ROM, translatoric joint play Cervical and thoracic spine: Assess pain and end feel If neurological signs (radiation,, burning, tingling, electric like sensations) > suspect nerve irritation involvement Neural involvement causes more ”permanent” symptoms

27. 7. ROM, segmental ROM, translatoric joint play Thoracic spine Is important for the function of cervical spine and shoulder In upper thoracic spine movements: → Cervical rotation – otherwise movement in cervical spine is limited (remember functional Cervical spine) → Bilateral shoulder flexion – upper thoracic extension → Single shoulder flexion – upper thoracic lateral flexion Costa I mobility assessment (AP, caudal)

28. 8. TOS tests Roos (Magee 2014, 345-346) Adson (Magee 2014, 345) Halsted (Magee 2014, 345-346 Test’s are designed for artery compression (subclavia) CRLF Test is designed for Costa 1 movement

29. Roos Sittin position, shoulder abduction 90 degrees, elbow flexion 90 degrees (arms behind frontal plane) Opening and closing hands for 3 minutes (1 minute is enough) If customer reports ischemic pain, heaviness or profound weakness, or numbness and tingling of the hand during testing, the test is considered positive for thoracic outlet syndrome on the effected side Report time and sensations

30. Adson Sitting position Locate radial pulse Cervical rotation to tested side Customer extends cervical spine (slightly) and at the same time PT extends and lateral rotates tested shoulder A disappearance of the pulse is a positive result Time?

31. Halstead Sitting position Locate radial pulse Cervical rotation and extensioni to other side from tested side Apply depression and lateral flexion and extension of shoulder A disappearance of the pulse is a positive result Time?

32. CRLF Sitting position Rotate cervical spine in the end of ROM Lateral flexion to the opposite side If end feel is hard, movement is limited, or the customer reports pain > test is positive > 1 rib in elevated position in the opposite side of rotation and causes dysfunction http://www.youtube.com/watch?v=vn9aiLA_E fo http://www.youtube.com/watch?v=vn9aiLA_E fo

33. PHYSIOTHERAPY Movement impairmet Therapeutic exercise Motor Control Exercises Joint Mobilization Neurodynamics: Nerve Mobilization Spesific Streches

34. Movement impairmet Therapeutic exercise Sahrmann 2011 -Ccervical spine -Thoracic spine -Shoulder Girdle (scapular motor control: remember the effect of scapular deperssion to brachial plexus, also dysfunction in upward rotation in abduction) -Taping as proprioceptive facilitation

35. Motor Control Exercises Strength and motor control exercises of intrinsic flexors and extensors  Decrease activity in scalenes & sternocleidomastoideus and levator scapulae

36. Joint Mobilization Cervical and thoracic spine limited segmental ROM Costa 1 mobilization Clavicle mobilization

37. Neurodynamics: Nerve Mobilization Slider (or tensioner), especially ulnaris > ALWAYS start with cervical sliders > apply neurodynamic slider (or tensioner)

38. Spesific Streches Pectoralis minor (& major) Levator scapulae Subclavia area, ”lypsy” (Biceps short head, Coracobrachialis)

39. Lähteitä Laulan, Fouquet, Rodaix, Jauffret, Roquelaure, Descatha. Thoracic Outlet Syndrome: Definition, Aetiological Factors, Diagnosis, Management and Occupational Impact. 2011. Journal of Occupational Rehabilitation 21(3), 366-373. Lindgren KA. 1992. The Thoracic Outlet Syndrome and the First Rib. Väitöskirja, Kuopion yliopisto. Lindgren KA. 1997. Conservative treatment of thoracic outlet syndrome: A 2-year follow-up. Arc Phys Med rehabil Vol 78. Sanders RJ. 2006. Thoracic Outlet Syndrome: review. Neurologist 14(6), 365-373. Shacklock. 2005. Clinical neurodynamics.