Thoracic Outlet Syndrome (TOS) is a neurovascular entrapment disorder involving the brachial plexus, the blood vessels that traverse from the base of the neck to the chest through a small passageway called the thoracic outlet, or some combination of both. The thoracic outlet can become even smaller due to an extra cervical rib, old clavicle fractures, and overgrowth of surrounding muscles, often seen in body building and other repetitive sports. However, the most common catalyst is an enigmatic neurogenic process that primarily presents in forty to fifty-year-old women with poor muscle development and posture.
Signs and symptoms depend on which structures are compressed. Neurogenic thoracic outlet syndrome generally compresses and irritates the nerves of the brachial plexus, the complex of nerves that supply motor and sensory function to the arm and hand. Symptoms may include weakness or numbness of the hand, unilaterally decreased size of hand muscles, and pain, tingling, prickling, numbness and weakness of the neck, chest, and arms. Venous thoracic outlet syndrome is caused by damage to the major veins. This condition often develops suddenly after unusual and exhaustive use of the arms. Symptoms can include swelling of the hands, fingers and arms, as well as heaviness and weakness of the neck and arms. The veins of the chest wall may also appear engorged. Arterial thoracic outlet syndrome is the least common, but most dangerous. It originates from congenital bony abnormalities in the lower neck and upper chest. Symptoms typically include cold sensitivity in the hands and fingers; numbness, pain or sores of the fingers; and poor blood circulation to the arms, hands and fingers.
Treatment strategies depend on the type TOS. Neurogenic cases usually benefit from therapies aimed at increasing range of motion to the neck and shoulders, strengthening muscles and promoting better posture. Venous cases often require blood thinners to reduce the risk of clot formation that can occur when blood pools in areas of decreased flow. If blood thinners prove ineffective, surgery is necessary to relieve the compression. Arterial cases most often require surgical interventions that involve removing a rib or other offending structures. Blood thinners and thrombolytics may also be required.
The different types of TOS highlight the importance of taking a thorough intake history before performing massage on clients that report symptoms of TOS. On the one hand, venous and arterial TOS should be considered absolute contraindications for massage therapy due to the potential for embolisms. However, 95% of TOS cases are neurogenic, for which massage therapy should be the primary recommended intervention. Interestingly, the Mayo Clinic website makes no mention of massage therapy as a treatment option. Since many people use this very reputable site, massage therapists should advocate for their clients to have a thorough diagnostic process.
Currently, surgery is recommended if the vaguely termed “conservative therapy” is ineffective. Yet, research continues to illustrate massage therapy as an independent discipline which may not be “conservative.” The three most surprising facts uncovered in the research for this paper were: 1) Travell and Simons’ method for releasing an elevated first rib; 2) the extensive muscular and modal MT treatment recorded in a 2014 case study in New Zealand as part of a 3-year, 3600-hour, bachelors of health science degree program in massage therapy; 3) the conclusion from a 2006 study that persistent disorders require the compound effects of multiple MT sessions. These facts suggest that the terms “non-invasive” and “conservative” must not be confused or interchanged. A curative MT treatment may well be more progressive as practitioners creatively and inventively seek to avoid invasive surgeries.
References:
Cleveland Clinic On-line Health Library@ myclevelandclinic.org
Hamm, Michael. “Case Report: Impact of massage therapy in the treatment of linked pathologies: Scoliosis, costovertebral dysfunction, and thoracic outlet syndrome.” Journal of Bodywork and Movement Therapies 10 (2006): 12–20. Print.
Simons, David G., Lois S. Simons, and Janet G. Travell. Myofascial Pain and Dysfunction: The Trigger Point Manual. 2nd ed. Vol. 1. 2 vols. Williams & Wilkins, 1999 (504-537).
Wakefield, Mary Lillias. “Case Report: The Effects of Massage Therapy on a Woman with Thoracic Outlet Syndrome.” International Journal of Therapeutic Massage & Bodywork 7.4 (2014): 7–14. Print.