Thoracic outlet syndrome TOS

TOS can involve a range of conditions which may compress or irritate the blood vessels and/or the nerves which pass through the region between the neck and the shoulder (the cervicoaxillary area).  As such it is more an umbrella term rather than a specific diagnosis.  Why?

The following is a list of SOME of the things which can lead to TOS (adapted from http://cdi.edu.au/diagnostics/drill14q3o.php

Congenital (born with) abnormalities include:

• Anomalies of C7 transverse process
• Cervical ribs
• Anomalies of first rib shape
• Enlarged scalene tubercle
• Variations in scalene muscle formation and insertion (including neural components travelling through its substance)
• Anomalies of costoclavicular ligament structure
• Anomalies of pectoralis minor or subclavius muscle structure

 

Trauma is another recognised cause of stretch or compression to the neurovascular bundle:

• Impact to the shoulder or neck
• Excessive bone remodelling after fractures of the clavicle or first rib
• Posterior subluxation of the acromioclavicular joint

 

Soft tissue causes implicated in TOS:

• Hypertrophy of the anterior scalene muscles (such as during increased use of the accessory muscles of respiration)
• Muscle fibre type adaptive transformation
• Spasm and excessive contraction following cervical spine injury
• Poor posture due to occupational stress and repetitive overuse – especially prolonged positions that include lowering of the anterior chest wall, forward slouching of the shoulders and forward movement of the head
• Excessive breast tissue

In effect an individuals symptoms may be due to one of the above or many (multifactorial) particularly as we age.


Douglas Scown

Chiropractic didn't work

Physiotherapists, Surgeons and General Practitioners often hear this while we (members of the Chiropractic profession) hear the opposite. Who's right?

I suspect that all clinicians are experts at overestimating themselves.  My mentors suggested that 'it's all unreliable' but to remind myself that all health professionals deal with the same thing.  Ironically you begin to get better at it once you accept that you'll never be 100% certain.  Rationally we know this but we constantly entertain the fantasy that we can be certain and deal with 'everything'.  We can't.

Chiropractors in one respect occupy an enviable position.  We deal with and are perceived as dealing with only one 'part' of the body - the spine.  We are well placed to be the 'go to' profession for spine diagnosis and the conservative management of it's related disorders.  Our biggest obstacle isn't how we are perceived but how we view ourselves and our reluctance to accept our position as just one of the many other health professions whose job it is to look after the populations health - if that's what they want.  That role requires self examination, humility and the willingness to communicate with medical professionals about THEIR patients using common language.

Chiropractic doesn't work or not work.  Techniques and treatments come and go depending on development but what we can say is we're a health profession with a long history of relative success in a particular field.  We overrate ourselves and are soundly underrated by the public and other professions.  Whose fault is that?  Ours.

Douglas Scown

TMJ (jaw) disorder (TMD)

TMD is surprisingly common and usually self limiting however a small group of the population (mainly women) can suffer from chronic pain and while we know a certain amount about this problem there is still robust debate about what is going on and how best to treat.  The good news is it's estimated that over 80% of cases respond well to non invasive, conservative approaches.  The most important aspect again is making as accurate a diagnosis as possible, trialing treatments and being prepared to revise or refer if progress is not sustained.

It's such a simple joint but unique with regards to the amount of use it gets (eating, talking, yawning) it's vulnerability to insignificant but repeated trauma and it's inherent mobility.  It's also a part of the face and thus neurologically highly sensitive so perhaps it's surprising that humans (who apparently love to talk:)) don't have more trouble with it.

There isn't enough room in a blog to go into the details of TMD suffice to say that a reasonable clinical approach is to consider what they call peripheral and central components to the problem.  Peripheral = the joint itself (which can include the skull) and central is when the central nervous system becomes sensitive to the joint.

Who do you see?  I suggest that people ask specifically if TMD diagnosis and management is something a practice commonly deals with.  As such what profession you consult is less relevant than if the professional is familiar with TMD and if they have a reasonable degree of success with it. 

Doug Scown