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

My Chiropractor didn't do that?

Like all health professionals we get stuck in our opinions as to the cause of dysfunction and what best approach to take when treating.  Most experienced practitioners understand that things change over time and we learn that not all our patients appear to respond equally to the same stimulus or treatment.  Why would it matter what treatment you use?  Surely it works the same way every time.

Treatment choices are numerous and confusing but thankfully science and research has given us clues as to why they might all be effective.  Physically based treatments involve applying a force to certain body structures.  Some of these structures (particularly the spine and neck) are the most sensitive structures to movement (especially rapid movement) and many of the issues we see involve to some degree a weakening or lack of responsiveness of the brain-muscle system which keeps us upright and oriented and any reintroduction of normal movement will potentially help.  It also appears that small rapid movements send a bigger 'signal' to the brain.  Slow muscle stretch for example sends a signal without a sharp high peak in electrical activity.  In effect the brain can be re sensitised to joint sensation using a variety of movement and sensation based approaches.  The clinical challenge is to determine what 'variety' will help which individual.

Can we predict chronic spinal pain?

We're familiar with spine pain as a result of trauma but why do some people develop chronic spine pain well after initial injury and can we predict who those people will be BEFORE they get symptoms?  It appears we might be able to do that.

Studies indicate that some people develop errors in sensorimotor control following neck injury.  This is the way your brain has control over the body.  All body part locations and movements are perceived by the brain via the nerves which are embedded in the mechanical structures.  So it's clear that damage to a joint may damage these sensation detecting endings and deprive the brain of the information it requires to control movement.  The term 'sensorimotor deficit' encompasses the errors we observe and is not only due to damaged nerves but the ability of the brain to rewire itself 'wrong' (maladaptive plastic changes).

The presence of these errors can predict the development of chronic pain before it happens and interestingly some individuals can experience these errors without any obvious trauma (so called idiopathic neck pain (or pain of unknown origin)).

Our brain is involved with perceiving the world around us and making sure we safely navigate our way through it moment by moment.  Body sway, poor balance, joint movement inaccuracy, head tilt, joint clicking, jerky eye movement and even difficulty concentrating are all aspects of sensorimotor deficit and are predictors of the development of chronic spinal pain.  Furthermore stress and anxiety are both known to exacerbate and even be associated with such disorders of movement.

Why some individuals experience these cognitive disturbances is thought to be genetically influenced (as is most everything:)) but a quick look at how we are wired up reveals that our emotional responses are influenced by how 'stable' we are.

These 'higher' relationships are less predictable in part because the neurology is far more complex and interwoven once we venture into the brain proper.

Spine meets Brain - a love story

So is your love story one of harmony and balance or is it like Wuthering Heights and totally dysfunctional?

People with pain don't think about anything else but the pain so talking about brains when you first meet is not a good idea.  However while the spinal joints and their components do tear, swell and hurt the research is mounting that tells a story of the complex sensorymotor relationship between the spine and the brain and what happens to each when things don't work.  Moreover research tells the story that physically based treatments work primarily because of the effect they have on the way the brain senses or feels the spine and it's movements.

The brain moves the spine and in turn receives feedback about movement, pressure, pain and a myriad other things.  Both change in response to each other.  They improve together and decline together.  People with long term spinal pain demonstrate muscle wasting on the side of injury, poor local joint control, poor postural control, poor pain control and changes in parts of the brain concerned with emotions and thinking and autonomic changes.  The autonomic system is housed in the brainstem along with the mechanisms which are sensing and controlling the spine, balance (orientation) and posture.  They are both housed there because they talk to each other ALOT.

This is why a common presentation would be 'chronic neck/shoulder pain and stiffness, headache, head tilt, postural instability (disorientation), feeling 'out of it', trouble focusing, unable to follow a moving target without swaying, and the list can go on.  Many of these findings change with application of physically based treatments and studies are suggesting that these findings precede pain.  That's saying that in chronic cases the brain gets things wrong BEFORE a person experiences pain.

What do we mean by 'wrong'?  A person should stand upright, level and be stable but typically many chronic spine patients are crooked, unlevel and unstable.  So when treating people we look at pain control and changes in body orientation as well as another indicator of improvement.

Exercises for spinal pain - What's the use?

The following is borrowed from Matthew Long at Clinical Development International (CDI) where you'll find the full article and it's references.

Quite a few large studies investigating the effectiveness of different exercises for chronic low back pain (cLBP) have come up with apparently confusing results.  As a group these exercises are directed at specific functional weaknesses in the core muscles which act as a dynamic 'girdle' to support the lower spine and pelvis.  Do these exercises work?

The answer is no. The answer is also yes and it's not always for the reasons we think.

Generally people report subjective improvement with exercise but some report reduced pain even when there is no real change in muscle recruitment and vice versa; others display improved muscle tone but don't report a reduction in pain.  Pilates and core stability clinics have gone through a phase of being the next panacea for cLBP sufferers but it's not backed up by research.  What's going on?

One problem is that cLBP isn't a diagnosis so people experiencing cLBP do not share exactly the same problems.   A one size fits all approach is a big issue with cLBP studies as they do not target specific conditions.  However there is still useful information to be gleaned. 

Chronic pain (lasting past an expected healing time) is produced by the brain.  It's a kind of memory of the injury and the brain becomes hypersensitive to normal movement.  The brain can act as a thermostat lowering the threshold or required intensity of sensations from joint movement and give the perception of pain during normal movement.  After all the function of pain is to stop you from injuring yourself but if the injury is in the past......  It's thought to be a normal protective mechanism which can get out of hand.  People with cLBP have displayed reduced cortical or grey brain matter so it appears that chronic pain actually results in brain atrophy.

'Move it or lose it' makes even more sense these days than it did before.  Overall ANY movement or exercise which the patient undertakes and enjoys or is otherwise motivated to perform has the ability to improve both joint mechanics and the way the brain 'feels' or perceives the joint structures.

It's important for patients to understand that moving is what we are primarily evolved to do and the lack of it leads to body AND brain wasting.

Conversely chronic neck pain (cNP) is a little different with improvements in neck muscle function coinciding with reduced pain both in the neck region and interestingly in distant areas like the lower leg (so like cLBP cNP also appears to have a 'thermostat' component).

DS