1. Souple comme un roseau


    from www.Breslev.fr R. Avraham Ifrah / Added

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    "la plupart des gens ont seulement joué dans ce monde , ils n'ont pas trouvé leur vérité" "Penser a la Shoah et ne pas perdre la FOI, continuer a aimer la vie...encore?!" "Besoin de vrais conseils pour survivre et plus encore maintenant" "Demain , je dois chercher a nouveau, pas une formule mathématique ..." "Le libre arbitre c'est que si tu veux tu fais..." "Tout ou rien, avant je faisais beaucoup et maintenant, alors je veux plus... Non! tu passes par un tunnel spirituel, alors allumes tes phares!!!" "Pour rapprocher, il faut savoir aller dans le sens de celui avec qui on parle" http://youtu.be/w5EXO8wYbGs http://www.breslev.fr/avraham-ifrah-Souple-Comme-un-Roseau,5472.html

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    • PRESENTATION: Thoracic Outlet Syndrome presented at 12th Annual World Congress Anti-aging Medicine, Las Vegas, 2004


      from Dr. James Stoxen DC / Added

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      Thoracic Outlet Syndrome by Dr James Stoxen DC Presented at the 12th Annual World Congress on Anti-aging Medicine Mandalay Bay Hotel and Casino, Las Vegas Nevada December 4, 2004 A presentation of the most effective diagnosis, treatment and prevention of Thoracic Outlet Syndrome (TOS) Thoracic Outlet Syndrome I’m going to talk today about conservative management of thoracic outlet syndrome. It’s a very controversial subject. I’m going to talk about sports trauma and postural epidemiology. We’re going to bring up some information that I hope that when we get done today you will be able to take what you learned back to your practice and help your patients. My office is in Chicago and the name of the practice is Team Doctors Treatment Centers. Thoracic outlet syndrome is a very controversial subject. In fact a lot of doctors don’t think it exists. Thoracic outlet syndrome is the most difficult neurovascular compression syndrome of the extremities to manage and that is because it has a variability of complaints. It also has a difficulty in the patient compliance in the treatment and reduction of the causative factors History of Thoracic Outlet Syndrome First of all, this problem is not a new problem. Galen who made the first mention of the cervical rib first mentioned it in the 2nd century AD. In 1910 Murphy gave mention of the effectiveness of the first rib resection. In 1927, Adson brought up the scalenectomy without cervical rib resection. In 1956 Deete coined the term Thoracic Outlet Syndrome. How prevalent is TOS I think that thoracic outlet syndrome is a lot more prevalent than we think. It’s based upon poor sleeping habits and posture. Postural correction is critical to the management of this thoracic outlet syndrome as I mentioned. The patient compliance is critical in eliminating causative factors. You have to be a nag. You have to constantly ask that patient. Are you sure you’re not watching television in the bed. Are you reading in the bed? Because if you don’t they will do it. They don’t think it’s important because you’re not saying anything about it, maybe only in passing. It needs to be stressed to them. So what we’re going to do is apply the appropriate treatment to correct this actual problem. Pain management can be seen with medication. That’s optional. We don’t use any medication in our office. No anti-inflammatories or painkillers are recommended and our patients seem to do just fine. Three Areas of Compression Thoracic Outlet Syndrome – Three Potential Areas of Compression Thoracic outlet syndrome is the often misdiagnosed cause of neck & shoulder pain, and arm disability. It is thought to be neurovascular compression seen at the thoracic outlet, which is something that anatomists can’t agree on. The actual name doesn’t properly describe the condition. It consists of 3 areas of potential regions of compression consisting of: The Intrascalene Triangle The Costoclavicular Space The Intrapectoral Space The Intrascalene Triangle This is bordered by the anterior and middle scalenes. The supraclavicular bundle consisting of the subclavian vein, the subclavian artery and the brachial plexus emanate from this triangle and it’s an area where any one of these structures can become compressed and cause symptomatology. The Costoclavicular Space The area below the clavicle and above the first rib represents the costoclavicular space. Few patients and doctors understand that the ribs actually go up this high at the face of the neck. The Intrapectoral Space The last space is the intrapectoral space and that is in the area of pectoralis minor and can be an area of compression. Arteries, Veins and Nerves pass through the Thoracic Outlet Doctors have to be aware of these multiple areas of compression and have an understanding of what symptoms can be related to each one of these areas so they can better treat the patient. The three neurovascular structures that pass through the thoracic outlet area are the brachial plexus consisting of cervical nerves C5, C6, C7, C8 and T1. The subclavian artery is the artery that supplies the arm with blood, oxygen and nutrients. The subclavian vein drains the blood away from the arm and back to the heart. Thoracic Outlet Syndrome is controversial in the medical community. Here is why... Underdiagnosed or Overdiagnosed Some physicians say that this syndrome is under-diagnosed. I read a letter to the editor in a surgical publication, which said that this physician said it was under-diagnosed and that more thoracic outlet syndrome actually existed, while other physicians say it was over-diagnosed. We say that it is under-diagnosed. No Gold Standard Test Exists The problem with this syndrome and the difficulty with this syndrome that many physicians have is that there is no gold standard test for thoracic outlet syndrome. In order to diagnose thoracic outlet syndrome you have to put together an array of historical findings, physical findings and a couple of provocative orthopedic tests in the region of the neck and shoulder to be able to make that diagnosis. Most common Treatment is Surgery The most common treatment today is surgery. According to the literature, if you have a group of 500 patients only 10% will respond to conservative therapy, which leads to 90% going to surgery. Doctors oftentimes give up on initiating conservative therapy and go directly to surgery. We have to put ourselves in the position of the patient. If you can see on this graphic here we have a surgery of the neck. There are many tiny important structures in this area. Patients are in great fear of surgery, especially in the neck so the answer is no patient wants to have this surgery Surgery is unnecessary with the right approach We have a very high rate of recovery from thoracic outlet syndrome with conservative care, and I am very happy to present that form of treatment to you today. I have not referred a patient for surgery for a thoracic outlet syndrome in 18 years of practice. That includes thousands of patients over these 18 years. I was very shocked when I looked into the literature. I was aware of the rhizectomy, removal of the first rib. I was curious about other therapies so I reviewed over 325 scientific papers that discussed conservative methods of therapy, including stretching and what the procedures and protocols were used to treat these patients conservatively. Why Current Conservative Therapy is Unsuccessful I think that after my presentation today, you will find out why these treatments were unsuccessful. You are going to have a better understanding of the most common cause of this syndrome. I feel that with a better understanding of what causes this syndrome, you will have better results with conservative therapy of this syndrome. History and/or Patient Presentation Symptoms of Thoracic Outlet Syndrome Any and all of these structures can be compressed leading to an array of symptomatology. Thoracic outlet syndrome relates to nerve and vascular compression symptoms; it leads to upper back and neck pain, shoulder complaints, numbness and even extremity weakness. Some of the more severe symptoms of thoracic outlet syndrome are upper extremity emboli, which occur when the blood supply is diminished when the clot is released into the arm. The arm can become ischemic and an area distal to the emboli can become gangrene, even in very rare situations. Another serious complaint that is not listed in the literature is unnecessary surgery; if more appropriate conservative methods can be used, then surgery would not be necessary. If you told the patient that you were going to do surgery to remove structures from the neck such as the ribs and muscles, the patient is not going to be too keen on this surgery. They are going to be scared Symptoms and Signs Vary in intensity There are varying degrees of subluxation that have the rib elevated in perhaps less than that amount on that particular patient; in other words, that there are rib subluxations that do not illicit a full blown thoracic outlet syndrome, but when stressed, you will have to say that the patient because of the biomechanics of the ribs, the ribs are subluxated, but not enough to cause numbness or compression of the subclavian artery vein and brachial plexus. However, when put in a provocative position, they are subluxated just enough to cause the positive test, but not enough to cause brain symptoms in the patient. Subclavian Artery Compression Signs and Symptoms You can have subclavian aneurysms and when the compromise of compression of the structures gets severe leading to ischemic, causing weakness of the arm and hand and grip strength, you can have potentially dangerous accidents related to dropping of things by the patient. What is a careful history Symptoms Symptoms of TOS The common symptoms of thoracic outlet syndrome usually begin with some stiffness in the upper thoracic area like in the ribs around the neck area, specifically in the traps and the upper back. What is the tingling or numbness in the fingertips? Artery or nerve? As I mentioned to you, there is tingling in the fingertips. Sometimes the tingling is only seen after conducting provocative tests such as Adsons and Wrights tests which means the symptoms are subclinical. If the patients fingertips or a portion of the upper extremity is numb or tingling without testing then it is a full blown TOS. The tingling usually happens more in the morning. The reason why it is seen mostly in the morning is because the position of the clavicle is not changing while sleeping. The position of the clavicle changes during the day. When the patient is reaching for a broom, or reaching for something out of a cupboard or waving to a friend, this elevation of the clavicle allows for blood supply to seep through into the arm and allows for the arm to be supplied with spurts of blood because the compression is relieved. Why are the tingling symptoms more common the morning with TOS? When the patient is sleeping, there is an aesthetic posture and there is not a lot of movement to stimulate the blood flow, which is why the patient has the tingling in the fingertips in the morning. The other reason is they commonly read in bed at night further compromising the thoracic outlet causing more compression of the vasculkar structures in the sleeping hours. Why do the hands swell in the morning with TOS? The patient has the highest degree of swelling in the hands in the morning with TOS. The swelling sensation called “glove sign”: in the morning, the patient feels the need to shake their hands out. Sometimes, the hand shaking method actually does bring blood supply down into the extremities, because they are elevating the clavicle and moving the extremity causing the need for additional blood to the region. The shaking of the hands actually allows the blood to come in and they are shaking the blood down into the extremities. This is something that the patient understands, based on instinct, when in fact they are actually correcting their problem temporarily. The problem is never corrected until you actually remove the compression of the vascular structures by manipulating the first rib inferiorally. Why do patients with TOS have upper back pain and sometimes shortness of breath at times? The pain and stiffness travel from the upper thoracic area and patients sometimes complain of chest pain in the upper thorax area. They also may complain of difficulty breathing. They talk about stiffness, and labored breathing and don’t realize it until you bring it to their attention. “Have you noticed lately that your chest feels tight and you have not been able to breathe as well?” And they will answer, “Yes, as a matter of fact I did.” It wasn’t something they were thinking about because they don’t understand the connection. Why does this happen? In fact, the reason the patient has a shortness of breath is because when the first rib subluxates in superiorly the intercostals muscles which connects the ribs actually allow not only for the first rib to subluxate superiorly, but the first rib takes the second, third, fourth and fifth ribs with it, because they’re connected. So what you are going to see is superior subluxation of the ribs of the upper thoracic spine and not just the first and second. Why do so many patients with TOS have headaches too? The other common symptom patients have with TOS is recurring headaches. The reason why is that they are in a reclining position watching television. Their neck in this position for so long that when they get up, their neck is more in a straightened, military or retrolisthesis position. If they leave their head in this position, they will not be able to see where they are going. It may seem silly, but postural reflexes kick in and an extension of the C0, C1, C2 vertebra occur to compensate for the tucking mechanism caused by the spastic scalenes. This hyperextension at level skull C1, C2, plus axis complex will actually cause compression of the first and second nerve of the spine and radiating headache pain as a result of this compression of the nerves and suboccipital regions. Cause of Thoracic Outlet Syndrome We are going to talk about the causative factors of thoracic outlet syndrome that will provide you with some insight on why it is difficult to manage. From what I gathered from the 300 + research articles and scientific papers I have studied, there have been some observations as to the causative factors that I have noted in my experience with patients with thoracic outlet syndrome, none of which was given mention in any of the 300 + scientific papers related to thoracic outlet syndrome. Therefore, it is difficult to say whether or not all of these physicians and scientists are missing something, but this is what research is all about – the sharing of information. I am hoping that we are going to bring some observations that we found and maybe add to the other research that has been done and we will be able to have a better outcome for these patients. I have found that the most common cause of thoracic outlet syndrome is a combination of things but primarily it is a superior subluxation of the first rib. In other words, the patient is fine for 30 years of their life, they come to you with some upper extremity symptomatology for approximately a year or some length of time and it is becoming worse. What is the difference with the patient who was fine at 31 and then at 32 has these peripheral nerve and vascular symptoms? They have the same structures but different symptoms. They have no growths or tumors. All we have to do is find out what changed, reverse the change and the patient is treated properly. Static Postural Stress and Traumatic Injury – Two Primary causes of TOS The cause of thoracic outlet syndrome should be broken down into two main categories. We have the cause of thoracic outlet syndrome into 7 causes in this slide. As I mentioned I broke it down into 2 main causes, traumatic injury and static postural stress. These other causes that are listed here merely “predispose” the patient to thoracic outlet syndrome. In other words traumatic injury such as when a patient is struck from behind in an auto accident, similarly a clip in football or a very hard punch in boxing, or a work injury causing a violent trauma to the anterior muscles of the neck causing a trauma to the anterior muscles of the neck, can cause pulling of the scalene muscles and an elevation of the first rib of the neck as a result of the misalignment due to the trauma. Static Postural Stress Static postural stress is what I feel is the most popular and the most common cause of thoracic outlet syndrome. It is where the position of the neck is held in a forward flexing position when the patient is leaning back which strains the scalene muscles because they must hold the head and neck from extending. Static Postural Stress – Mechanism of Injury In the literature I studied, it states that the neck is held in the extension position. This position does not cause a strain on the scalene or flexion muscles of the neck. For instance, if you were to take your arm and hold a purse or a liter of liquid and hold it out extended with your arm flexed at 90 degrees for one hour, pretty soon your biceps, tendons, and your joints in your elbow and your shoulders, muscles in your shoulder will become very soar stiff and your elbow will become inflamed. Example 1: Reading or Watching TV in Bed The same type of philosophy or theory is that if you are sitting in your bed with two pillows propping up your neck, watching your favorite television show in this position for approximately 1 – 2 hours, the scalene muscles will be in an atonic contractile state for a very long period of time and the same thing will happen to these muscles. The scalene muscles attach on the first rib, so as the tension is increased on the scalene muscles, we feel that the scalene muscles elevate the first rib and cause the subluxation, the scalene muscles also become inflamed as a result of the subluxation, the entire area, as well as the scalene muscles will become inflamed and cause a compression of the thoracic outlet group of structures. Example 2: Computer use Computer use where you’re actually leaning back in a reclining chair, or reading in bed, as I have mentioned before, just as much as watching television in bed, which I feel is the most common cause, or laying on a recliner or sofa, with the neck in an extended position. Example 3: Leaning back in the Car while Driving Operation of a motor vehicle with the neck extended as well. Nowadays the car seat can be reclined; it can be straight and other various positions. A lot of young people think it’s really cool to lean the seat way back, and sit like this and they may be on a long route for half an hour, an hour or they may be in the car quite a bit; this constant stress on the anterior muscles causes imbalance and raise the first ribs and causes the compression and thoracic outlet syndrome. Traumatic Epidemiology Traumatic epidemiology such as whiplash is seen in sports. As you can see a group of boxers that are getting hit, obviously that causes stress to the anterior cervical area and can lead to thoracic outlet syndrome, automobile accidents and traumatic work injuries, as I mentioned before. Physical Examination Findings - Cervical Range of Motion Cervical range of motion and flexion. We have a decreased range of motion and stiffness in the lower cervical and upper thoracic area. Cervical range of motion that I have seen is not the most prevalent range of motion but it is apparent and the patients usually complain of pain in the upper thoracic area around C6, C7, and T1. Extension when they extend the back, they feel a pinching sensation in the first and second thoracic ribs in the spine area. Their rotation usually is pretty good. I find that most of them can rotate about 70 – 75 degrees. Rotation is not as significantly altered as lateral flexion. With these patients you try lateral flexion, and they’re getting maybe 5, 10 or at the most 15 degrees when normal is 45 degrees. Also what you’re seeing in lateral flexion is that when you laterally flex the left, the right scalene will become prominent. You place your finger on it and it feels so tense. It feels like a palpable hard band and it’s very stiff. When the range of motion in the cervical area and the anatomical structures are affected as well as the biomechanics become abnormal in the neck area. Spasms in the Scalenes In this particular slide, we’re talking about postural evaluation. What you’re going to do is sit in a chair in your office and you’re going to demonstrate the posture that the patient is in that causes the tension on the anterior scalene muscles which is the gentleman in the bottom picture and the lady who is leaning back in the chair. You and I both know that this is how many of us and a lot of children sit; and a lot of people have thoracic outlet syndrome. Swelling in the supraclavicular area and around the neck The swelling in a supraclavicular space is amazing to me because it’s so obvious and so blatant but few doctors ever notice it. I have had numerous patients who have come to me with swelling in the supraclavicular space. They have been to several physicians, none of which has made comments in their notes. The swelling comes from the inflammation which results from the joint inflammation. Example of supraclavicular swelling As you can see on the top picture here, you can see the upper border of the clavicle on the patient and this patient below was involved in a motor vehicle accident at a fairly high speed. She has bilateral thoracic outlet syndrome. As you can see from the photograph, the superior border of the clavicle is obliterated. Also, you don’t see the sternocleidomastoid muscles and we don’t see any muscles structure in these patients and they are thin. In thinner patients, it is more obvious. There is really no fat there. So it’s not fat, it’s swelling. You should look for swelling of the supraclavicular space in your patients. TOS can be subclinical and still signs of supraclavicular swelling can be noted I have patients who come in my office for a lower back adjustment. They look at me and when I see the left side of the supraclavicular space is swollen, I ask them “Do you have numbness in your left hand periodically, more than in your right hand?” In nine times out of ten, they’ll say, “Yes, and how did you know?” Like I’m a magician. How did you know I had numbness in my hand? There is no documentation in the forms the patient filled out where they note their symptoms? Nobody had mentioned to the staff or me about this symptom, and they weren’t even interested in discussing it with us. They came in for their lower back. It was an incidental that had started approximately one, two or perhaps six months ago. But just by my observation, the supraclavicular space was swollen and the patient, I feel, has this thoracic outlet syndrome. Swelling in the hands Usually it’s better to take a photograph of the hands and evaluate it that way. I found that can be a very helpful tool, because sometimes you don’t see it, and it can be seen well through a photograph. The second thing is to look at the tendons. If the tendons have been obliterated by edema, you might be looking at a patient who has had difficulty in drainage of the blood from the extremity. It kind of balloons out and they’re going to get a little tingling – that’s when it’s starts to affect the arterial supply. In this situation, the patient becomes a little worried and it is at that time that the patient usually comes to see you. These are actual pictures of patients that have thoracic outlet in my office. This particular patient that you see with the hands on the top picture is the lady in the previous picture that had the supraclavicular swelling. As you can see on the right hand, it is much larger than the left. In fact, this enlargement is a swelling and is a result of the fact that the venous return is blocked because of the superior rib subluxation or some intrascalene type of compression on the subclavian vein not allowing the blood to escape from the hand. On the lower picture, we have a gentleman who has the same syndrome. Not only does his right hand appear to be bigger, but the wrist and forearm also appear to be bigger. I saw vaguely that there were some differences in the hands, but when I took a photograph of the patient, it became very obvious. My feeling is hat this is something you should you use as a tool because it brings out the differences more strikingly. Manual Muscle Testing and TOS Rotator Cuff Muscle Testing Shoulder Orthopedic Tests Because se of all the attachments in the neck and the shoulder area, you’re also going to find that the shoulder range of motion is going to be affected. It’s affected or decreased in 44% of thoracic outlet syndrome according to a very large study that I reviewed. What happens is the elevation of the first rib causes an ultra biomechanics of the shoulder, because se the shoulder articulates on the dome that is re presented by the first, second and third ribs. Therefore, if you’re going to alter the foundation by which the structure by which the structure moves upon, you’re going to cause damage to that structure. It’s no different from the structures of a building affecting the first, second and third floors. It’s very simple. Rotator Cuff Syndrome and TOS Other muscles originating from the chest, neck and shoulder are further affected predisposing the patient to rotator cuff syndromes and impingement syndromes. The first muscle that is affected is the superspinatus. I am going to demonstrate to you the biomechanics of what goes wrong. The first rib subluxates, causing a raising of the clavicle, and as a result added tension is placed on the superspinatus. The superspinatus muscle test is usually weak, and I’d say that on 50 – 60% of those patients that have long standing thoracic outlet syndrome for more than 3 or 4 months. So you need to also do an evaluation of the shoulder mechanism because this usually is the second area of emphasation of the thoracic outlet syndrome. Muscle groups that are commonly affected are the anterior cervical muscles as I mentioned to you because of the fact that you’re holding the muscles in a contracted position for a long time. These muscles should not be put in a contracted position for this long of a time and that’s why they become weak and spastic and lead to elevation of the first rib. The superspinatus as I had mentioned and also the latissimus dorsi intrinsic muscles of the fingers – when you’re doing your physical examination you should measure the strengths of the intrinsic muscles of the fingers because that’s the first area of weakness that you’re going to find that the patient will experience when they start to lose grip strength and strength in the hand as a result of a fairly lengthy compressive forces, the forces that are occurring in the brachial plexus, subclavian vein. Rotator Cuff Muscle Testing The rotator cuff in advanced cases does not take long to evaluate, and is necessary and important, therefore you should do it. In the x-ray findings, you’re going to find a loss or a cervical curve or a retrolisthesis, called a military spine, whiplash spine, I don’t care what you call it, the bottom line is that either A) it’s straight or B) it’s curved in the opposite direction of the way it’s supposed to be. What you have to understand is that the cervical curve is designed in such a way to function as a curve. If you take the spine out of its position and normal alignment, you’ll find that the joints are going to wear out faster. It’s compared to your vehicle being out of alignment; the tires are going to wear out faster. Any moving part of machinery, will wear out faster. Orthopedic Tests Like I mentioned before, in an orthopedic test, which is what most practitioners rely on for diagnosis of thoracic outlet syndrome, there are very provocative tests that have been developed over the years that assist the clinician to recreate the symptomatology to locate the area of vascular and nerve compression. I think that locating the exact area of nerve compression is important, but what I have been finding in my clinical work is that the majority of these tests are positive when you have thoracic outlet syndrome and I’m going to tell you why. Also, what the doctors complain about is that these tests create a lot of false positives. I will tell you that there could be a very valid explanation for this. When the first rib elevates and causes a compressive force upon the brachial plexus, subclavian vein and artery, then we would say that that rib is subluxated to a large degree. (+) Hyperabduction Maneuver - Roos Test Hyperabduction Maneuver Let’s review those tests; first of all you have hyperabduction maneuver in this particular situation, as you can see, what we are doing is elevating the arm. This will place a strain on the thoracic outlet bundle and subclavian artery vein and, the brachial plexus because if the pectoralis is in a spasm or tension, not allowing the shoulder to move properly, then of course, the nerve and vascular structures will be compromised and the patient will have symptoms. What you’re talking about is abduction at about 280 degrees, you’re going to take the radial pulse and it will illicit a decrease or diminish radial pulse or you will not be able to feel the radial pulse at all. Roos Test The patient complains of subsequent numbness immediately following the test. Now normally nerves don’t act that way; usually vascular structures act that way. The elevated arms test or Roos test is considered the most reliable test for thoracic outlet syndrome where the patient is placed in this position, opening and closing the hand for approximately 3 minutes. You know, the movement of the hand should stimulate blood flow into the arm, but in these particular patients, blood flow is not good enough due to the compressive forces that are brought out by the malposition of the ribs and the structures in the thoracic outlet area. So this is the most reliable. (+) Adsons Test The Adson’s maneuver is when a patient takes a deep breath and holds it. As the patient takes a deep breath, obviously, the thoracic ribs will elevate. Holding the breath will keep the ribs in that position. They are going to hyperextend the neck, which is going to cause the scalene muscles to be stretched back across the subclavian artery vein and the brachial plexus area. If the patient has an elevated rib, this involves the scalene muscles, in fact that will cut off the air supply or cause the compression of brachial plexus muscles and illicit the numbness. In fact, what we find is that the symptom is reduced arterial blood flow. There is no more pulse within 3 to 5 seconds. The patient then complains of numbness. You ask the patient, “Is your arm going numb?”. The patient answers “Yes, it is.”. You don’t say anything; the patient says “you know, I’m feeling some tingling sensations in my fingers. The costaclavicular test narrows the costaclavicular space by bringing the clavicle close to the first and second rib. When the patient draws the shoulder downward, that causes the compression of the subclavian artery vein and the brachial plexus. Positive tests are when the radial pulse is diminished. These diagnostic tests are very good to show that there is some compressive force in the thoracic outlet area, but by no means do they point toward immediate surgery. (+) Costoclavicular Test False Positives suggest TOS is over diagnosed Because I feel that this posture of leaning back to watch television, leaning back in the car in multiple positions, and many automobile traumas: everyone in the United States has had on average of at least one car accident in their life. Therefore, these traumas as well as sports injuries, to affect the anterior cervical area are so prevalent that I believe that some are clinical, and others subclinical. Some of these provocative tests were performed on normal individuals. These patients were probably not normal. More detailed evaluations of the motion of the first rib, certainly whether that rib was in a good position, or aligned properly or whether it was affected should have been performed. These evaluations were not done according to the literature. So we cannot say that false positives were elicited. But we may say that it’s a possibility that we found subclinical of thoracic outlet syndrome and not necessarily false positives. I hope you understand that. Manual Muscle Testing When evaluating thoracic outlet syndrome, one of the physical evaluations, which is very important in your physical, is you want to do manual muscle testing. A doctor who is astute in manual muscle testing can usually isolate muscles that have been put into atonic protective spasm or a weakened position. After a lot of practice, you can become very skillful at this technique. Shoulder Orthopedic Tests - Rotator Cuff Syndrome and TOS - Superior Rib Subluxation or First Rib Motion Palpation The spinal examination will yield a superior subluxation on one or both of the first ribs. Various different studies of motion of the first ribs having the doctor placing the thumb on the first rib in the back on the neck and actually tilting the head to the side in extension – what you’re finding is that rib does not move. Usually what is supposed to happen is that it is supposed to disappear down into the thorax and then bringing you back to allow it to reappear. What you’re finding is that you have an endplate or end field, which is very stiff. Normal mobility does not disappear. It feels like it’s immobile; that’s when it’s not moving. What happened if the ribs do not move? Ribs have to move in order for normal respiration to occur. They have to move up and back. If the ribs do not move, the patient will have labored breathing. The first rib can subluxate either from trauma or static postural stress from a car accident or sports injury. I feel that while trauma is a very significant source of damage to the neck, static postural stress is a more common cause of thoracic outlet syndrome. We are going to talk about that more. Some mention of static postural stress is made in the literature but it is my opinion that there needs to be more discussion of static postural stress as the cause of thoracic outlet syndrome. Costal Chondral Junction Subluxation As we mentioned before, subluxation of the upper thoracic vertebral segments in costa chondral and costa junctions or joints- As I mentioned before, when the rib subluxates superiorly, due to the fact that it is connected through the intercostals muscles, to the 2nd, 3rd and 4th ribs. What you’ll find here is arthritic changes. I’m going to go over that in a minute. You’re going to look for that on the radiographs you’re going to look at the chondral costal junctions, costal vertebral transverse junctions, and you’re going to look for increase in the white calcium deposits and buildup of white calcium deposits on these joints. Diagnostic Tests for TOS Diagnosis is difficult, because there is no gold standard test, so historical tests and physical findings are extremely important and the diagnosis is based on these historical and physical findings which are corroborated by perhaps some diagnostic and imaging testing, nerve conduction, sensory, velocity testing and SSEP tests, if you care to use those. We haven’t had the need to use those tests because we are treating the patients clinically. When to order diagnostic tests I like to order diagnostic imaging tests when I’m not getting the results that I’m looking for, rather than order these tests on every patient that walks into the office. I feel that clinically if I can help the patient within the first two weeks, I’m on the road to recovery and there is no need to order these diagnostic tests. Of course, if I’m not getting the results that I’m looking for, and I may have to dig deeper to find something I’m looking for, that’s when I order these tests. Like I said, there is no gold standard test we’ve been going over and over it again for thoracic outlet syndrome. The clinical judgment has to be used. There are some diagnostic tests such as electrophysiological evaluation, multi-detector CT and 3-D reconstruction, Venography, Magnetic Resonance Angiography, Radiography, Doppler ultrasonography and SSEP potentials. 1. X-ray Examination Radiography: When you take your x-rays, you’re going to take cervical flat plate films and thoracic, AP lateral films. The first thing we do when we evaluate the patient is to look for the bilateral cervical ribs. You know what? Cervical ribs are in less than 1% of the population. As I mentioned before, we have seen many thousands of cases. A lot of these patients have had x-rays taken as a result of traumas and peripheral nerve type of neuropathy. We are not finding cervical ribs on a lot of patients. I would say that it’s not less than 1%, it’s less than 1/10th of 1% or less. I remember, maybe 1 case of cervical ribs out of the entire array of patients that I have seen in approximately 18 years of practice including 2-4,000 new patients per year. You’re looking at variable heights of the first ribs as well as you’re looking for the intercostals space. The spaces between the ribs should be equal. If there’s a greater space on the right than on the left, then obviously on the right there have been some ribs elevated. Or on the left, some ribs have subluxated inferiorly. You’re looking for the arthritic changes in costal transverse junctions. That?s arthritic change movement as a result of lack of movement or poor movement or aberrant movement in these ribs. You’re looking for military neck, retrolisthesis and degenerative joint disease in the first rib in the sternum as well as in the costal transverse junctions. Retrolestisis is a common finding in TOS We’re going to find that this retrolisthesis is found in 80% of the patients. Why? Because like I said, attachment of the scalene muscles is on the anterior portion of the anterior process of C2, C3, C4, C5 and C6 and when you have to hold the head up for a very long period of time what it does is it actually pulls the curvature out of the spine and this is not a very good thing long term. Also as a result of the malposition of the first rib, you’re going to find degenerative joint disease and the sternal costal junction. In other words, when the first rib loops around to the front, it attaches to the sternum. If you look very carefully, a lot of time you’re going to find a lot of calcium deposits and deformation in the joint. Many people overlook this. It’s been overlooked quite a bit. You’re also going to see degenerative joint disease of the costal transverse of the upper ribs. Costochondral arthritic changes Here’s a picture I found in a book discussing how the patient had just gotten out of surgery In fact and had the left cervical rib removed as a result of long standing thoracic outlet syndrome that did not respond to conservative care. And if you look very carefully where the arrows are on the right what I found is that on the cervical rib, the first, second, third and fourth ribs, there is a fairly large amount of calcium deposit that’s on the costal transverse junctions and the costaclavicular junctions you’ll see the darkened areas of the joint space and adjacent to that area you’ll see the calcium deposits, which means that the normal biomechanics have been altered and that is evidence of what I had mentioned before that when the first ribs are elevated, because of those ribs, the intercostals connect the ribs 1, 2, 3 and 4 together that when the first rib elevates, it brings all the other ribs along with it. It does affect locking the costal transverse joints and causing degenerative joint disease in that area. 2. Electrophysiologic Test - When to order Electrophysiologic Tests Electrophysiological tests from three or four of the literature that I read, said that it was effective in determining thoracic outlet brachial plexus bundle compression. What you have to understand about the brachial plexus is that they distribute themselves superior to inferiorly 5,6,7,8 T-1. The most commonly affected is T-1 because it’s closer to the first rib causes numbness downward to the ulnar distribution. What I’m finding is the whole arm is numb. However, according to the studies, impairment of the nerve conduction, primarily F-waves were decreased in amplitude in the ulnar and sometimes the median nerve. Obviously, the ulnar nerve is more T-1/C-8 distribution than the median, which represents more of the gamut of the brachial plexus. This could help localize the brachial plexus lesion and may help to rule out segmental systemic neuropathy such as herniated disc in a particular area of the cervical spine. You’re not going to find this a very effective test if you do not have access to an MRI or have not ordered it yet. We see this impairment after the arms are raised in a provocative position in other words, the F-wave is normal and the patient is in a neutral position when the arm is raised in a provocative position as in Adsons, Hyperabduction Maneuver, Costaclavicular Maneuver, you will see that the symptoms of the F-wave will be diminished Electrophysiologic Test - only for a long-standing anomalies and severe atrophy The most recent studies of these symptoms are related to thoracic outlet syndrome and the electrophysiologic test is that this test is only used for a long-standing anomalies and severe atrophy because in the initial phase of this problem, the F-waves are not diminished and you’re not going to find this a very effective test for a recent onset of thoracic outlet syndrome. Therefore, I don’t feel it’s really necessary. Do I order these tests in my office? No I don’t. The reason is that because like I said before, I only order the tests when I’m not getting the results. I’ve never really had a problem with thoracic outlet syndrome in my office. I’m getting very good results with it, so there is no need to expose the patient to diagnostic tests which are medically unnecessary. You must document the need for a diagnostic test. When to order Electrophysiologic Tests A need for a diagnostic test is used to differentially diagnose or determine to a better extent what is wrong with the patient. If I feel that the patient is recovering in the first five or six visits and making progress, I am going to continue with care, it looks like I am on track, and I am not going to order these diagnostic tests. If the patient takes a turn for the worse, or I’m not getting the results I’m looking for, certainly I will order the diagnostic tests to look into it further to determine whether I haven’t seen what I need to see or I need to see something that I can’t seen based upon the orthopedic tests, the history or physical examination I performed. That ‘s obviously protocol for any type of orthopedic, chiropractic or neurological type of practice. 3. Multi-directional CT and 3-dimensional reconstructions Multi-directional CT and 3-dimensional reconstructions: There has only been one study, which I have seen. It reports to be very promising. I don’t know I haven’t had much time to look into it. There is not much literature on this. I am not going to run out and order multi-directional CT on every patient that walks in my office with tingling in the fingertips. As I mentioned previously, I use these tests sparingly. Doctors use these tests more often on patients – that’s your clinical judgment 4. Venography One author stated that venography was the only reliable diagnostic tool to diagnose thoracic outlet syndrome. 5. Doppler ultrasonagraphy Doppler ultrasonagraphy was another test that was mentioned in a few studies. There was no real discussion of the reliability or sensitivity of this particular test. It was considered as promising. 6. Magnetic Resonance Angiography Magnetic Resonance Angiography consists of taking an MRI of the patient in the normal position, and then another MRI is taken of the patient in the provocative position. This MRI must be done in an open MRI scanning unit because of the fact that you have to alter the position of the patient’s arms. It cannot be done in a closed MRI scanning unit. That’s something you have to understand. Also, you have to find a radiologist who understands thoracic outlet syndrome, anatomy, biomechanics, as well as being willing to do two MRI’s of the body: one in the provocative position and one in the normal position. This was done by one particular group of practitioners looking for a way of diagnosing with diagnostic imaging the thoracic outlet. I don’t think it should be done routinely in practices. 7. CT Angiography CT Angiography: This is a very interesting test, which I found in the literature that showed a visual of the thinning of subclavian artery as it passed through the intrascalene muscles. It was very nice evidence that this actually occurs. Treatment of Thoracic Outlet Syndrome Conservitive therapy vs Surgery - Conservative Management is Challenging Conservative management has been very challenging with thoracic outlet syndrome. The majority of the patients, over 90 %, in most cases are having surgery of the neck to remove the first rib or a cervical rib in the neck and also surgery to remove muscles in the neck. I don’t know about you, but no surgery looks very exciting for patients and it’s a very depressing and frightening experience for patients. If the surgery is in the knee it’s not as bad. If it’s in the neck it’s very scary. It’s very close to the head; there’s the possibility of infection. Patients are very frightened of any type of surgery of the neck; it’s a very sensitive area, and physicians have to be aware of that. We sometimes become numb to these factors and as physicians we should put ourselves in the patient’s position and work a little harder at finding better options to surgery with conservative therapy. Case Study Example One of my patients who came to me that we were treating and told me what he was experiencing in the last 6 months before he came to our office. His wife remarked that he dropped full cups of coffee without any warning. He dropped tools. He had difficulty performing his job. He was a paramedic and he was dropping tools and when you are dropping things you can have dangerous accidents. These finite movements of the hand, which are very important in some occupations, become very compromised. It is very dangerous in some occupations become compromised and you can have dangerous situations because of this Address the cause Most common Cause is Static Postural First Rib Subluxation However, what we talked about before, which in my opinion is the most common cause of thoracic outlet syndrome is static posture epidemiology. As you could see in this picture, we have this gentleman who is leaning back in the chair, you can?t see it, but his thorax is approximately at a 75-degree angle. He is watching television. As you can see, in order to keep his head from flipping backwards, because he is on an angle, he has to tense up the anterior cervical muscles, including the scalenes to keep his head in that position. The head weighs about 8 or 9 pounds and that may not seem like a lot of weight, but if you had to sit in that position, it would certainly take its toll on the anterior scalene middle scalene and the anterior muscles. You must address the abnormal ergonomics or posture. You have to repeat it daily and keep talking about it until they can’t stand hearing about it any more. You have to address their sleeping posture. A patient asks about pillow. A pillow can’t be too thick because it causes strain on one side. It can’t be too thin, because it causes strain on the other side. The pillow should provide a nice comforting support for the head and allow the neck to be in a neutral position throughout the sleeping. That’s all, and the patient has to go out to look into that. They have to research it themselves and find a pillow that’s going to work for them. What I recommend is that when they’re at a store, they can lay down and look in a mirror to see whether their neck is in a neutral position or not. Is it straight? Yes or no. If it is angled, then it’s no good. Don’t buy it. No other neck stretching exercises are recommended. Static Neck Extension or Neck Flexion? In the literature, it discusses the posture of leaning forward, as in looking at the computer that is not a good posture for thoracic outlet syndrome. As I mentioned before, the static posture of leaning forward really puts more pressure on the extensor muscles, which does not really compromise any nerve structures. However only in a case of hyper-extension or maybe a disc injury, but those are only seen with traumatic injuries and not necessarily with static postures. What we’d rather say is the causative factor, is that when the patient leans back, the anterior muscles have to maintain the head in this position for a long period of time as in the picture with the girl seated at the end of the slide. Static Posture Self Test If you take your hand and place it on your anterior muscles on either side of your trachea and your esophagus, and you lean back you’ll note that there will be a hardening or tension of these muscles. You’ll be able to see for yourself just by palpating your neck, and as I mentioned before, even if you’re holding a small item for a long period of time, the amount of tension can cause damage to the joints and the muscles. A careful History can help you differentiate these other syndromes with TOS Something to keep in mind though, the history of the patients is fairly common and repeatable. When we are faced with a patient who may have thoracic outlet syndrome, it is extremely important that we do a careful history to determine what type of lifestyle this patient has, and ask pertinent questions to see if they have the causative factors that create this problem. Like I mentioned before, I usually ask the patient, “Are you reading in bed” Do you have a television set in your bedroom? Do you watch TV in bed and how many hours a day? And look to the patient who is going to underestimate that time, they don’t want you to think that they are lying in bed all day and watching television. If they tell you it’s 5 hours a day, you could pretty much guarantee it’s between 8 and 10 hours a day. When we press the patient for the truth, they usually tell us that it’s more time. Medication - Why medication alone will not work In fact, I’d like to note that the actual changes in the biomechanics are reducing the pain, and not the painkillers. If we use the painkillers, we don’t know whether our treatment is effective. I think that is worse than actually diminishing some of the pain. The patient can handle it. You tell the patient that the pain is a warning signal telling us whether our treatment is working. It’s a guide that tells us whether we are being successful in the treatment of their condition. Sure I don’t mind if a patient takes medication prior to bed in order to sleep at night. However, the use of medication, I think is unnecessary. I have never had a patient absolutely beg me for medication. ‘Please, please, find me a medical doctor to get me some drugs so that I could sleep at night.’ I’ve just never had it happen – not in 18 years. Therapeutic exercises that were mentioned in the literature are contraindicated. No wonder they are not getting results. As I mentioned, stretching, or lateral bending, neck rotation exercises, and flexion exercises actually lift the ribs and make it worse. This is something that I don’t recommend; in fact, it’s contraindicated, and if you do it, you are not going to get any better. That’s the way it is. Manipulation - Why superior first rib correction is a necessity Manual manipulation is also a key component to successful outcome of thoracic outlet syndrome. Superior first rib subluxations cause compression of the thoracic outlet area, so therefore manual first rib adjustments inferiorly are the only treatment procedure that will establish normal biomechanics in position of the first rib. Included on the costalt ransverse and the costavertebral junction. You also have to adjust the upper thoracic spine. Thoracic rib subluxation must be reduced and must be reestablished or you will not get the patient well. I don’t care how much therapy you use, how much medication you give the patient, how much stretching exercises, you’re not going to get the results until you move the first rib. If I could not adjust the first rib, nobody in my office would be well. I rely on that specifically as a way of opening up the thoracic outlet spaces. Without it, I don’t think I would have any success whatsoever. It’s mandatory. When treating these areas, you need to manipulate or bring motion back into those ribs; you have to have a fairly good technique for adjusting those ribs, because ribs have funky movement. They are difficult to treat and adjust, because of their attachment on the two areas of the vertebral spine and their motion is very strange. Sometimes when adjusting ribs, the patient can feel sharp pain during the adjustment and then relief immediately after. I use a very gentle technique. I have had rib problems from a car accident in the past and understand it better because I have experienced it. I have studied manual spine manipulation techniques of the ribs in great detail and feel confident about it. I know that in the beginning it is quite difficult to master the art of manipulating ribs because of their strange configuration. You really have to practice it. Can you correct both the abnormal biomechanics causing TOS and recurring headaches at the same time? As I had mentioned to you, these headaches are fairly common in thoracic outlet patients. You’re going to have to make a decision when you make correction of the spinal misalignment. I found that if you try to correct the upper neck and the lower neck, sometimes there is a problem and there is too much stimuli to the spine. Sometimes you have to work on the lower neck to realign or correct the subluxation of the first rib and do some neuromuscular reeducation or muscle deep tissue work to the upper cervical region to prepare it for adjustments later. After the TOS has calmed down in about a week or two you can start to work on the C0 C1/2 subluxations which cause the headache symptoms. I think it’s a better approach to treat these patients clinically, based on my experience. Physiotherapy - Why therapy is difficult alone Physiotherapy such as ultrasound on the upper thoracic area and the lower cervical can help to reduce the inflammatory process and promote healing. Physiotherapy such as electrical muscle stimulation can help to reduce the spasms in the upper thoracic area. I do not recommend it around the scalenes because you have the carotid sinus in that area. We do not use electrical muscle stims on the anterior cervical area. However, we do use it on chest muscles, as long as it is not near the heart. We do use it on the upper thoracic ribs. It does provide comfort and it does reduce spasms for the patient and it promotes healing. Stretching - Why and when some stretching makes this condition worse Actually what I found is that stretching of the neck is actually contra-indicated in this syndrome because the attachment of the scalene muscles between the 2nd, 3rd, 4th, 5th and 6th cervical and the first rib, so by laterally stretching and flexing the muscle on the left, what is actually happening is that the patient is using the scaling to levitate or elevate the first rib on the left side. So in fact, when you’re stretching the neck, you’re in fact subluxating the neck even further into a position of superior subluxation. In the literature, it discusses the treatment for thoracic outlet syndrome is to laterally flex and stretch the neck, and if you’re wondering why you’re not getting good results, because laterally flexing the neck actually makes the condition, in my opinion, worse. Manipulation - Why improper manipulation canmake it worse The correction of the superior first rib is a necessity. Our goal in mind in the treatment of this patient is to lower or bring the ribs inferiorly and to reduce the tension of the scalene muscles. Those are the two main goals of therapy. By positioning the rib in a lower position, it will allow more space in the costoclavicular area for the structures to pass. There are no real muscles that actually pull that rib down, so it has to be manipulated. It has to be manually adjusted. I haven’t been able to find any other way to reposition the first rib or cervical ribs, other than manual adjustments. Scalene Muscle Spasms must be reduced Of course you can remove some of the muscle spasms and some of the tension on the first rib, the muscles that actually attach on the first rib, being the scalene muscles. If you are going to reposition the rib so that it allows for better passage of the structures, then you’re going to have to manipulate it with the least amount of restriction to motion as possible. Neuromuscular Reeducation The goal of this phase is to eliminate the protective muscle spasms that are actually tonic and constant in the cervical spine in the chest and region in what I call neuromuscular re-education. It’s basically called deep tissue; it’s also referred to as trigger point, Nemo technique. There are many names for it. I call it neuromuscular re-education. You use it on the scalenes, the muscles of cervical flexion, the clavicular division of the pectoralis minor and the subclavius muscle which is an often overlooked muscle, pec major, latissimus dorsi, anterior dorsi, upper and middle trapezius and other rotator cuff muscles. Understanding the Technique Here we have a picture of the subclavian muscle, which is right underneath the clavicle. When that muscle is in tension, it can actually cause a compressive force on the brachial plexus and the subclavian artery vein. The way I do this, is I actually lay the patient on their side I hold the patient from their back and I put my thumb right up underneath the clavicle and push it right up underneath the clavicle and I hold that position. I say, “It hurts, doesn’t it?” they say, “Yes it does, a lot of pain”. I ask “Is it a 10 out of 10, 10 being the worse pain?” They answer, “Yes it is.” “Alright, what’s going to happen is that this pain is going to go down in chunks, it’s going to melt away. When it’s melted away to 0, I want you to tell me. But if you tell me that it’s melted down to zero, when in fact it’s a 1 or a 2, I guarantee you that tomorrow you will have achiness all over. So you’re going to do the right thing and tell me when it’s gone down to 0. Right? "Right." Okay, let’s go to work. So I take my thumb, I shove it right up into the subclavian muscle, I apply deep tissue pressure, I hold it, without moving and I wait for the muscle spasm to melt. NMRE to the Scalenes Here we have treatment of the scalene muscles. I’ll tell you that when you apply neuromuscular re-education, or deep tissue pressure of a constant variety to this muscle, it hurts badly. The patient is wincing. They are in a lot of pain. They’re begging you to stop. It recreates the numbness down the arm. Their arm is going numb; they can’t stand it any longer. I say “relax, cool down’. Sometimes I have to tell them a joke. I usually sing. That always works. Tell them it doesn’t hurt you as much as it hurts them. It’s going to be difficult to get them to talk because it’s close to the trachea and the esophagus area, but you have to be persistent and do it. The importance of Scalene muscle NMRE The bottom line is that if you don’t reduce the spasm, the scalene muscles will remain in tension and continually elevate the first rib. It has to be done. Pain will shoot all over the arm. They’ll complain of the shooting pain in the arm. Just get through it. It will be about 3 or 4 points. You’re going to work your way up to the base of the skull hitting all those points. There will be about 3 or 4 points on each side and they get through it. Pretty soon you’re going to go back and work that muscle each day. After about 10 treatments, if it’s done properly and you have not missed any muscle areas, that when you put a pressure on there, the pain will drop about approximately 10%, and the spasm will drop 10% per visit. NMRE Technique So after approximately 10 visits, plus or minus 1 or 2, you’re going to see that there really won’t be any pain in the scalene area. They are going to put the pressure there on that muscle and you’ll say remember when I put pressure on that muscle the first day and you almost jumped out of your skin, your hair stood up, and your eyes rolled to the back of your head, and you turned red and you looked like Don King? Yes. Well you don’t look like that anymore; you’re not feeling those pains any more, are you? And they say "No". Okay it’s because you’re getting better. And you are getting better, aren’t you? Yes I am, in fact I am getting better. That’s what happens, they get better. The neuromuscular re-education can also address the abnormal muscle spasms or tenacity of the spasticity of the area of the supraspinatus. And here we show the application around the supraspinatus in the top right. On the lower right you’re going to see where I’m going to apply the neuromuscular re-education to the lower cervical area so I can get a better adjustment of the first rib. That’s attachment of the rib to the lower thoracic spine area. Why manipulation is not listed in the literature as an effective remedy for TOS The medical community has made 99% of the published articles and studies that have been made on thoracic outlet syndrome, whereas the chiropractic physicians are the only practitioners that actually make the correction of the rib in the inferior position. That is another reason why the literature states that conservitive therapy for TOS results in a poor outcome and results are not good. We’re not looking at any particular profession; we’re looking at a procedure that will decrease the pressure on neurovascular structures –Plain and simple. We’re not looking at who is better or who’s not. We’re looking at a procedure that is in the doctor’s bag of procedures that is going to be able to relieve the patient’s symptoms by way of repositioning the bone that is causing compression on the structures. Cracking the neck - Why this makes TOS worse In these patients that stretch and crack their neck, sometimes if you ask them, they say they crack their neck 10 and 15 times a day. When I see a patient doing that, I tell them “You’re going to have stop cracking your neck. I have a way of correcting the urge.” With treatment, this urge will diminish. Soon, after a period of treatments, they will no longer feel the urge to crack their neck all the time, because the stiffness will be reduced. What usually happens is that the subluxation is actually not in the neck; it’s in the upper thoracic area. Therefore, when the stiffness is in the upper thoracic and lower cervical area. When they self adjust or “crack” the neck they are using the lateral flexion and rotation maneuver to reposition the bones of the cervical spine. At the same time the scalenes are lifting the first rib closer to the structures which emanate from the thoracic outlet. There are so many supportive structures with the ribs, pectorals and the muscles of the upper back as well as in the shoulders. By moving or self adjusting, the only adjusting that is going to take place is in the middle cervical area, which only causes a hyper mobility as well as what I mentioned before, lateral flexion to the left side will actually have the scalene muscles elevating the rib even further causing further compression of those structures that emanate. Therapeutic exercises or rehabilitation Phase II is when all the muscle spasms have been reduced. You have to constantly re-evaluate the patient for spasticity of those postural muscles that were once involved because sometimes they slip and go back to reading in bed or reading on the couch, or they go back to watching TV in bed. You have to keep a careful eye on them and reinforce your recommendation for proper posture and proper anatomical position both at work, in the car, on the couch and in the bed – these are the main areas. Continue to manipulate the first thoracic rib. I read in one study that said wean the patient off the first thoracic rib adjustments after Phase I. It’s just the opposite. You maintain the adjustment of the first rib and here’s the situation. You cannot adjust the first rib. I urge you practitioners to find a physician or an allied health care professional that can perform manual manipulation and neuromuscular re-education of these areas, because it’s about the patient. If you can’t do it, then you need to find somebody who can. Therapeutic exercises or rehabilitation for thoracic outlet syndrome is only done after all spasms have been reduced and the subluxation is fairly well reduced. Do not incorporate exercises when there are spasms or pain still elicited upon deep tissue work and neuromuscular re-education. Exercises to strengthen rotator cuff muscles, specifically the superspinatus, posture muscles like the trapezius and levator scapular will actually elevate the shoulder and take the pressure off the nerves and the arteries. Deep breathing exercises will also help because as I mentioned, the ribs are subluxated as a result of lifting of the first rib. The first rib has the tension on the intercostals muscles and they subsequently move the first rib as well. Deep inspirations as well as flies and flat pull downs, incline and flat bench with deep inspirations. Take a big deep breath--- stretch out the chest --- and sometimes you’ll actually hear cracking or “tronar” as they say in Spanish – or a release of the sternal costal junctions. There is some release of pressure there and subsequent feeling of well being. Conservative vs Surgery When you’re looking at determining whether conservative care is recommended or surgery is recommended, always choose conservative care. According to literature conservative care was successful in only 10- 15% of the patients. As I mentioned previously, the reason I feel this is possible, is that if you do not tell the patients to stop sitting in this position for a long time, they are going to recreate the problem for you. You’re going to do some therapy, adjustments of the first rib and if they lay on the bed for 2 hours watching TV, these muscles are going to tighten up and lift the rib right back up again. So without really understanding causal relationship between posture and how it brings out thoracic outlet syndrome you won’t be very effective in reducing the causative factor and you’re not going to get the patient well. First Rib Subluxation in the literature In my studies of the over 300 articles I read and studied very carefully, I do not find one mention of this factor in the treatment of the patient. Not one mention of this position or how it affects the first ribs. 90% of these patients get first rib or cervical rib resection or scalenectomy. Nine out of ten are getting surgery of the neck. I haven’t had one patient have neck surgery. It is very difficult for me to understand and that’s all I’m going to say. Surgical Approach - When do you need surgery? When do you need surgery? Surgery consultation should occur if the patient is compliant and still has not reached some relief after about 12 weeks. Surgery consists of removal of the first rib and scalenes. Surgery should be followed up with nerve gliding exercises. Surgery is either from the cervical area or the transactulate area. What I can tell you about this is that as I said before, in 18 years of practice with thousands of patients, I have not yet had one patient who went for surgery for scalenectomy or thoracic outlet syndrome type surgery. There is something to be said for that. Conservative care is a viable solution to thoracic outlet syndrome. More research needs to be done and people should take note of the findings that we have in this presentation. According to literature, doctors were doing this hyperabduction, Adson’s costaclavicular tests and then saying okay it’s time to do surgery when the tests were positive. I believe that’s jumping the gun in a big way – something that we never did. I am shocked that this is happening. We find the same exact findings that orthopedics do and when we make correction of the first rib to lower it to remove the subluxation and to work on the muscles around the cervical thoracic area around the shoulder, these problems are going away. If there were a way of treating this conservatively, who would want surgery? Nobody. Nobody wants to have an operation on their neck. Therefore, it is better to go through the course of conservative therapy. The results of surgery seems to be 65% long-term success rate, partially 20% of the population and 50% of the patients have no relief. So you went through surgery of your neck and your symptoms are the same. I don’t think that’s a good situation. The rate of occurrence is between 5 and 10% of these people who have 60% long-term partial relief and the reason is because of scar tissue. They recommend that nerve gliding exercises immediately after surgery will help to reduce the scar tissue formation causing the occurrence. Conservative care, I believe that if there was an insidious onset of thoracic outlet syndrome, that if we could see what changed and we could reverse the changes to the original positions or biomechanics that were present when the patients did not have pain, that we can actually normalize this condition and bring the patient back to normal

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      • Rebel Musig live @ Tunnel Vienna 2010-11-13


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        • Film z TUNNEL ELECTROCITY 2007


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          Film z imprezy Tunnel ElectroCity 2007 która odbyła się w Klasztorze Cystersów w Lubiążu - 14.08.2007. Info: http://1408.pl.

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            Lecture by artist Christopher Baker as part of the MAS Context 2014 Fall Talks in Chicago. The lecture took place on Tuesday, September 2, 2014 at the Graham Foundation for Advanced Studies in the Fine Arts. Bruce G. Moffat is a transportation enthusiast with many years of service at the Chicago Transit Authority. He is the author of several books about Chicago’s transportation, including Forty Feet Below: The Story of Chicago’s Freight Tunnels (Interurban Pr, 1982), The Chicago Tunnel Story: Exploring the Railroad “Forty Feet Below” (CERA B-135, 2002), and The “L”: The Development of Chicago’s Rapid Transit System, 1888-1932 (CERA B-131, 1995). He is co-author, with Michael Williams and Richard Cahan, of Chicago: City on the Move (Cityfiles Press, 2007). Video shot by Ben Derico and Pat Elifritz. Edited by Ben Derico.

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            • 2013-11-22 Hour 2 Chad Hudspeth Bob Anderson


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              Declare Your Independence with Ernest Hancock on LRN.FM / Monday - Friday, 9 a.m. - Noon (EST), Studio Line: 602-264-2800. Chad Hudspeth (Endless Food Systems) comes in studio to talk about the Doomsday Prepper episode that featured his family, his aquaponics, and his prepping methods. Bob Anderson drops by to join the conversation. Webpage: EndlessFoodSystems.Com

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              • 2013-11-22 Hour 3 Chad Hudspeth, Bob Anderson


                from Ernest Hancock / Added

                13 Plays / / 0 Comments

                Declare Your Independence with Ernest Hancock on LRN.FM / Monday - Friday, 9 a.m. - Noon (EST), Studio Line: 602-264-2800. Chad Hudspeth (Endless Food Systems) comes in studio to talk about the Doomsday Prepper episode that featured his family, his aquaponics, and his prepping methods. Bob Anderson drops by to join the conversation. Webpage: EndlessFoodSystems.Com

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                • Attention, Travaux !


                  from Imago / Added

                  16 Plays / / 0 Comments

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                  • Welterbe in Gefahr - Dresden und die UNESCO


                    from momo cat / Added

                    492 Plays / / 0 Comments

                    Die 33. Sitzung des Welterbekomitees findet vom 22. bis 30. Juni 2009 in Sevilla, Spanien, statt und es wird erneut über die Waldschlößchenbrücke abgestimmt werden. Auch für die Unesco wiegt die Entscheidung schwer, gibt sie im Falle Dresden nach und erkennt den Weltkulturerbe-Status nicht ab, können auch ihre Kriterien in der Gesamtheit unglaubwürdig werden. Wird es zu einer einvernehmlichen Lösung in diesem Konflikt kommen und möglich sein, die Blamage einer Aberkennung des Weltkulturerbe-Titels zu vermeiden? Brücken verbinden Menschen, führen Völker zusammen und sind Symbole für architektonischen Mut und Kreativität. In Dresden dagegen spaltet das Bauprojekt "Waldschlösschenbrücke" seit nunmehr zehn Jahren die Bevölkerung nicht nur in der Stadt selbst, sondern bundesweit und sorgt sogar international für Aufregung. Es ist eine unendliche Geschichte. Am 15. August 1996 beschloss der Stadtrat von Dresden den Bau einer weiteren Brücke über die Elbe. Der Verkehr in der nach der Wende neu erblühten Stadt war inzwischen zum Ärgernis für viele Bürger und die Vertreter der lokalen Wirtschaft geworden. Zwei Jahre später erfolgte der erste Spatenstich für die Waldschlösschenbrücke, ungeachtet des absehbaren Konflikts mit dem Antrag an die UNESCO, das Dresdner Elbtal mit dem einmaligen "Canaletto"-Blick auf die Altstadt als Weltkulturerbe anzuerkennen. Mit fast 68 Prozent hatten die Dresdner für die Brücke votiert. Allerdings war ihnen nicht klar oder sie wurden nicht entsprechend informiert, dass mit der Brücke, die von Architekturkritikern schon damals als "Monster" bezeichnet wurde, der Titel des "Weltkulturerbes" in Gefahr geraten würde. Nachdem aber der Stadtrat sein "Nein" zur Brücke einige Monate später bestätigt hatte, begann der politische und juristische Hickhack zwischen der Stadt Dresden, der Region und der Landesregierung von Sachsen. Seither beschäftigt der Fall nicht nur die Gerichte. Bürgerinitiativen und Naturschützer haben gegen das aus ihrer Sicht untragbare Projekt Klagen eingereicht und damit im vergangenen Jahr Erfolg gehabt. Weltweites Interesse konnte dabei eine Fledermaus, die sogenannte "kleine Hufeisennase" auf sich ziehen. Die Gefährdung dieser seltenen Tierart durch den Brückenbau wurde gerichtlich anerkannt und das Projekt zunächst gestoppt. Wenig später wurde dennoch weiter geplant und gebaut, nachdem das Oberverwaltungsgericht den Spruch der untergeordneten Kammer wieder aufgehoben hatte. Dennoch hat die kleine Fledermaus im Interesse der Brückengegner einen Teilsieg errungen. Die Autos werden künftig die Brücke in Sommernächten nur mit einer Höchstgeschwindigkeit von 30 Kilometern in der Stunde überqueren dürfen. Schilda lässt grüßen. Am 3. Juli 2008 schließlich entschied das Weltkulturerbe-Komitee der UNESCO bei seiner Sitzung im kanadischen Montreal, der Stadt Dresden noch einmal eine Chance einzuräumen. Diese Chance scheint ungenutzt zu verstreichen. Die Bauarbeiten gingen in den vergangenen Monaten zügig weiter und die politisch Verantwortlichen sahen und sehen keinen Handlungsbedarf. Der Film dokumentiert die verschiedenen Phasen des "Brückenkampfes" und führt uns zu einigen Weltkulturerbe-Stätten in Europa, nach Lille, an das Pariser Seine-Ufer und in das idyllische Loire-Tal. Die Autorin fragt Experten und politisch Verantwortliche nach der Bedeutung des Titels für die ausgewählten Orte oder Landschaften, aber auch nach den Kriterien, nach denen die UNESCO den begehrten Titel verleiht. Ist die Veränderung einer weltberühmten und nach der Zerstörung wiedererrichteten historischen Kulturlandschaft lediglich eine "Geschmacksfrage" , wie der ehemalige sächsische Ministerpräsident Georg Milbradt meinte, oder geht es hier um mehr? Der Film versucht eine Antwort zu geben. (Deutschland, 2008, 52mn) ZDF Regie: Henrike Sander

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                    • "Remembering Patrick Woods"


                      from Peter Seda / Added

                      198 Plays / / 0 Comments

                      Two years ago Jen and I posted that I was running The Tunnel to Towers Race in honor of Patrick Woods asking if any one wanted to join me. Within minutes people began to ask, "How is Pat?" I was shocked that so many people did not know that Pat had been killed on 9/11. I decided that I would connect the dots and let people know what happened to our friend. I, therefore, asked some of his closest friends to help me in rememebering him. This is dedicated to Patrick Woods and to all those who knew and loved him. Director, Producer, Narrator Peter Seda Narration written by John Infortunio Camera Ivan Uskokovic Editor Daniel Lozano Special thanks to Interviewees

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