Chiro presentation on TOS
 

A Dr. Stoxen from the Chicago area gave a presentation on TOS in 2004, which I found interesting. *edit* if you search Google you will find it with these search terms:

vimeo stoxen thoracic outlet syndrome

I found these things especially interesting:

-- His comments on posture were spot on for me.

-- He points out that the first rib has no muscles that can pull it down, so it needs to be adjusted manually/externally.

-- He advises against certain neck stretches due to their pulling on the first rib. Interestingly, my chiro in Los Angeles warned me against the same thing.

-- He claims a high success rate with non-surgical treatment.

In addition to sharing this with you, I'm interested to know what your thoughts are on the contents of the presentation?

This is my first post btw. I've had mild TOS symptoms for years--without knowing what TOS was or what was going on--and then it "blew up" in early July. I've just started chiro and Egoscue exercises, and plan to add trigger point self therapy soon.

I also found this presentation very interesting and revealing. I am convinced that in many, many cases the TOS has its origin in a bad posture, forward head and shoulders (like in my case :rolleyes:) Also the facts stated in the presentation challenge many physical treatments I have undergone. The most bewildering statement is that you should do no stretching of the neck, something which is done by almost every physiotherapist (at least here in Germany :confused: ).

Yesterday I started the Sharon-Butler-selfcare program and I have to admit that I am totally confused now. Will this program help me or will it totally ruin my neck and cause more pain?

The physio says that my first rib is fine, can I trust her?

What do you think?

KR
Monica

I think we need to define stretching..

There is the often/usual PT way of push thru it no matter how you feel after...:(

and the gentle stretching mentioned by Sharon Butler.
"just a tiny hint of a sensation"

It is the smallest of a stretch sensation, and if that is too much after- or a day later - then you do even less of it when the discomfort is gone.

You want to aim for no added discomfort from her program, and then move forward slowly & gently to the next step.

I had to read her program quite a few times for it all to sink in about the fascia and how it reacts & is involved. And I have forgotten much but a few parts of it are stuck in my head.

Regarding the Butler stretches, I would like to hear if people have used them to resolve their TOS or at least get a significant reduction in symptoms (> 50%?). Maybe I should ask that in a separate thread.

The Pete Egoscue material is well reviewed at Amazon, which gave me the confidence to try it. I'm only a week in, but have already seen improvement. These *do* involve stretches, but not the side neck stretches that the two chiros (Stoxen and my local) advise against.

Also, I've been reading "The Trigger Point Therapy Workbook: Second Edition" which doesn't advise against stretching so much as it advises against stretching before releasing trigger points. I'm paraphrasing here, but the concern seemed to be that muscles that were chronically tight due to trigger points would not benefit (much) from normal stretching. I can't comment on the results, because I haven't started yet.

And of course we're all a bit different so what works for one might not work for others. All we can do is share, experiment and seek out a solution.

hey can you please tell me which neck streches the chiro advised against?

If I recall correctly, it was any stretch of the scalene muscles because they are attached to the first rib. The concern is that the first rib will be pulled further higher and reduce the space between the collar bone and the rib.

If you do a Google image search on "scalene" you will see which muscles these are and what they attach to. You can also watch the video. Also there is a text transcript below the video. It includes this:

(He also emphasizes that the patient must correct all postural problems that are involved or they will not get better permanently.)

On the other hand, the physical therapy (PT) people seem to recommend stretching those muscles in order to loosen them.

I am neither a chiro nor a PT and am only sharing what I've been hearing. Since I'm trying a chiro and he stated that side neck stretches were off limits, I'm following that course of advice.

Best regards.

Well i can see what they mean , but this has just left me very confused as my PT recommends that streching the scalene muscle will help the situation.

When i strech the scalene i Put my thumb on the first rib and press down on it and look the other way, i can actually feel the first rib and its not moving. Also if i press down hard enough on my first rib i can feel it lower very slighty, after all my PT sessions he has done a good job loosening up the first rib thats why this all possible.

So im wondering now, do i continue with the scalene streches or not?

Well I find the details of your stretching very interesting. You are holding the rib in place to avoid the problem the chiros are concerned about and you can feel it lower slightly. What's not to like? I would continue.

Can you produce a pic of the stretch with the thumb placement and everything? Either your own or one you find on the web on that matches? I would love to have one.

Ill have to take a pic, But pretty much what i do is exactly this

1.Put one hand behind my back as you would in a normal scalene strech
2. With the opposite hand i use the thumb and feel around until i can feel the first rib, it right under the upper traps just have to push down a bit.
3. Then i put pressure on the first rib with my thumb and turn my head away so it streches.

I can easily feel the first rib and when i push down on it hard it can feel it lower very slighty. I dont do it to often though cause it hurts a bit and can cause inflamation if i do it to often.

Im going to a chiro this week so ill check and see if there is anything wrong with what im doing.

Top Rib mob or stabilization for stretching -
see the bottom picture on this page-
http://www.nismat.org/ptcor/thoracic_outlet


"advises against stretching before releasing trigger points"
I've read this a few places also.

Thanks, it looks interesting, but I'm worried it will compress that entire area further. I've gotten major relief from propping up my arm to open that area around the collar bone.

I've been wondering if the Acuforce 7.0 Massage Weighted Tool could target the first rib more precisely than the towel approach. After I see hellothere's pic, I'll decide if I want to be the guinea pig. :cool:

I also would be very much interested in this question since I have started the program last week. The shoulder circling is painful no matter how far I raise the shoulders. Is this ok? I do it very gentle, but still it hurts but I am sure I cannot just skip this excercise. :confused:

We could start another thread on this if there does not exist one already, if you want to.

KR
Monica

I tried the "moving version" of Chinese Chi Kung / Qigong and had the exact same problems with the shoulder. Plus I was worried that all the motion would add to any inflammation in the thoracic region. For that reason, I switched to the "static version" called Zhan Zhuang.

If you want to start a new thread for fresh discussion on people's results for the Butler stretches, feel free!

I couldn't endure listening to the entire presentation as his speaking skills were frustrating, so I read the text below.

I like a lot of what he had to say and his "theories" seemed reasonable, but the no stretch rule is confusing me. I can see never purposely performing a stretch, but I stretch throughout my entire day in normal activities. Driving is the first thing which pops in my mind, turning to back the car up, merging on the freeway, etc.

Is there a difference from what he terms a "stretch" to normal day to day movement?

I was also wondering if anyone ever had the maneuver performed on them which he describes as shoving the costoclavicular (think this was the muscle) up under their clavicle until they want to scream, waiting for the 10 to become 0 in pain and then releasing? I may ask my PT to torture me and see what happens.

Anne

I think in the pages that come with her TOS program (my copy is from 2003) - I believe she says if something hurts skip it or go back to what you can do with no pain or symptom increases.

and she says often to modify any of the moves so that you can do it - don't fore or push thru pain as it sets you back.

Yeah, of the 90 mins, 30 of them were "uh, uh".

I would think so. In day to day life, you don't hold those positions for very long, and you only carry them as far as needed. In intentional stretching, people might hold a stretch for 30 seconds or longer, and they might consciously or unconsciously put a fair amount of force in the stretch, often using an arm to pull the body part further. That seems very different than ordinary usage, right?

I have not and would also love to hear from anyone that has. Also, if anyone is in the midwest, I hereby volunteer them to go get treated by Stoxen and report back the results. :winky:

i agree on stretching i feel better when i just stretch the muscles with my fingers a little

I've been doing that too lately. Running the fingers along the muscle while willing it to relax and elongate.

he said something like no muscle can counteract the scalene pulling the ribs up but does serratus anterior do that

i posted a link to him awhile back, he's good. i feel sorry for all of you getting spasms *knock on wood*..stretching made my spasms worse. its more of a preventative thing imho

yeah i pull apart my scm muscle EVERY NIGHT it does help.

heres' my routine, if my hand isnt exhausted.. lie down in bed. get out cvs epsom cream (with magnesium) use it all over my scm and upper traps. i kind of rub/elongate with my fingers. it feels really good

I'm not an anatomy expert, but when I read the description at:
http://en.wikipedia.org/wiki/Serratus_anterior_muscle

It does not sound like those muscles can pull the ribs in an upward vertical direction. I also don't get the impression they could when I look at google image search results.

i mean..holding your ribs down in place. or it holds your shoulder to your ribs. hrm.

i hear my ribs thudding around a bit which i guess is better than them being completely stuck.

im trying to google about muscle temperature increasing and blood. all i can read about is how its a good thing, i give up. gah.

Does anyone have the text on his presentation? His Vimeo has a Privacy lock on it now and I can't view it. Teaches me for making fun of his exceptional speaking skills. :eek:

LOL.

I did not save the text. Unfortunately, when I search for it on Google, I do not get a "cache" link like I do for many other pages. Also, the presentation is not on YouTube.

Can anyone dig it out of their local browser cache?

I think I found a copy of the video here-
http://airtravelhorrorstories.magnif...Syndrome-by-Dr

no transcript tough...

:ROTFLMAO: Air Travel Horror Stories? LOL

Thanks Jo-Mar! Better listen to the part I want to hear before he locks this one up too.

Anne, I volunteer you to make a transcript. ;)

Ha, ha - funny! On the positive side, there will be plenty of pauses for writing sloooooooowly. I will transcribe the bits and pieces which I found interesting. (ie. rib adjustment and shoving that muscle up under your collarbone).

Wonder if he made Air Travel Horror stories as someone sat next to him on a long haul flight and heard um's, huh, mm, um's for 10 hours. :D

Ha, ha - funny, but true. :D

Here are my notes from when I originally watched it:


== Tips from Dr. James Stoxen, DC

773-735-5200 Office Line
773-735-8656 Fax
info@teamdoctors.org
6430 S. Pulaski Rd. Chicago, IL

http://www.youtube.com/user/TeamDoctorsStore

http://www.teamdoctors.org/

http://vimeo.com/drjamesstoxendc

Goals:
Lower the first rib.
Reduce the tension of the scalene muscles.
The rib has to be manually adjusted because there are no muscles to pull it down.
Manual adjustments are required.
Chiropractors emphasize this correction.

Pillow for side sleeping must keep head level so the neck is in a neutral position.

Don't lean back in recliner (or bed when watching TV). This causes the scalene muscles to engage to keep the head level. This is worse than leaning over which engages the cervical muscles which are not related to reducing the thoracic area.

Don't laterally stretch the neck because it raises the top rib (superior subluxation).
Stoxen thinks this makes the condition worse.

Lateral flexion test can often produce an incredibly tight scalene muscle band.

You must fix all ergonomic problems all the time.

Vascular compression is often relieved when the patient raises their arm.
That's me.

At http://vimeo.com/22362794 0:46 he shows swelling in the supraclavicular space

DC:

Physiotherapy such as ultrasound on the upper thoracic area and lower cervical can reduce inflammation and promote healing.

EMS in some areas.


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

Dr. James Stoxen

http://vimeo.com/22362794

Conservatie management of TOS

Postural epidemiology

Most written material is by medical physician's who emphasize 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."

Sidenotes:
He implies that ~10 visits and more are necessary for recovery, or 12 weeks or so.

He saw an CT angiogram that showed a narrowing of the artery as it passed through the scalene muscles.

He does not introduce therapuetic exercises until he has reduced spasm and eliminated first rib subluxation.

Chroma: That's impressive note taking. I listened to him again and I do like a lot of things he says, but I also question some stuff.

First Rib Superior Subluxation is the cause. The 1st rib is connected through intercostal muscles to 2-4. Ribs need to move up and back, if not you'll have labored breathing. (This applied to me)

No watching TV in bed. (guilty)
Pillow must place your head in neutral at night. No tension in any direction on your scalenes. (must find a new pillow)

Ultrasound and TENS on the lower cervical and upper thoracic beneficial along with other muscles. Avoid the carotid artery and heart.

Subclavius Manuever: Patient lies on side. Your "neuromuscular re-educater" holds your back with one hand and shoves your subclavius muscle under your clavicle. When you are no longer screaming in pain, release, but not until it registers zero on the pain scale.

Hands-on therapy is a must. All spasms must be taken out of scalenes, and other muscles. Theory contradictory to other TOS protocals, but I agree with him from my personal experience.

First rib needs to be adjusted inferiorly. This is a must and key point. Mandatory to get well.

After all the spasms are gone and rib adjusted, the provider must keep checking as spasms can creep back. Don't do any excercises until all spasms and subluxations are under control.

The things I question are his 12 week recovery plan before a surgery consult. Most people have had this condition for a long time as they've not been able to find a cause or appropriate therapy. Can't tell you how many times I've been told it will take as long to recover for the duration you've had the injury. He must be a miracle worker.

No patients begging for meds? He's a DC so he can't prescribe meds. Call me a skeptic, but 18 years and no patients on meds other than night time sleep is hum, um hard to fathom.

Need a 12 week vacation to Chicago to test him out.

I agree that the success rate could be much lower, as well as your point about the meds. When treatments are not successful, people will often seek further help elsewhere without necessarily informing the last treatment provider. I think he believes what he is saying, but doesn't necessarily know about some of the inevitable harder cases that continued elsewhere.

But regarding the duration of treatment, I'm skeptical that there is some natural law, rule or trend that it is the same length as the duration of the symptoms. I myself am getting about 10% better which each chiro visit, so hopefully I'll be a living example. :D

One other thing I'd like to mention about getting chiro treatment, provided your chiro has intelligence and skills, is that you may find that you have additional issues. Not only is it worth getting them resolved, but these issues can interact with each other. Getting an expert to identify the network of problems and break it up has its merits. Other experts may be suitable for this as well including DOs and PTs.

My worry was unfounded. At the time, I didn't understand the position of the first rib or the approach described there. Although I would still make sure that the towel was not pulling on the collar bone as well. One could use a strap instead of towel for more precise placement.

@hellothere, how did the above stretch work out for you in the long run?

Dr. Stoxen DC REPLY, HELP, SHOULD I USE HIM NOW
 

Hi
Long story short (maybe).lol I have tos am scheduled for pre-op Mon should I cancel or postpone and go to Dr. Stoxen. I would have to borrow the money and he would treat me in 2-3 days or until the problem is resolved. I sent him a note on his, contacts on his site and he emailed me telling him to call before 12:00 pm midnight and I just made it by a few minutes. After I spoke to him I found his presentation you talk about. Have you or Chroma found anymore about him. My pain np told me to look up here for people who have seen him or know someone who has. Of course with surgery there is cutting vs. not w/Dr. S. He has sooo many accoulades (sp?), it almost looks like too many and it's hard to know what to do. Yet, if all of this is true is it better to go to him. After seeing him the key will be, no old habits to bring you back to where you stand now, he said when I spoke to him for an hour and a half. I'm desperate since the timing is so bad. I just saw the info here the other day and looked him up and now I don't know if I should call to postpose my pre-op and surgery and go to him first or forget him and go to my procedures. HELP HELP HELP! It is 2:30 on Fri on 5/10/13 before my pre-op on Monday 5/13/13 and surgery on 5/21/13. HEEEEELP!

Hi- I think it is always better to try everything you can before doing surgery- but I wouldnt hold out hope that this guy is going to cure you in 2-3 days. you need to be realistic and give it time-its taken me a year to feel better and I do but I am not cured. I dont remember what your diagnosis symptoms are. if you have a cervical rib or not- VTOS , ATOS? These have better results with surgery than Ntos.

Questions- How far do you have to travel to see Dr. Stoxen? Can you easily reschedule your surgery? I think its important to feel comfortable with your surgery choice. Try pm'ng or e-mailing the persons that have seen Dr. Stoxen and get more info. encourage them to post here for the rest of us.
Good Luck-

Sorry for all the stress your are going through.

I wish had some key breakthrough information for you, but I don't. I'm out in Cali and haven't worked up to trekking out to Chicago for a round of Stoxen's treatments.

His comments resonate very well with my situation. Through other hands-on providers and my own assessment, I know that I do indeed have tight scalenes, edema above the collar bone, etc. Therefore, if I ever get close to surgery, I will try Stoxen first.

If you feel the same way then try Stoxen first. If you don't, that's a harder call.

jkl626 has some good questions and points to consider.

Another option is to seek out someone that is nearly as skilled as Stoxen...in your own area.

There has to be other advanced PT , bodyworkers and chiropractors that can do many of the same things stoxen talks about..

The DC I went to was very skilled and very helpful for me.
He had extra training & many years of knowledge & experience.

You could ask Stoxen if he knows of anyone in your area that might be helpful??
He could teach and build a network of care providers...:rolleyes::rolleyes::cool:

irisheyesmilin,
Sorry, but I can't recall your dx or sx or tx that you have tried already, or what your avg pain level or worst sx are...:o