Shoulder elevations for treatment of TOS
 

I'm kicking off a new topic thread for this. The article was brought to our attention by boytos:

It was published in the American Journal of Surgery, Feb 1993. Hey it's nice to see surgeons being respectful of non-surgical approaches. :)

Table and Figure

The first link is missing the Table I and Figure I, but I have purchased the article. I'm not allowed to share copies of the article according to the terms of service of the site that sold it. However, I will describe some things from it.

The exercise is to elevate shoulders and hold for count of 5, then relax shoulders. Then repeat.

There is no warning to be careful not to engage the scalenes, scm, etc. Although I'm sure you all would agree with me that there should be.

The first table shows 3 weeks of exercise, as mentioned in the public abstract. Exercise is every day, so 21 days straight. Number of times per day is 5 - 6 which surprised me. Reps range from from 10 to 20. Week 1 is no weights; week 2 is 3 lb weight in each hand; week 3 is 5 lb weight in each hand.

Perhaps this is how one exercises when trying to change posture or body shape, as opposed to just simply strength.

Figure 1 shows mean symptom levels before and after the program for things like pain in hands, in arms, in neck, pins/needles, weakness in hands, in arms. On a 10 scale these were between 5 - 7 with the pain elements being higher than the weakness. After the program, these were between 1.5 - 3 for improvements in all areas.

Additional Comments

Note that the researchers excluded patients with serious problems like cervical rib or positive EMG results showing nerve entrapment. Basically they seem to be treating people with what I often see called "disputed NTOS" and/or mild ATOS/VTOS.

Also, the following site which was linked from ScienceDirect shows that 31 articles referenced this one. I'm guessing most of them cite it in passing like "...physical therapy has been used to treat thoracic outlet syndrome [3]...", but it would be interesting to know if any of them say anything more specific, whether critical or complimentary. boytos, I nominate you for that research. :D

http://www.scopus.com/results/citedb...QGTpVKrpzN%3a2

That's a gnarly URL; I don't know if it will last. But if you poke around the web you should be able to get the list.

My Plans

Regarding me personally, I do have a depressed shoulder girdle on my TOS side although it looks better to me than it did months ago when my health crisis hit and this journey started. And I've also improved with fewer and less severe symptoms. Furthermore when my shoulder girdle became more depressed by power walking with arms straight, that's when my symptoms got worse.

So I may try this protocol in order to make further progress, but probably not til mid-Jan or later as I'm in the middle of other things.

I may also share it with my PT and see what she says first.

Further Research

This was written in the early 90's. Is the information still current? Did anyone replicate this? It's only 8 patients.

If it does work there are further interesting questions like: Should you do it for 4 weeks? 5? How many times per day is optimal?

This also stimulates the idea of doing further searching on the web with terms like:
"thoracic outlet syndrome" elevate shoulders
"thoracic outlet syndrome" shoulder elevations

...to see what else comes up. I have not done this yet.

Hey boytos, any other papers on exercise programs for TOS besides that PRI/football one?

Hi,

Hypothesis about the results

The results of the cyriax release and the orthosis for TOS seems valuable to explain the results of shoulders shrugs ( if any ) : passively elevating shoulders with the trapezius.

Problems about this exercice :

It is know to aggravate symptoms in some patients. That sure. Why ? i don't know. I make a hypothesis :

First, it does not seem to involve scalenes. So scalenes hypertrophy is unlikely to explain the aggravation. But it is a possibility
Maybe it stimulate nerve irritation, so the inflammation spread. The nerve inflammation can then induce muscle hypertrophy and increase vascular and nerve compression. But if it was the case, it would induce ulnar and carpal tunnel entrapment. Not necessary, but at least sometimes. If nerve symptoms are already important, then there is more chances for aggravating symptoms by this method. Because it would mean that nerves are hightly sensitives.

If it is, then specific anti-inflammatory may be valuable. I think about anti tnfa, heparin, and all that.

Then it has been tried for 'pure' Vtos, with failure. Hypothesis :
If there is compression of the vein between the anterior scalene and ligament, it may not help.
Direct damage like aneurysm may prevent healing.

For the moment it is very unclear. My advice is to try it before surgery.

As i try shrugs, i start to think it involve scalenes.. but anterior, medium, scm ? confusing....

Maybe heparin injection in scalenes can prevent their hypertrophy ? :

Heparin inhibits skeletal muscle growth in vitro.
http://www.ncbi.nlm.nih.gov/pubmed/3342932

It seem that it involve scalene when you roll too much shoulders..

i think there is a risk of scalene hypertrophy, you realy need to do this propely in perfect alignment to isolate shoulders and trapezius to the best.

I'd be curious to know how exactly this "shrug" is recommended to be done.

Is it a straight up shrug? Or more of an up and back so you are squeezing your scaps together on the way down?

If there is proof that this helps, I'd add this into my workout rotation.

KY

My text "elevate shoulders and hold for count of 5, then relax shoulders" is straight from the paper. They did not give any finer points to how to do the exercise.

I'd really like to know if, since 1993, anyone has tried reproducing the results. Also, did the authors continue to use this approach for TOS patients over the years?

Yes, and sometimes it work, sometimes not, sometimes it aggravate the problem.

In http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2953353/

There is :

http://www.ncbi.nlm.nih.gov/pmc/arti...53/figure/F10/

I couldn't find "Figure 10" in the text, so I'm not sure if they discuss it at all. I'm not sure what they are trying to convey from the diagram. What's your interpretation and how do you think it is significant to the shoulder elevation approach?

Any luck?
 

I know it's an old post - but did anyone have any luck with these? I've been advised to incorporate shrugs into by my PT, however, the levator scap just seem to flare up. It's apparent I have upper trap wasting and is a cause of my TOS, due to the droopy shoulder, but it seems I need to stall the levator scap and scalenes from firing, in order to get the upper trap working in isolation.

Any info, please shout up.

Dan

Upper Trapezius exercise
 

This is my first post but I may be able to help.

I have some experience with this after consulting Lyn Watson, an Australian PT who has published two recent and significant papers on TOS:

Watson L, Pizzari T, Balster S. 2009, Thoracic outlet syndrome part 1: Clinical Manifestations, differentiation and treatment pathways. Manual Therapy, 14(6):586-595

Watson L, Pizzari T, Balster S. 2010, Thoracic outlet syndrome part 2: Conservative management of thoracic outlet syndrome. Manual Therapy 15(4):305-314

**

Lyn is a very strong proponent in the "Upper Trap" school of TOS, which states that it is largely delayed and insufficient recruitment of the UT that causes poor scapula mobility. Her main exercise for me was to (for the right hand UT):

Lay on left hand side, with your right arm along your body and left hand across your chest and loosely gripping your right UT between the neck and shoulder. Try and engage the muscle so you can feel it tense and draw your shoulder upwards. Try to isolate the UT and make sure you don't use any rhomboid. The aim is not to build strength yet but to engage the muscle independently of the others. Do 20 times holding for 5 sec. As you progress you can hook a thera band around your feet and hold tensioned in right hand to add resistance.

I have worked with the UT alot, but have found greater success working with the serratus. There is quite a contrary school here in Europe that says TOS is largely a result of poor scapula upward rotation by the serratus. I found a PT who was a shoulder specialist and had amazing results.

Now if only I could cure the herniated cervical disk that has caused all this...