Hi All,

I just registered and posted an introduction here, and would love to hear opinions on the following.

I'm currently receiving physical therapy under the Barral system. I've had 6 sessions so far, and no noticeable change in symptoms during the 3 weeks in which these sessions have been held. In addition to the sessions, I have homework in the form of a series of stretches for the pec minor, scalenes and brachial plexus area.

I've just been offered the chance to receive scalene block injections from the neurologist that diagnosed me with TOS. They are offered as a therapy rather than an additional diagnostic, albeit I understand they would perform both functions.

I'm concerned that if I take the injections whilst continuing the therapy, and I experience relief, I may not know what *worked*. I'm further concerned that if injections provide relief, what that means for the long-term.

So my queries mainly are the following, but any comment, experience and counsel is welcome:

What are your thoughts on receiving both physical therapy and block injections simultaneously?

Are block injections a sustainable solution?


Copied from from intro thread

I'm a 34 year old male. I'm an office/desk worker and until 2 months ago very active physically via resistance exercise, cycling and climbing.

I've been diagnosed by a Neurologist with bilateral vascular and neurogenic thoracic outlet syndrome, combined with bilateral ulnar nerve entrapment, which I believe can also be described as double crush syndrome.

The diagnosis was made on the basis of:

# My description of symptoms
# Physical exam by a manual physical therapist and neurologist
# Electromyography and Nerve Conduction Velocity exams
# MRI of my upper back/neck/shoulders
# Ultrasound to measure arterial blood flow upon abduction of the arms
# X-Ray to look for cervical rib or other abnormality

My first symptom, which lasted for 2 months before I sought help, was awakening from sleep with numbness present in left and/or right hand 4th and 5th digits. That was my one and only symptom for 3 months. After 3 months, and to the present day, my main complaint is that within 30-45 minutes of sitting/standing/walking with my head and neck unsupported, I develop pain in the rear neck area, which sometimes spreads to my trapezius and shoulders. I have less serious and frequent pain in my ulnar nerve around the elbow and forearm.

I'm currently undergoing physical therapy with a physio using the Barral system (a french physio)

I always liked to try only one thing at a time, for the very reason you described. Otherwise, there's no way to know which thing helped.

Good luck.

Sorry, you're going through this but it sounds like your doctor(s) are on top the situation. I was dx with TOS due to the exams done in the office, positive EMG study and positive vascular studies; too. It's rare to have a positive EMG.

Re: question regarding combining treatments.

First, I think the protocol is to try scalene blocks to see if you experience a temporary decrease in symptoms. If you do, then you'll more likely to experience relief from surgery. At least this is what I was told back when I started this journey in 2003/04. They inject some anesthetic that wears off over a few hours later. For me, the injection produced immediate relief (~10-15 minutes) and yes, the pain/symptoms gradually returned 2-3 hours later. I think it depends on the doctor as to what medication is injected so others may not have the same experience.

In your case, if you haven't seen any real difference in 6 PT visits, it might be worth trying the shots. If the scalene block works, then they may suggest a botox shot into the middle scalene. The effect of botox is supposed to last about 4 months (per my doctor). For me, it lasted almost one month which surprised my doctor and had her switching from the "conservative camp" to asking if I was considering the surgery. The complete relief from the symptoms for only a month was worth the shot of botox. Again, it supposedly shows if you're a good surgical candidate if you experience relief.

Combo of PT and shots:
For me, after the botox shot was given, I was sent back to PT as it was considered the ideal time to try to improve everything while the middle scalene was temporarily out of commission.

Three months after the botox shot, I had the surgery and haven't looked back, nor regretted my decision. I have been symptom free on that side for 6+ years now. I do have TOS on the other side due to a cervical rib and I am seeing the gradual increase in symptoms.

To make a long story short, the scalene blocks are a good diagnostic tool and should be done. You can ask them more questions about how long the effects of the shot lasts, what medications are used, etc.

Sheri, thank you for the comment and information.

When you received the injection, did you have constant symptoms? Pain or numbness?

I ask because currently only experience significant pain after a period of having my head/neck unsupported. I would certainly notice the difference if an injection prevented this pain from developing, as it is quite reliable, but I'd have to deliberately create the trigger conditions.

For any interested:

I asked the physio who is treating me for his opinion on accepting the scalene block injections, and shared my concern about combining treatments.

His opinion was rather different. The points he made were:

# You, me, your GP, and Neurologist don't know the cause of your TOS
# We are treating your symptoms now, and if that provides relief, thats great
# It is not necessary for you to try and act as a single subject controlled study
# So you should go for the injections if you want to try them
# If you get relief after taking the injections, thats great, it is not necessary to identify causation between the physio and the injections

I looked up the Barral system and they have some interesting videos showing it on you tube -

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

At the time of the injections, I wasn't in constant pain but it was having a definite impact on my life. I don't remember numbness ever being a symptom on the operated side. I have intermittent numbness on the left side (non-operated side) that did resolve with the scalene block. It returned a few hours later.