Thanks Tam and Jo; I truly belive this is all tos, and I think I may have some rsd as well after having my surgeries last year, my left arm has never been the same since Functional capacity evaluations, when I was released from work recovery the first time I felt some better but after lifting weighted crieghts beyond shoulder level and working above head tasks my shoulder and left arm have never been the same, my neck has good and bad days but the left arm, hand, scapula area in the back... My neck is so tight by times, I just can't take the pain anymore, Hoping whether it helps my case or not someone can tell me whats wrong and help me get some sort of relief. Tam your response is starting to make things clearer for me.

I'm not sure but I thought I read somewhere that

Ice was not a good thing fearing rsd.

I think the rsd forum would probably have information on if ice should be used.

Deborah from the old Braintalk forum posted this, she was given these by Dr Sanders when she saw him at an appointment

The initial treatment of TOS is certain types {or modalities} of physical therapy {PT}. Over the last few years, we have learned that a few modalities of PT are effective, while MANY OTHER modalities are ineffective or can make the symptoms WORSE. The recommendations below are based on the experience of OVER 1000 patients who have received therapy for TOS.
RECOMMENDED MODALITIES:

1.) Neck stretching exercises. Holding each stretch a minimum of 15-20 seconds, using your hands to help hold the head in the stretched position, and NOT trying to stretch through severe pain. If a stretch HURTS, reduce that range of stretch. Do NO MORE than 3 repetitions at one sitting; do this 2-4 times a day or more.

The 2 positions that are useful for TOS are:
1) Neck rotation and
2) Head tilting.

2.) Posture correction. Proper posture for people with TOS includes:
1) Head back,
2) Chin down and,
3) Shoulders relaxed in a neutral position, NOT STRETCHED BACK SO THAT THE SHOULDER BLADES APPROACH EACH OTHER, This position should be maintained as much of the time as possible when standing an sitting.

3.) Abdominal breathing: Practice this lying flat on your back on the floor.

4.) Nerve glides.

5.) Feldenkrais method. This is a total body approach of slow gentle movements of arms and spine with an emphasis on learning what motions bring on symptoms in your body and developing ways to avoid these motions. There is a national registry of Feldenkrais practitioners across the United States and practitioners in your area can be found on the Internet by looking up: www.feldenkrais.com

MODALITIES THAT OFTEN DON'T WORK AND CAN MAKE SYMPTOMS WORSE:
1. Strengthening exercises
2. Theraband use
3. Resistance exercises with machines
4. Neck traction
5. Exercises with weights
6. The concept of "No pain - No Gain"

The above are guidelines that have been effective in TOS patients. They will work for many people, but not everyone. Additional modalities of PT are indicated for other conditions that accompany TOS, such as fibromyalgia, shoulder tendinitis, cervical spine strain, and others.

Therapy must be individualized and it is best carried out with the guidance of a physical therapist plus additional training in the Feldenkrais method, usually with a different therapist.

Much more information about TOS can be found in the book, "Thoracic Outlet Syndrome - A Common Sequela of Neck Injuries", by Dr. Richard Sanders. The book describes the causes, symptoms, methods of diagnosis, treatment, results and complications of treatment, and other aspects of TOS.

If someone is raising your arm and moving it into positions it is going against your natural limits. Like an IME putting up your arm and moving it around saying, you have FULL RANGE OF MOTION, BUT if you did the same thing, raised your arm, and did the range YOU could do it would not be as high, far, long, and would be very uncomfortable.

You are at your natural limit. No one should ever allow a doc or PT to move the arm..they should ask you to place your arm to where they want it, then it is your limit and not beyond.....
Anything with resistance, like laying on a table with hand wirghts lifting, thera bands, and hand bikes is bad.

Also, doing a doorway arm lean, don;t be overzelous and lean into it ten times of you hurt at five.
Another thing is passive traction, some some hands on your head and gentle not pressure to release helps, if they use a contraption that bears weight in it, it is too much for sick/inflamed nerves.

I like Biofreeze- or ice, I mix 2 part alcohol and 2 parts water, in double ziplock bags.
ALso, lidoderm patches and valium for muscle spasms. It is what keeps me able towork part time.
Oh and a hottub....
di

Hello; Thanks Ocgirl and DiMarie, I was laying on the table and she was moving my arm all around and bending it at the elbow. The traction was gentle on my neck no turning just along the cervical spine. I think it's time for a change in treatment, more stretching or something, no more... Thanks for your replies, it's truly appreciated. Thanks again

ps what are nerve glides

good point OCgirl- my doc told me to watch my posture, and NOT to hold my shoulders so far back. I had/have this nasty habit of holding my shoulders too far back because they are slumped forward. Doc said that doing that (trying to make my shoulderblades touch, esentially) actually can contribute to any nerve/arterial compression thats going on....

Di- why do you mix alcohol and water in ziplock bags?
I usually mix that stuff in a glass

Hi Hairdresser,
I think that I read that you are having a MRI soon.

In my experience the regular MRI does not show the information you need to diagnosis tos.
My regular MRI came back completely normal, the 3DMRA I had with Dr Collins at UCLA showed severe bilateral neurovascular compression. It showed dilated blood vessels that should not be dilated and compression from the bones and scalene muscle on the brachial plexus and vena cava (huge vein)

It there a large teaching hospital that has a 3DMRA? If not just keep in mind that the regular MRI will not show what you need for tos.

Anything overhead is not a good thing for tos. I remember Dr Ahn telling me keep things below the shoulder.

I got this from the American Pain Foundation, I think Dr Annest wrote it.



Diagnosing TOS
Physicians may use many different tests to determine if you have TOS. Your doctor may have you undergo one or more of the following tests:

• Plain X-rays. The standard X-ray shows bony structure the best.
• Magnetic Resonance Imaging. An MRI scanner may be shaped like a torpedo tube or a four-poster bed, and can be very noisy with banging and tapping during the scan. It is sensitive to the hydrogen atoms in water molecules and produces finely detailed pictures of almost all the tissues of the body.
• Angiography. Angiography is an X-ray exam of the arteries and veins to diagnose blockages and other blood vessel problems.
• Arteriography. Arteriography involves injecting a special dye into the bloodstream to make the arteries visible and then taking X-rays to see if they are damaged.
• Venography. Venography involves injecting a special dye into the veins to make them visible and then taking X-rays to see if the veins are damaged.
• Electromyogram (EMG). Occasionally, more information about which nerve is involved is needed and an EMG is ordered. This study uses small needles or skin electrodes to measure the electrical response in muscles related to specific nerves or nerve roots. If the response in the muscle is abnormal, this can give your doctor information about the status of the nerve going to that muscle.
• Nerve Conduction velocity (NVC). NVC tests the speed of impulses through a nerve. The nerve is stimulated with electrodes placed on the skin. The nerve activity is recorded by the electrodes and measures the time it takes for electrical impulses to travel between the electrodes, which allows your doctor to calculate the nerve conduction velocity.
• Computerized Tomography. Known as a CT or CAT (Computerized Axial Tomography) scanner, this instrument is shaped like a big donut and is sensitive to the hardness of tissue. Hard tissue, such as bone, appears white, soft material such as water appears black, and tissues of intermediate density are seen as shades of gray. CT scans work best for bone problems.

TOS is usually associated with at least one other medical condition. Other common conditions associated with TOS include: biceps/rotator cuff tendonitis, shoulder impingement syndrome, cervical spine strain, fibromyositis, cervical disc disease, spinal stenosis, cervical arthritis, brachial plexus injury, carpal tunnel syndrome, pectoralis minor syndrome and TMJ abnormalities.
Overview | Causes of TOS | Signs and Symptoms | Getting Help | Diagnosing TOS
Medications | Complementary | Physical Therapy | Psychology | Surgery
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Here is what he says about PT


Thoracic Outlet Syndrome Physical Therapy
Physical therapy (PT) is an important part of treating TOS. It’s best to work with a physical therapist who has experience treating TOS. When done correctly, physical therapy may improve TOS symptoms enough that more invasive therapy is not necessary. If surgery becomes necessary physical therapy improves outcomes after surgery.
Conservative management of TOS with physical therapy begins with a comprehensive assessment. A physical therapist’s assessment will include tests that, when used with medical diagnostic tests, can contribute to a more accurate diagnosis of TOS.
A specific TOS evaluation focuses on the following:

• history of symptoms including mechanism of injury if applicable,
• static posture and dynamic posture,
• joint play of cervical and thoracic spine,
• 1st and 2nd rib mobility,
• clavicle and shoulder mobility,
• over used and/or underused muscles, and
• upper limb neurodynamic tests.

Specific tests for TOS used by physical therapists are Adson’s test, stress abduction test, postural positioning tests, supraclavicular test and costoclavicular test. 90% of patients with TOS have tenderness over the scalene muscles and can have their symptoms reproduced with the stress abduction test.
Each patient with TOS has different signs, symptoms, and causes of the syndrome. Physical therapy should address individual differences. It is very important that the treatment administered does not worsen nerve symptoms at any time throughout the rehabilitation. It is also very important that the patient take an active role in continuing their care with a home exercise program in addition to clinical treatment.
Physical therapy for TOS can be divided into three phases.
Phase 1 – Managing Acute Symptoms
During the first phase of physical therapy, the therapist concentrates relieving the acute or severe symptoms of the syndrome. He or she may educate the patient about the anatomy involved in TOS and the purpose of the techniques he or she is using to treat the symptoms.
The physical therapist may use ice to control swelling and manual techniques to relieve swelling. He or she may position your arm for comfort and may use a shoulder immobilizer until pain is reduced. The physical therapist will guide you through passive range of motion (PROM) exercises, active assisted range of motion (AAROM) exercises, and active range of motion exercises (AROM) of your spine, shoulder, and joints.
To control nerve pain, the physical therapist may use ice, positioning and desensitization techniques such as vibration, brushing, or touching with various textures.
During phase one, the physical therapist will address bony or soft tissue restrictions as tolerated by patient and educate the patient about neutral joint positioning. The physical therapist will begin stabilizing muscles, as well.
Phase 2 – Pain Stabilized
During phase two, the physical therapist will introduce more exercises for stabilization and neutral positioning. He or she may introduce neural mobilization techniques of specific nerves and will continue to work on joint and/or soft tissue dysfunction with manual techniques.
By the end of phase 2, the patient should be able to control cervical, thoracic, lumbar and scapular neutral positions in sitting, standing, supine/prone and side-lying.
Phase 3 – Progressing to function
During phase three, the patient will progress to functional movement slowly, with a focus on actively controlling neutral positions before adding weight.
TThe physical therapist will make recommendations about ergonomics and working. He or she will add resistance to exercises so that muscles can be strengthened. The patient and physical therapist work on continuing to progress to increased function and activities.
Next Steps
If, at the end of six to eight weeks of physical therapy, no significant progress has been made, the patient should be referred back to the physician or specialist for re-evaluation. If conservative physical therapy fails, the patient may undergo surgery or be referred to a chronic pain management program.
If surgery becomes necessary, physical therapy improves outcomes after surgery. After surgery, however, the emphasis is placed on maintaining freedom of the plexus to minimize scar tissue.
Overview | Causes of TOS | Signs and Symptoms | Getting Help | Diagnosing TOS
Medications | Complementary | Physical Therapy | Psychology | Surgery
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