RIB(cage) THEORY

Dr Sanders reports on TOS
Common Symptoms
The most frequent complaints are numbness and tingling in the fingers; pain in the neck, shoulder, and arm; headaches in the back of the head; weakness of the arm and dropping things from the hand; worsening of the symptoms when elevating the arm to do such things as comb or blow dry one's hair or drive a car; and coldness and color changes in the hand. The symptoms are often worse at night or when using the arm for work or other activities. During the year 2005, we have become aware of a large number of patients who, in addition to these symptoms, also have pain in the anterior chest wall, just below the collar bone along with pain over the shoulder blade. Until recently it was thought that these later symptoms were also due to TOS, but now it has been learned that they are due to a condition frequently accompanying TOS, namely pectoralis minor syndrome.
Cause
TOS is most often produced by hyperextension neck injuries. Auto accidents that cause whiplash injuries, and repetitive stress in the workplace, are the two most common causes. Some of the occupations that we see causing TOS include, working on assembly lines, keyboards, or 10-key pads, as well as filing or stocking shelves overhead. In some people, symptoms develop spontaneously, without an obvious cause. An extra rib in the neck occurs in less than 1% of the population. People born with this rib, called a "cervical rib", are 10 times more likely to develop symptoms of TOS than other people. However, even in men and women with cervical ribs, it usually requires some type of neck injury to bring on the symptoms. Pectoralis minor syndrome appears in more than half of the patients who have TOS. It results from the same type of injuries that cause TOS.

And Peter I Edgelow suggests the following 5 points if TOS sufferers are to improve
In the physical examination of these patients, there are consistent findings that must be addressed before adequate progress can be attained:

1. The patient must become aerobically it. (read fit, towelhorse)
2. There is often present asymmetrical weakness of the small muscles that control movement of the thumb. (Flexor and abductor pollicis). This weakness can be reversed by self-traction for 30 seconds (diagram 1) and weakened again by mechanical stress to the neck such as compression.
3. There is a pattern of chest breathing and an inability for the patient to perform relaxed breathing with the diaphragm.
4. There is loss of mobility and increased sensitivity of the nervous system, especially the brachial plexus. (The nerves that pass from the neck to the arm.)
5. There can be coldness of the hand particularly the ring and little finger.

Treatment must be directed to reversing these 5 issues if they exist. The home program is designed to help the patient accomplish this on his or her own.

DR Steven D Feinberg writes
SYMPTOMS
The character and pattern of symptoms will vary depending on the degree to which the nerves and/or blood vessels are compromised. The patient may complain of tingling, numbness, weakness and discomfort particularly down the inside of the arm going into the hand. There may also be swelling, paleness and coldness of the arm and hand. Other related symptoms may include headaches in the back of the head and pain in the neck, shoulder and arm. Symptoms can be brought on by overhead activities such as hair combing, or at night when sleeping on one side which can put pressure on the structures within the thoracic outlet. Each of these maneuvers/positions causes a tightening or compression of the thoracic space. Thus the nerves and/or blood vessels may be compromised and produce the associated symptoms.
TREATMENT
More commonly and appropriately though, first-line treatment is directed towards a physical rehabilitation program, in which physical therapy plays a large role. Initial treatment emphasis is placed on weight loss, postural re-education, and shoulder girdle exercises along with stretching, strengthening, conditioning and the passage of time. Evaluation of activities of daily living and the workplace environment is a must. Physical therapy management of TOS requires accurate evaluation of the peripheral nervous system, posture, and the cervico-scapular muscles. Patients should be instructed in postural correction in sitting, standing and sleeping, stretching exercises, and strengthening exercises of the lower scapular stabilizers beginning in gravity-assisted positions to regain normal movement patterns in the cervico-scapular region. Other techniques include evaluation of joint mobility and muscular imbalance. Patient education, compliance to an exercise program, and behavioral and ergonomic modification at home and work are critical to long-term successful conservative management. Selected patients may benefit from trigger point injections or acupuncture treatments.

If one does an internet search there are hundreds of references to a) TOS and over-weight and b) TOS and chest breathing.

In my TOS situation I had a severe pain in my thoracic spine and subsequent wry neck (but still working 60-70 hours a week for 10 weeks after my injury fitting roller shutters, in built wardrobes, shower screens etc.). 6 months later I am laying down 16 out of 24 hours a day. At the end of the 10 weeks my family went on holidays and I was still doing 15 kilometre (10 mile) bush walks up mountain slopes. I am amazed at how significant the loss in physical ability that occurred with my body, 6 months after the injury. The less I did, the less I could do. It was a downward spiral that was made significantly worse by a rehab program which included neural stretching and lifting weights in the gym. Most days I would lie on the couch as soon as I returned from the gym sessions. I believe, I would have been better off at work where I could control what I could do rather than being told “no pain, no gain”

As my condition worsened I had great difficulty sleeping. I would end up sleeping on the lounge very often. I found that sleeping on the floor on a 1inch thick foam mattress meant that I was much less likely to wake up with pain in my neck and a headache which extended from the back of my head and made its way to my face depending on the severity. I slept on this mattress on the floor each night for over a year. The more comfortable I made the mattress, the more likely the headache. I worked out that the more comfortable the mattress the more likely I was to sleep on my back, this caused the headaches.

Physiotherapists told me that I was chest breathing and showed me exercises to correct this problem. I was unable to correct the problem. Muscle spasms in my upper back were persistent and very painful. Treatment for these spasms would often make them worse to the point where the soreness extended around to the front where my ribs joined my sternum. Sleeping on this ribcage was very uncomfortable. Laying on this ribcage made matters worse. An x-ray in 2006 for an unconnected matter showed that I had hyper-inflated lung fields. Medication to correct my breathing has changed my world around. Muscle spasms are significantly less, my mattress feels like a different mattress, I am not exhausted as I used to be, I now have a soft ribcage. A soft ribcage is a much more comfortable thing to have.
I know now that the changed breathing pattern combined with the increased pressure on my diaphragm from being 12 kilograms (26 pounds) heavier, much of it around my waist had contributed to the way that my rib cage affects the nerves, muscles and other structures in my upper body. (the experts say chest breathing and being overweight causes problems, they don’t say why, I believe it is under rated significance of the effect that an immobile ribcage has on TOS) The problems with my rib cage have caused deterioration in my condition and have been a significant hurdle in the quest for improvement. I am now closer to how I used to be preTOS.
Some people have cervical ribs removed, some have non-cervical ribs removed, some have botox in muscles which connect ribs (I was told that I had myofascial pain of the erector spinae muscles, and offered botox), some have muscles which connect to ribs removed (scalenectomy). My suggestion is try strategies which soften the rib cage, it will make nerves and muscles and joints between vertebrae and ribs feel so much better. Try not to lay too much on the ribcage, try not to put too much pressure on the diaphragm which forces the ribcage up.

Forget truncal strengthening.
Forget posture, if attempts to improve one’s posture mean increased pressure on tight muscles and nerve bundles this will only make you worse.
Neural stretching and nerve glides are much easier over a soft rib cage.

I hope this might help someone, regards Towelhorse