WHAT IS THORACIC OUTLET SYNDROME

Another overdue blog about a very common problem that lands a lot of people in our office who have often been worked up medically and released with no good explanation or treatment plan.

The term thoracic outlet syndrome is an umbrella term encompassing several clinical syndromes, which all have to do with compression of nerve and/or vascular structures between the neck and shoulder.

Once the cervical nerves exit the inter-vertebral foramen, a.k.a. the space or hole between two adjacent vertebrae, they will join and repackaged themselves in three branches that will then travel downward into the upper arm and give rise to the three major peripheral nerves: radial, median, and ulnar. Shortly after their redistribution from cervical nerve roots into peripheral branches, they are joined by nerves and arteries exiting from the thoracic cavity, to form the neurovascular bundle. You will often see the abbreviation NAV, to describe respectively nerve artery and vein, that travel together. As a result, any of these thoracic outlet compression syndrome subtypes will almost always include a combination of symptoms due to compression or irritation of the nerve as well as compression of vascular structures. As a result, the symptoms can include not only pain, numbness, but also change in blood flow into the upper extremity that can manifest as sensation of cold and discoloration.

The most common causes of thoracic outlet syndrome is that I find myself treating in the today practices are as follow:

– the scalene muscles are really a big player. They respond to cervical injuries by going into spasm, or developing scar tissue from things like hyperextension whiplash injuries. The soft tissue injury to the scalenes will often result in strangling or adhesions to the neurovascular bundle and brachial plexus. It's relatively easily to palpate the problem if you know where to look and how much pressure to apply. If the scalenes are causing the thoracic outlet symptoms, you can reproduce it by lightly compressing the muscle into the neurovascular bundle. A normal interface of the scalenes with the brachial plexus will move out of the way and cause no symptoms with light to moderate pressure.

– Improper alignment of the anterior first rib to the posterior clavicle. This is often the result of upper thoracic sprains and or shoulder girdle sprains, especially a chronic clavicular and sternal clavicular injuries. After the neurovascular bundle and brachial plexus exit the scalenes they have to "dive" posterior and underneath the clavicle to enter the anterior axillary area.

– Deep pectoralis minor and coracoclavicular injuries or repetitive strain injuries. There's a pretty narrow space behind the pectoralis minor for the neurovascular bundle to travel. Most modern humans are very predisposed to compression in that area because of our poor posture, with our shoulders hunched forward and constantly internally rotated. As a result there is not a lot of margin for an additional minor injury to the shoulder such as falls, heavy pushing, and certain athletic injuries from trying to do push-ups or presses. I should say that seatbelt injuries from motor vehicle accidents are notorious for triggering new thoracic outlet symptoms and a lot of patients.

– Last but not least, the subscapularis muscle deep in the anterior superior armpit is also a common culprit. As the largest of the four rotator cuff muscles and a significant shoulder stabilizers, it sits just below and very close to the neurovascular bundle deep in the armpit. It's very easily triggered with falls and throwing injuries, as well as repetitive strain injuries.

Treatment of thoracic outlet syndrome needs to start with specific identification of the area of compression, and the structures causing the compression. For the most part the treatment plan is going to consist of a combination of cervical and thoracic alignments, a lot of very specific soft tissue releases to separate nerves and vascular structures from the compressing soft tissue, and addressing some of the chronic postural distortion patterns that predispose to the compression in the first place. But treating thoracic outlet syndrome can be surprisingly rewarding, since many cases do respond pretty quickly within a few treatments, partially because many of the structures are not usually associated with more complex long-term degenerative changes that are slower to respond to conservative care.

Vertigo from the neck or inner ear ? The swivel test

Dizziness and vertigo is one of those problems like fatigue that can make you cringe when it shows up in the office because there are so many possibilities as to what's causing it. Anything from cardiovascular to inner ear to medication to blood pressure to mild head injury etc. However when it comes to positional vertigo that is often triggered by change in position of the head and neck, the two main culprits are going to be the cervical spine in the inner ear and sometimes a combination of both. Most of the time the testing can be a little bit elusive because the testing itself will activate both the cervical spine and the inner ear at the same time. (For example Dixie Hall Pike test). The swivel test can be a useful add-on to other testing because it will hold the head stationary while deeply activating cervical rotation, thus eliminating stimulus to the inner year and vestibular system while deeply stimulating the cervical spine. All you need is a good old-fashioned swivel stool or chair and a good pair of steady hands to hold the head.

ADOLESCENT ATHLETIC MIGRAINES AND FERRITIN

july seems to be the time when of our teens tackle some ruthless sports training camp. I've seen a fair amount of those beat up bodies, full of new muscle bundles and a few injuries, show up for treatment at the office. This flood of athletic teens has reminded me of an important topic I've meant to blog about for a while.

Adolescence seems to be a time when migraine patterns can emerge. Hormones get a lot of the blame, and there is some partial truth to that, although I feel that it's often an easy copout without looking at other causes. (Much less trying to understand hormone imbalance and correct them). Injuries to the cervical thoracic spine, athletic head injuries, and some nutritional deficiencies can also be a huge trigger in genetically predisposed individuals. The good news is that there is some recovery path available. Today I want to talk about one particular subset that affects especially young athletic females. The pattern and distribution of the migraine is similar to other migraine headaches, but the timing seems to often coincide at the end of physical activity, indicating a metabolic trigger to the headaches, as at the end of the menstrual cycle rather than before or during menstruation. Over time however, the temporal correlation to exercise and menstruation becomes less clear as the migraine pattern becomes more frequent.

Migraines can have multiple triggers. One common mechanism among many migraine patients is the drop in available energy production in the central nervous system, since neurons hold a negative charge that requires a lot of continuous energy production in the brain in order to be maintained. If the energy production drops very suddenly, or persistently, the neurons lose their charge and can fire in large patterns, causing a random wave of what's called depolarization that can lead to a migraine.

Energy production in the brain requires several things: stable blood sugar (some people can metabolically adapt to ketone fats as an energy substitute for non-high-intensity activities), adequate blood flow, adequate oxygen concentration, adequate electrolytes balance. So episodes of hypoglycemia and low electrolytes can definitely be a ripe terrain for migraine to spike. I think most teenagers and their parents have already figure that out with pre-exercise electrolyte as well as making sure they've had some sort of preexercise snack.

The contribution of low oxygen concentration however does not seem to be on many people's radar. This happens mostly when a teenager is borderline anemic, or has low iron/low iron reserves. Oxygen concentration in the brain is dependent upon not only the blood flow to the brain but also the amount of oxygen carried by hemoglobin in the red blood cells.

Young athletic females are especially vulnerable to iron deficiency anemia or low iron reserves because of three main factors:

– adolescent females menstruate, often at the time that they pick up the intensity of the athletic activities. They do not necessarily make up the iron loss of menstruation at the time that the need increases. Some of the early periods can be irregular and very heavy too compounding the problem.

– Athletic female teens are increasingly engaging in strength training as part of their sports practice, which is excellent news for the overall health, bone health, and injury resilience. The main protein founded muscle is called myoglobin, which requires a lot of heme iron to manufacture. This is the same heme iron that incorporated into the red blood cell hemoglobin. Practically this means that strength training diverts some of the heme iron resources into muscles and away from red blood cell production, increasing the risk of anemia. This phenomenon has sometimes been referred to as the myoglobin shunt.

– The complex landscape of teenage eating habits, tied into body image, food preferences, and some desire to pursue more vegetarian diets, can often lead to very low content and bioavailability of iron and supporting minerals in the diet.

Assessing an athletic female teenager for the potential of suboptimal iron reserves as a migraine trigger is not as straightforward as you would think. The body is very good at compensating for low iron and maintaining apparently normal routine lab values for a very long time. In order to really assess the iron status, a patient will need a CBC, iron panel including ferritin, which is often the first value to drop before seeing any changes in the red blood cell count. My rule of thumb with our young athletic females is to see a ferritin in the 50 range, to give the margin for fluctuations during the menstrual cycle. Be aware that technically the range of what's considered "normal" ferritin on many of our labs is as low as 10, which is clearly not sufficient for most people much less someone involved in high-intensity athletics.

Restoring normal iron and hemoglobin reserves is also not a straightforward as you would think. Common iron supplements tend to be very irritating to the G.I., resulting in constipation, poor compliance, and not necessarily improving iron levels. My recommendation is to combine more easily absorbable forms of iron with cofactors of copper and zinc, and take them and minimum of twice a day, in smaller doses, and ideally three times a day for the first 30 days until the patient starts feeling better. This obviously should be in addition to changing dietary pattern to have more bioavailable forms of iron for a couple meals a day. In addition, I want to make sure that the athletes is having a pre-workout electrolyte and creatine bolus, and that they have had adequate caloric intake including some healthy form of carbohydrate no more than two hours before an intense exercise session. This will help support sustain energy production for their body and their brain during exercise. Ferritin should also be monitored at six weeks, and 12 weeks, to make sure you adjust the supplement dose into a healthy non-toxic range over time.

CHIROPRACTIC, DIZZINESS AND NECK PROBLEMS

I have had a little bit of time recently to look through some research articles that were backlogged in my reading list. I found a couple real gems in the process.

The prevalence of dizziness in patients presenting for chiropractic care with neck and shoulder pain is remarkably high. It's not usually the primary complaint,but is mentioned when we are asking about additional associated symptoms such as headaches visual changes dizziness tingling and hearing changes. Dizziness is surprisingly common with neck pain. There is a good physiological reason for that: the balance centers in the brain receive information from a variety of structures including the inner ear, the feet and ankle, and the cervical facet joints, which are highly affected by the irritation of mechanical disturbances to the cervical spine.

When the balance centers try to integrate information from the various peripheral sensors, if one part of the system sends faulty sensory information that  conflicts with what the inner ear, the visual system and the feet are reporting, It's going to be manifest as confusion in the balance centers and can be expressed as a sensation of dizziness. This is the primary mechanism by which cervical mechanical problems can manifest as a sensation of dizziness. Conversely, the resolution of that faulty sensory information from the cervical facets by manual adjustments can reset the sensory input and make it fully integrate with the rest of the peripheral sensors , thus resolving the symptoms of dizziness.

This research article reflects that reality, with a surprisingly high number of patients reporting resolution of the dizziness from chiropractic intervention while traditional medical evaluation and pharmacological approach does not. It's good news for the chiropractic patient.  Not so much for those of us who have been working in the chiropractic field for a few decades, but it was somewhat of a surprise to the researchers who ran the study.

https://pubmed.ncbi.nlm.nih.gov/26362851/

Chiropractic and the stellate ganglion

A good friend of mine asked me a question about the stellate ganglion in regards to a family member’s injection procedure and asked me how chiropractic interacts with that structure, which reminded me that at some point I had wanted to write a quick blog about it.

The stellate ganglion is a larger node of the autonomic nervous system that is deep in front of the lower cervical spine. It's a large cluster of peripheral autonomic nerve cells that are involved in regulation of several important autonomic functions in the neck and chest including: heart rate and regularity, opening and closing of the blood vessel in the upper extremities, some pain perception and anxiety threshold, regulation of tears and saliva production.

The stellate ganglion is of interest to chiropractors because of its proximity to the anterior lower cervical spine and the fact that it's sensitive to injury especially from rapid extensions such as whiplash. This may explain some of the symptoms that patients often report after an extension cervical rapid injuries such as palpitations, nausea, abnormal cold and hot sensation in the face and hands, feeling anxious, unusual runny eyes nose or dry mouth.

Manual adjustments to the lower neck, upper back, and anterior first rib as well as deep tissue myofascial release deep in the anterior lower cervical spine can have an impact on the regulation of the stellate ganglion and associated autonomic functions. I have found in 30 years of clinical practice that especially addressing the muscular injuries of the anterior cervical spine in patients post whiplash and concussion can make a huge difference in long term symptom management. And I believe that some of that impact is probably due to relieving stress on the stellate ganglion from Injured and scarred surrounding soft tissue structures.

CHIROPRACTIC ADJUSTMENT, COORDINATION AND DEXTERITY

I have recently renewed my enthusiasm for digging into chiropractic basic sciences research, especially in the area of neurological efficiency, as my husband discovered the index to chiropractic literature as part of his fellowship in integrative medicine through the Weil Institute in Arizona.

There have been a series of research conducted using very sophisticated tools to measure the efficiency of intracranial signaling speed in patients receiving spinal manipulation. I am extremely grateful for a pioneer Canadian researcher who spent quite a bit of her research career in New Zealand and inspired a whole generation of younger researchers to expand on her earlier work using transcranial magnetic stimulation. To boil it down, the technology has allowed the use of an external magnetic device applied to the skull to modulate speed of transmission between incoming sensory output and outgoing muscular signaling. The technology also allows the researcher to very accurately measure the speed of transmission and the brain. As a general rule, faster transmission results in much more efficient human motor activities such as decreased response time (think athletic performance but also daily activities such as slamming on the brakes to avoid an oncoming vehicle), and overall improved speed and dexterity. This particular study was quite interesting in that it looked at how neck pain affected the speed at which an affected patient could type a series of letters (patients with neck pain were much lower than their counterparts without neck pain), and how a chiropractic adjustment not only restored typing speed to normal in patients with neck pain, but those adjusted individual actually outperformed the control group who had no neck pain and no adjustment.

We often talk about chiropractic for pain alone, but it's important to realize that pain is only a small fraction of our overall neurological functioning. Our earlier chiropractor pioneers were much more interested in the overall neurological function of their patients than pain alone. The study would certainly have reinforced their pursuits, reminding us that chiropractic can be a powerful tool to help humans perform their best, including much more efficient speed dexterity and coordination of the upper extremities for important modern human tasks such as typing.

https://www.researchgate.net/publication/323463302_Subclinical_recurrent_neck_pain_and_its_treatment_impacts_motor_training-induced_plasticity_of_the_cerebellum_and_motor_cortex

CHIROPRACTIC FOR PELVIC OUTLET CONSTIPATION: WHEN YOUR GUT AND YOUR BUTT DON’T LINE UP

CHIROPRACTIC FOR PELVIC FLOOR OUTLET CONSTIPATION: WHEN YOUR GUT AND YOUR BUTT DON’T LINE UP

After 30 years of practice I am glad to report that I learn new things almost every day and for certain every week. And recently I had 2 cases, one pediatric and one adult, that made me realize that certain subtypes of constipation are closely linked to distortion patterns in the spine, pelvis, and pelvic floor.

On my wish list is the ability to take the full pelvic floor clinical management review, which may happen in the next year when I'm able to make time and travel to the teaching outfiit I have selected. In the meantime, I have been hitting the books and doing short online webinars to try to get a better understanding of the pelvic floor anatomy, which in our profession and historical training has been a little bit of "no man's zone" of management, although I've come to appreciate over the last few years that it could often be the missing link between the trunk and the lower extremity.

The tongue-in-cheek title of this blog actually comes from a patient trying to describe her problem, as she had developed some unusual constipation, which really was the inability to release stools from the very lowest part of her rectum, following a pretty severe lumbar and gluteal injury. She felt foolish describing to me the sensation that her lower rectum did not align with her anus, with the sensation that it was almost sitting too far back onto the sacrum. But in reality she was describing exactly what was happening to her. It is a known clinical presentation that has been assigned an ICD 10 code (the official medical nomenclature of every medical condition for the sake of insurance coding and research): pelvic outlet constipation,K95.02.

Constipation is a term that covers a variety of symptoms that have an equal variety of causes. Pelvic outlet constipation is a very specific form of constipation that does not involve other traditional causes (low intestinal wall muscular activity, low fiber/bulk, internal stool dehydration). It is the inability of the lower rectum to empty out the stool content through the anal sphincter. Upwards digestion and motility and bulk are okay, but things are literally mechanically stuck trying to get out at the very end. Patients will describe a different sensation from other forms of constipation, sensing that the stool is very low, causing a lot of pressure in the rectum, and an urgent need to evacuate, but no matter how much they push they feel that things are stuck and not able to get out. This can cause the patient to spend an inordinate amount of time trying to push very hard, to the point of causing local injury in the form of hemorrhoids and occasional prolapse.

To make sense of this phenomenon you need to understand the basic anatomy of the lower colon in relationship to the pelvic floor and the pelvis itself.

The distal colon descends from the left lower abdomen into the front of the sacrum, where it's posterior to the anal opening. The muscular sphincter is surrounded by a complex set of pelvic floor muscles, which can move the sphincter further forward under voluntary control, thus holding stool in the rectum rather than letting them evacuate.

In order to let stool pass through, the pelvic floor muscles need to relax so that the sphincter can move a little further backwards and align itself with the rectum. In addition, the sphincter must be central in the pelvic floor, not shifted or pulled to one side, in order to have the easiest and smoothest stool evacuation.

If you look at the anatomical drawings of the pelvic floor muscle and the lower colon, you will notice that the pelvic floor muscles attach to the entirety of the bony pelvis, from the posterior part ( ilium and ischium, sacrotuberous ligament, tailbone) to the anterior part behind the pubic bone. In addition, all the pelvic floor muscles are innervated by by the lower lumbar segment and sacral segments.

The intimate neurological and structural connection of the pelvic floor to the lumbar spine and pelvis means that distortion patterns, trauma, repetitive strain of the lumbar spine and pelvis can result in some significant distortion of the muscular activity and tone of the pelvic floor, with the risk of chronically altering the central positioning of the sphincter in relationship to the lower rectum. This means that at the time of voluntary evacuation, it would take more effort and straining to bypass this suboptimal relationship between the lower large intestine and the outlet.

It occurred to me at the time I started writing this blog that I've probably been incidentally treating a lot of mild pelvic outlet constipation cases for a while, as a byproduct of my chiropractic treatments to the lumbar spine and pelvis. However it's only more recently that I've started paying attention more closely and in more detail to the structures of the posterior pelvic floor, which abuts structures we routinely palpate in the lower sacrum, inferior external rotators of the hip and sacral ligaments. I've also started asking the patients a few more pointed question about symptoms, which they may not volunteer, partially because these body parts are pretty private and partially because people don't make the connection between their G.I. symptoms and their lumbar pelvic symptoms.

To be effective, a chiropractic treatment in patients suffering from pelvic outlet constipation needs to incorporate several elements: addressing the structural alignment issues in the lumbar spine and especially in the pelvis; addressing the muscular imbalance of the external rotators of the hip, especially the most inferior group; addressing abnormal tone texture and scar tissue in the posterior pelvic ligaments (sacrotuberous and sacral spinous); and being able to give the patient basic information about how to do a proper pelvic floor stretch and strengthen based on which side is involved.

I'm also very fortunate to have access to several excellent pelvic floor specialty providers (physical therapist and occupational therapist) in my area of practice, who can take care of more direct pelvic floor manual therapy in patients who need it

K59.02

Outlet dysfunction constipationK59. 02 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2024 edition of ICD-10-CM K59.

https://www.icd10data.com/ICD10CM/Codes/K00-K95/K55-K64/K59-/K59.02#:~:text=Outlet%20dysfunction%20constipation,-2016%202017%202018&text=Billable%2FSpecific%20Code-,K59.,ICD%2D10%2DCM%20K59.