Neuro Advances

A Diagnosis of Exclusion



•    Director's Letter
•    NOVA
•    Schwannoma Case
•    Chiari Malformations
•    Neuroscience at UCSB
•    Neurogenic Thoracic Outlet Syndrome
  PFO Closure Device

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Barry Ross, MD
Rehabilitation Medicine
Cottage Rehabilitation Hospital

Thoracic outlet syndrome (TOS) is caused by the compression of the brachial plexus or the subclavian vein or artery. The diagnosis of TOS is generally made on the basis of history and physical examination and rarely on imaging studies or neurophysiological testing.


Neurogenic Thoracic Outlet syndrome (TOS) can result from a neck trauma or repetitive stress movement injuries—such as using keyboards or working on

assembly lines—which may cause changes in the scalene muscles, resulting in compression of the transiting nerves of the brachial plexus. Venous or arterial TOS may also occur due to the overdevelopment of muscles, as is seen in bodybuilders.


Diagnostic screening may include the elevated arm stress test (EAST), which is designed to trigger symptoms or obliterate the radial pulse, sometimes producing an audible bruit over the subclavian artery in the scalene triangle. Electrodiagnostic tests are only positive in 20 percent of patients in subsequently confirmed TOS.


“Neurotoxin [Botox®] treatment allows the scalene muscles to relax, enabling patients to engage in effective physical therapy,” says Barry Ross, MD , physical medicine and rehabilitation physician at Cottage Rehabilitation Hospital. “Physical therapy is often the most effective conservative treatment because it improves structural or postural issues that contribute to patient symptoms.”


Diagnosis and Treatment

TOS is characterized by exertional pain, numbness, and weakness in the affected shoulder and arm. Ipsolateral headaches, hand swelling and Raynaud’s phenomenon are frequently noted.


“TOS is an underappreciated cause of shoulder and arm pain,” says Dr. Ross. “It is important for physicians to recognize the symptoms of TOS in their patients and refer them to specialists experienced in effectively treating this condition.” For more information or to refer a patient to Keck Center for Outpatient Services, contact the Cottage Rehabilitation Hospital outpatient admissions office at (805) 569-8900.



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In patients with chronic disabling symptoms who have failed physical therapy, trigger point injections and, perhaps, scalene Botox injections, surgery may be required. With the possible exception of patients with surgical ribs, transaxillary first rib resection is the procedure of choice. Good results can be expected in 70 to 80 percent of these patients.
One of many interventions used by Barry Ross, MD, physical medicine and rehabilitation physician, to treat patients with thoracic outlet syndrome and other musculoskeletal and neurologic conditions is aquatic therapy, which is available at The Tuohy Foundation Aquatic Center at Cottage Rehabilitation Hospital.