TREATMENT

What is the treatment? The diagnosis is therapy, because these patients may go to numerous doctors but the diagnosis is not entertained. The patient becomes disappointed because of the lack of diagnosis, they also continue to have the pains and frequently they feel that they are judged to be malingering. This puts honest patients in a very difficult position. They may think that they are having mental problems because they know that they have the pains and they are frequently being told that they are exaggerating the symptoms or the doctor can't find anything wrong with them. Many of these patients are depressed, the posture is slouchy. Awareness of this fact and the use of the Zung test is advocated. It is well known that one of the most effective ways to detect depression is to ask the patient.

The diagnosis of thoracic outlet syndrome is made easy by using the Selmonosky Diagnostic Triad. The person who is trying to substantiate the claims of the patient or client should know that when a doctor sees a patient with thoracic outlet syndrome, the physician cannot differentiate what has been the triggering factor in the development of the symptoms. If I examine a patient who has thoracic outlet syndrome I am not being told if it was spontaneous, secondary to an accident or trauma, or secondary to repetitive work; I cannot differentiate the causative triggering factor.

I can make a diagnosis of thoracic outlet syndrome but the etiological factor can escape at the present time unless there is a severe case of a large cervical rib. Otherwise I cannot possibly decide or make a statement about the etiological diagnosis. The etiological diagnosis cannot be made just with the history and physical examination.

Part of the treatment is physical therapy, but with somebody who is aware of the Thoracic Outlet Syndrome manifestations and has a special training in the treatment. Some exercises are also very important, correction of the posture, checking that the patient is not depressed.

Surgery is the last of the treatment choices and only has to be performed when no improvement in the condition occurs. The patient has to be screened by a psychiatrist or a psychotherapist and the patient should know the pros and cons of the procedure and the possibility of failure and damage to the nerves and vessels, and he/she has to be well motivated.

There has been evidence in the medical literature that employment in an upper extremity repetitive work has a higher incidence of upper extremity and shoulder problems that include thoracic outlet syndrome. The main point for the insurance companies who are responsible for managed care and Workman's compensation is how we can predict if a worker will develop symptoms of thoracic outlet syndrome before they go to work in a repetitive motion environment. This is an important subject, because if you individualize these patients without discriminating, it could be beneficial, not only for the insurance company, but the industry as well, and especially for the worker because he/she will avoid long-lasting pain problems.