Thoracic Outlet

Syndrome (TOS)
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C/C: Pt ℅ pain (graded 3-4/10 on VAS) et bothersome

paresthesia on B UE

Pt’s Goals: “Gusto ko maka balik ubra nga wala na ga palanakit

kag gabiring akon nga abaga kag butkon”
/S/ /S/

C/C: Pt ℅ pain (graded 3-4/10 on VAS) et bothersome

paresthesia on B UE

Pt’s Goals: “Gusto ko maka balik ubra nga wala na ga palanakit

kag gabiring akon nga abaga kag butkon”
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Medications
Medication Dosage Frequency Indications Adverse Effects
Ibuprofen 250mg, oral As needed Pain Headache, dizziness,
nausea, fatigue,
vomiting, tingling or
numbness in hands and
feet, constipation
Albuterol 0.18 mg (2 puffs), As needed Exercise-induced Tachycardia, headache,
inhaler Asthma throat or nasal irritation,
shakiness in arms, legs,
et feet
Dabigatran 150mg, oral BID Prevention of blood Nausea, indigestion,
clots stomach pain,
dizziness, joint pain or
swelling
Lisinopril 10mg, oral OD Hypertension fever, sore throat,
headache, dizziness,
cough, kidney et liver
problems
/S/
Ancillary Procedures
Procedure Date Findings Hospital
MRI February 10, 2023 C3-6 degenerative RMCI – (Dr. Lian Diaz,
disc disease c C3-4 MD FPOA)
protrustion et C4-5,
C5-6 bulging
NCV February 10, 2023 Conductions at RMCI – (Dr. Lian
median nerve through Diaz, MD FPOA)
carpal tunnel et ulnar
nerve at elbow
Arterial Volume February 13, 2023 Abn arterial blood flow RMCI – (Dr.
through B subclavian Napallatan, MD)
arteries c
hyperabduction of
arms
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Past Medical History

Consultation/ Hospital Date Significance Outcome
Admission
Consultation RMCI – (Dr. Reyes, MD) April 1, 2016 Pt reports inc. fatigue et DOB at (+) Activity-Induced Asthma
work
Admission RMCI – (Dr. Tejano, MD) September 17-23, 2017 Pt had an incident with Angioplasty
myocardial infarction

Consultation RCMI – (Dr. Pura, MD FPOA) December 26, 2022 Pt reports neck, back, et arm (+) Left TOS
pain
Consultation RMCI – (Dr. Diaz, MD FPOA) February 10, 2023 Referred for MRI et NCV (+) C3-6 degenerative disc
disease, (+) conductions on B
median et ulnar nerve

Consultation RMCI – (Dr. Napallatan, MD February 13, 2023 Referred for arterial volume Abn arterial blood flow on B
FPOA) studies subclavian arteries, (+) B TOS

Consultation RMCI – (Dr. Pura, MD FPOA) February 15, 2023 Referred for cervical epidural et Relief of neck et arm pain
facet injections
/S/ /S/

Family History
Conditions Maternal Paternal Patient
HTN (+) (-) (+)
CAD (-) (-) (-)
CA (-) (-) (-)
Asthma (-) (-) (+)
DM (-) (-) (-)
Cardiac Conditions (-) (-) (+)
Others:

Findings: Pt’s maternal side has (+) HTN et Pt has (+) Asthma, HTN et Cardiac Condition (Hx of MI)

Significance: Pt has (+) Asthma, HTN et Cardiac Condition (MI)

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General Health Status: Pt describes her health as fair as she is able to indep perform
ADLs but often complains of paresthesia et pain esp doing overhead motions et activities
that deal with heavy objects

Personal/ Social History:

- Pt is married c 1 daughter
- Prior to onset of Sx, pt likes to jog (~2km) every weekend c her husband

Employment/Work Status:
- Pt works as a charge nurse in her local hospital
- Pt spends her time working for ~ 6 hours et 4x a week depending on her on-call shifts
- Her husband drives her to work et commutes going home (~15 mins)
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Personal/Social Health Habits:

- (-) Softdrink, milk, tea drinker
- (+) Coffee drinker (~2-3 cups per day)
- (+) Alcohol drinker (1-3 beers every 2 weeks)
- (+) Smoker - 1 pack per day → 3 pack years

Prior Level of Function

- Pt was indep in all her in all aspects of ADLs as to ADEPTC prior to first injury

Current Functional Status:

- Pt requires +1 assist in overhead activities, but performs ADLs independently c difficulty d/t
paresthesia and pain
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Living Environment: Pt lives in a 3-storey apartment c her husband et daughter.

Pt usually uses the elevator in their apartment complex.

Type of House Apartment

Stairs 10 steps per flight (riser height: 6 in, width: 22
in), 2 flights per floor
Type of Flooring Wooden
Kitchen & Dining Room - Living Room ~ 5m
Living Room - Front Door ~ 3m
Pt’s Room - Living Room ~ 3m
Pt’s Room - Shower ~ 2m
/O/
OI:
Mesomorph
Pt is amb. s AD
(+) Postural deviations
(see postural ax)
(-) attachments
(-) deformities
(-) edema
(-) bruising
 /O/
Cardiopulmonary Assessment
● Pulsation: Normal sinus rhythm
● Breathing Pattern: Paradoxical breather, c ￬ diaphragm
recruitment
● Chest Symmetry: Normal
● Chest Expansion: decreased
● Auscultation: N heart sounds, Vesicular Breath sounds
● Mediastinal Shift: Normal
● Tactile Fremitus: Normal
● Percussion: Normal
● Cough: Normal
● Sputum Analysis: Normal
● Hydration: Normal
● Dyspnea Scale: Grade 1
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Findings: pt presents c a ￬ ROM in bilat.

Cervical lat. flexion, rotation et extension c
more pronounced limitations on the R; et ￬
L shoulder abduction

Significance: pt presents c ￬ ROM on bilat.

cervical lat. flex, rot, et extension; et L
shoulder abd. 2 to mm tightness scalenes,
SCM, et pec maj.
/O/

Findings: Pt presents with 4+/5 R Finger Adduction et R

FA pronation; 4/5 strength in R Thumb MP et IP flexion, R
finger abduction et R wrist extensors; 4-/5 R FA
supination et L FA Pronation; 3/5 L thumb MP et IP flexion
et L wrist extensors; 3+/5 L Finger Adduction et Abduction
et L FA Supination secondary to mm weakness.
/O/
 Significance: Pt presents with a score of
/O/ 19/20 on the Barthel Index of Activities of
Daily Living. Pt is inep. in all aspects as
to bowel bladder, grooming, toilet use,
feeding, transfers, mobility, stairs, et
bathing except for dressing wherein the
pt may require assistance in the activity if
overhead motions are required 2 to pain
et ￬ shoulder abd on the L UE.
/O/
Significance: tests that rule in for TOS et mm
tightness are (+) et consistent c the pt’s current
sx; other tests that aim to reproduce or rule in the
pt’s sx from other sources are negative, ruling out
the possibility of other neurological causes of the
pt’s current impairments.
/O/
Findings: pt presents c a total score of 56/100. Pt can mostly do all of the mentioned items but with
mild to severe difficulty. Specific items wherein the pt was unable to do an activity entirely was changing
a lightbulb overhead (5), recreational activities involving impact on the UE (18), et recreational activities
involving free arm movement (19).
Significance: pt presents c a total score of 56/100, reflecting the the pt’s current level of disability et
severity caused by ￬ UE function 2 to pain, mm weakness, sensory impairment, et LOM.
ICF
PT Diagnosis

Pt. has MD Dx of Thoracic Outlet Syndrome c significant difficulties seen

in overhead activities et recreational act. c impact et free movement of the
UE 2 pain et paresthesia, ↓ mm strength et ROM, et sensory deficits on
the bilat. UE, postural deviations, et chest expansion deficits.
Prognosis
The Pt has a good rehab potential given that the pt is eager to participate in
rehab, has a strong support system, is CCC as to PPT, etc is financially
stable. However, d/t diff in overhead et recreational act, pain et paresthesia,
deficits seen in MMT, ROM, sensation, et chest expansion, as well as
postural deviations, the pt may be hindered from performing the interventions
at an optimum and reach his highest level of fxn.
Prognosis
 Practice Pattern

Practice Pattern 5G: Impaired Motor Function and Sensory Integrity Associated
With Acute or Chronic Polyneuropathies
 Focus of PT Rehab

Improve mm strength, ROM, et postural deviations. As well as improve fxnal

limitations in overhead et recreational act.
Long Term Goal
Rehabilitative: The pt will perform indep. dressing (graded 2 as to the barthel
index) et overhead et recreational act. of the UE c mod diff. (graded 3 as to
DASH) p 20 wks of PT Tx Sessions

Preventative: The pt will maintain a dash score of > 56 during 20 wks of PT

Tx Sessions
Problem List
1. 56/100 as to DASH score
2. ½ in dressing as to barthel index
3. (+) Roundback c forward head
4. Paradoxical breathing pattern c ￬ diaphragm recruitment
5. ￬ Chest expansion
6. ￬ ROM on bilat. Cervical rot, side flex et ext; et L sh abd.
7. Impaired superficial, deep, et cortical sensation on the UE
8. ￬ MMT on bilat. wrist et finger motions
9. Grade 1 tenderness on the bilat. SCM
10. 3-4/10 pain on the L UE as to VAS
Short Term Goals
Short Term Goals
Short Term Goals
 PT Summary

The Pt. is a 56 y.o female c a MD Dx of TOS who presents c significant diff in

overhead activities, free arm et impact activities of the UE d/t pain et
paresthesia, deficits in sensation, mm strength, rom, et AbN breathing that
hinders her optimal participation in working as a nurse and fulfilling duties as a
mother et wife. The Pt needs PT rehab to address these limitations.
/P/
MD Prescribed
● Stretch the ff mm: scalene, pectoralis mm, SCM, Levator scaps.
● Use minimal strengthening devices like therabands et 1lb weights.
Interventions
Pt will be seen as an OP @ 3x/wk for ___ c the following management:

Pt will be educated first about condition et tx, perform the proper warm up et cool down exercises a et p tx sessions and PT
will also monitor pt’s V/S a, during et p tx sessions.

1. HCP on the shoulder x 42° C c 8 layers of towel x 20 mins

2. Deep Diaphragmatic Breathing x 3 mins
3. Nerve tissue mobilization c SH abd 90 deg, elbow ext, wrist et finger ext x 6 reps x 3 sets
4. Scalene stretch c arms at the back et c/l cervical flex et rot. X 6s hold x 3 sets
5. Shoulder blade squeezes x 10 reps x 3 sets.
6. Pectoralis stretch in supine c roller at the back o pt c SH abd 90 deg et elbow flex 90 deg x 6s hold x 3 sets.
7. Standing rows c yellow thera-band x 10 reps x 3 sets as tol.
8. Seated Chin Tucks x 10 reps x 3 sets
9. Arm Circles c 1lb wrist weights x 10 reps x 3 sets as tol.
10. Standard Push-ups x 10 reps x 3 sets as tol.
11. Gentle Sitting Back Extension x 6s hold x 3 sets
12. Slow Pull-apart c yellow thera-band x 10 reps x 3 sets as tol.
Suggested PT Management
Suggested PT Tx:
1. Massage therapy
2. Kinesiology Taping
3. Scapular Stabilization
4. Positional Release Techniques
Home Exercise Program
Pt will be provided by a handout with clear and simple instructions including pictures and specific
details such as the number of reps, counts and sets to be done at home.

General Instructions: Pt must follow the proper warm-up et cooldown exercises a et p for 10 mins.

1. Walking around the house x 3 mins

2. Grasping exercise on towel in sitting x 15 squeeze x 3 sets
3. Scalene stretches on bilat. Sides in sitting or standing x 6s hold x 3 sets
4. Pectoralis stretch c bilat. elbows on door frame in standing x 3s hold x 3 sets
5. Quadruped thread the needle x 6 reps x 3 sets
6. SH abd et scapular rot. in prone x 10 reps x 3 sets
Pt Education and Precaution
Pt Education:
1. Pt must be educated about his condition: causes, effects, signs, and symptoms
2. Educate the pt proper body et posture mechanics.
3. Pt will be educated on the importance of PTR
4. Pt must be educated to do the HEP to have a faster recovery
5. Pt must be educated about energy conservation technique
6. Pt should notify PT if they feel dizzy or nauseous.
7. Pt will be educated on how to properly take own v/s for monitoring purposes.

Precaution
1. Pt should be cautious when lifting heavy objects to avoid aggravating sx.
2. Pt should be cautious when taking vasodilator drugs and smoking at the same time.
3. Pt should be cautious when doing overhead activities to avoid neurologic sx.
4. Pt should avoid any strenuous activities to prevent asthma
5. Pt should avoid putting heavy objects on the shoulder.
6. Pt should avoid repetitive movement on the shoulder
7. Pt should take rest periods when performing any activities
8. PT should be aware of patient's comfort & tolerance during treatment/exercises
9. Pt should be aware of her tolerance to exercise esp when doing strenuous activities to avoid activating the pt’s
asthma.
Home/Ward Instruction
1. Pt’s family members is instructed to learn about pt’s HEP for assistance et is advised to
follow precautions to avoid worsening pt’s condition
2. Pt is instructed to follow the given HEPs et to not forget to follow the said warm-up et
cool-down exercises, a & p exercises
3. Pt is instructed to take in precautionary measures all the time et avoid any activities that
could aggravate his sx
4. Pt is instructed to practice proper body mechanics et postures a, during et p exercises
Recommendations and Referral

PT Recommendations
1. Pt will be encouraged to keep a healthy lifestyle.
2. Respectfully recommend the pt counseling on habitual smoking.
3. Respectfully recommend the pt to not sleep on the affected side.
4. Respectfully recommend the pt to rest the arm on a pillow for ~ 30mins before bedtime
5. Respectfully encourage pt to do daily stretches to improve mm strength et prevent TOS

Referrals:
1. Refer the pt to a dietician to have a well-balanced meals.
2. Refer pt respectfully to seek an OT for motor skills improvement
 #rciconnects

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