Key points

Introduction

Physical therapy for neurogenic thoracic outlet syndrome (NTOS), an inherently unclear, complex, and multifactorial condition, is challenging on many fronts. The region is anatomically complex, symptom patterns are variable, and concomitant conditions in the cervical spine and shoulder are frequent, muddling the presentation. The diagnosis is often delayed, because symptoms of pain and paresthesia persist into a chronic state. Impairments, chronic pain, and functional limitations from the condition can cause significant impacts on activity participation and quality of life. The physical therapist is often presented with a centralized neuropathic pain problem with a musculoskeletal origin. Despite the challenges, conservative treatment is recommended before surgical interventions, and can be effective. In a recent prospective observational cohort of patients with NTOS, 27% of 150 patients achieved satisfactory outcomes with physical therapy alone. There are no randomized controlled trials assessing the effectiveness of physical therapy. The variability of the patient presentation and controversy around defining and diagnosing the condition make performing and comparing studies on rehabilitation challenging. The most recent Cochrane review does not provide Level 5 evidence in support of a standardized management plan. The condition remains a diagnosis of exclusion. The management remains an individualized approach merging psychologically informed strategies with interventions addressing the mechanical factors associated with compromise of the neurovascular container.

Historically, physical therapy management has been directed at improving scapular and shoulder girdle stability, mobility, and mechanics Approaches described in the literature include shoulder girdle elevation, ^, cervical and shoulder girdle strength and mobility exercises, scapula stabilization and stretching of pectoral and scalene muscles. Cervical traction has been recommended as well. Other investigators have advocated for addressing breathing mechanics, implicating overuse, and overactivity of the pectoralis minor and scalenes as a factor in thoracic outlet compromise ^, Additionally, the impact postural control is thought to have on breathing mechanics implicates the need to consider postural alignment and core stability to allow for improvement in diaphragm function. ^, Limitations in mobility of the thoracic spine are described in the examination and treatment of this region as well as manual therapy interventions directed at impairments. ^, A staged approach has been recommended in addressing these impairments, based on careful examination, an understanding of the relevant anatomy, biomechanics, and neural irritability levels. ^,

In recent years, the growth of pain neuroscience education and cognitive behavioral therapy informed physical therapy ^, have offered physical therapists’ additional tools to aide in the management of chronic complex pain conditions such as NTOS. These psychologically informed physical therapy practices are optimized when used in conjunction with a comprehensive biomechanical assessment and management strategy designed for the individual needs of the patient. A thorough history and clinical examination are essential components to developing an effective plan of care. This is also the baseline for establishing trust with the patient to aid in the validity and effectiveness of your teaching.

Interview

During the history, clinicians should listen for patterns consistent with vascular or NTOS. Patients with vascular TOS often describe claudication symptoms after repetitive strenuous upper extremity activities, although others may have an onset spontaneously. Neurogenic TOS may involve a history of trauma or overuse to the cervical spine or shoulder, including whiplash, labral tears, throwing, and traction injuries. Comorbidities should be noted with consideration to conditions such as Ehlers–Danlos syndrome, cervical spine degenerative joint disease and spondylosis, and known anatomic variations such as a cervical rib or extended C7 transverse process.

Symptom patterns vary and may include pain in the cervical spine, chest, scapula region, headaches, numbness, paresthesia, and temperature changes throughout the extremities. Therapists should take note of the symptom qualities, as well as location and onset of aggravating and alleviating positions and activities. Irritability—how easily symptoms come on and how quickly they subside after an aggravating activity—guide the clinician in the selection of which tests and measures will be useful. Many patients with chronic NTOS are in highly irritable states and tolerate few examination procedures. Early physical therapy intervention in these patients is best served focusing on positioning and activity modification for symptom reduction. Past and current management strategies, including previous courses of physical therapy and home exercise routines, are relevant in understanding the tensile and compressive loads being applied to the thoracic outlet container and the typical symptom response in relation to these. Some patients have a greater sensitivity to tensile forces through the cervical spine and shoulder girdle. They describe an increase in symptoms with static postures, such as working at a computer, carrying objects at their side, or objects pulling down on the shoulder such a strap from a bag, a bra strap, or even a heavy jacket. Sleeping without adequate shoulder support can be provocative. Their symptoms often increase after trying to stretch the cervical spine or pectoralis musculature and they often have poor tolerance to shoulder depression and retraction exercises. Other patients have greater reactivity to compressive loads through the shoulder girdle and describe limitations with overhead activity either with weight or repetitive activities without weight. Many patients have components of both tensile and compressive load sensitivity, necessitating an approach aimed at repositioning for tension reduction as well as decreasing overactivity and load from the provocative musculature. The use of patient-reported outcomes is important. The Disability of Arm Shoulder and Hand has been found to be helpful for scaling the intensity of the current functional impairment, creating goals, and assessing for change in response to treatment. To better understand the role pain education could have in the patient’s recovery, the therapist should listen for and pose questions for indications of the individual’s attitude toward their pain experience and consider the use of additional psychometric tools such as the Fear Avoidance Beliefs Questionnaire.

Physical examination

Given the variability of the presentation and the lack of highly sensitive and specific clinical tests, the diagnosis of TOS is challenging. A thorough examination is an essential element in the clinical diagnosis of TOS. The examination, in combination with elements of the history, guides the clinician’s management approach and provides indications of the prognosis with physical therapy treatment.

The clinician should begin with a detailed visual inspection of the patient. Signs of cyanosis in the hands or edema should be noted and are concerns for vascular compromise that may require referral for urgent care. The clinician should look for atrophy in the hand, arm, and shoulder girdle. Supraclavicular fullness, suggesting the presence of an elevated first rib, cervical rib, or edema in the region should additionally be noted.

A detailed postural assessment is one of the most important examination components for a physical therapist. Given that the diagnosis of TOS indicates a compromise of the neurovascular bundle in this region, the physical examination needs to investigate how that area could be compromised. The concept of regional interdependence applies here, and the interplay between alignment, movement, and function shapes the mechanical component of the plan of care.

Given the anatomic variability seen in both asymptomatic and symptomatic patients, postural observations need to be taken in the context of the patient’s pattern of symptoms and the influence postural corrections or modifications have on them. A structural ribcage asymmetry such as pectus excavatum or a fixed scoliosis can contribute to dysfunction that impacts the prognosis and plan.

Postural assessment includes observing the alignment of the patient in different planes, noting the position of the cervical and thoracic spine, the relationship of the thorax and the pelvis, and the position of the shoulder girdle. This relationship should be examined in standing and sitting, because it can change. Considerations in each plane and potential implications of the posturing are described elsewhere in this article.

In the sagittal plane, note that the position of the cervical spine in relationship to the thoracic spine. A forward head introduces the possibility of tightness in the scalene and sternocleidomastoid muscles, as well as the suboccipital muscles posteriorly. Restrictions in mobility of the upper and lower cervical spine are of additional consideration. A flattened cervical lordosis could indicate shortened sternocleidomastoid and scalene muscles. Note the curvature of the thoracic spine, increased or flattened with depression or elevation of the sternum. Many patients with TOS present with flattening of the midthoracic spine, kyphosis of the upper thoracic spine, and elevation of the sternum. It is important to note the position on the ribcage in relation to the pelvis. The presence of a swayed back posture in which the ribcage is positioned posteriorly to the pelvis has implications in optimal diaphragmatic functioning, core stability, and the influence of loading forces through the upper extremity during arm activities. ^, A shoulder girdle that is retracted and depressed can contribute to tensile forces across the thoracic outlet region and compressive load between the clavicle and first rib and is often described in the literature as a droopy shoulder. A flared lower rib angle can indicate lengthening of the abdominal muscles. This can inhibit optimal diaphragmatic use, thus relying more heavily on accessory muscle activity for respiration. The examiner should note if the knees or elbows are hyperextended, suggesting systemic hypermobility.

In the frontal plane, the examiner observes again for a dropped shoulder with a lower clavicular angle, scapular depression and inferior rotation. A cervical shift is sometimes seen away from the more involved shoulder, contributing to tension across the proximal portion of the plexus.

Considerations in the transverse plane include and anteriorly sitting humeral head and rotations through the cervical, thoracic spine, or pelvis.

If the patient has resting symptoms, the therapist can consider repositioning postural faults and assessing the impact on symptomatology. The examiner should also note if the postural faults are fixed or mobile, because this may have implications in joint mobility restrictions and the relationship between muscle length and strength.

After a review of posture, the examiner begins the process of ruling out alternative, more likely diagnoses. A detailed guide on the assessment of the cervical spine and shoulder are beyond the scope of this article, however, at a minimum they would include active and passive motion, neuromuscular screening, strength, muscle length, and special testing of the cervical spine and shoulder complex. Symptom reproduction with cervical side bend and rotation away from the involved limb can suggest tensile sensitivity. Symptoms with rotation and side bend toward the affected side suggests loading sensitivity. It is important to note that underlying cervical and shoulder pathologies are frequently present in NTOS and may be primary or secondary contributors. Cervical radiculopathy is a condition that is more common and can have similarities in presentation to NTOS. Attempts have been made to cluster examination procedures in the aid of clinically diagnosing a cervical radiculopathy. Wainner and colleagues looked at the upper limb tension test, active range of motion of the cervical spine limited to less than 60° toward the affected side, positive relief with cervical distraction, and the Spurling test. Four positive tests indicated a greater than 90% probability of a cervical radiculopathy. The upper limb tension test was found to be the most useful in ruling out a cervical radiculopathy. In a recent systematic review, Thoomes and colleagues suggested clinicians should consider that a combination of a positive Spurling test, axial traction test, and arm squeeze test may be used to increase the likelihood of a cervical radiculopathy, whereas a negative outcome of combined upper limb neural tension tests and arm squeeze test may be used to decrease the likelihood. The Spurling test has been found to maintain a high specificity across studies. It is important to note that patients with TOS often have positive neural tension testing and limited cervical motion. In those individuals that are tensile sensitive, cervical traction may increase symptoms, and the Spurling test is often negative, except in older patients with facet joint disease.

Clusters of positive examination findings have been shown to offer more diagnostic utility in ruling in a neurogenic TOS diagnosis. There is moderate evidence to support the use of the Halstead maneuver, Wright’s test, Cyriax release test, and supraclavicular pressure test; however, they do not allow for the diagnosis of TOS exclusively and have been subject to high false-positive rates.

Assessing the muscle length of the pectoralis minor and scalenes should be done with caution because these are often provocative positions, especially in patients with heightened irritability levels. The density of scalenes can be palpated as well as pain and tenderness with palpation of the pectoralis minor.

Latissimus length and pectoralis length should be assessed with ribcage fixation in neutral. The examination should include an assessment of breathing mechanics. The resting position of the diaphragm can be observed in hook lying and provides information regarding its relative length. An increased angle at the base of the ribs suggests a lengthened diaphragm at rest. The patient’s ability to exhale and inhale without excessive accessory (pectoralis minor, scalenes, sternocleidomastoid) muscle use is observed and starts to give an understanding of the patient’s individual adopted pattern. The clinician can assess the patient’s ability to change that pattern within the examination.

Functional testing

During the examination, it is important to determine if modifications to alignment and positioning have an impact on symptoms with functional movements. The intention is to create just enough of a change in postural alignment to have a positive impact on the tensile and compressive loads affecting the thoracic outlet. Results of this assessment can have an impact on prioritization of treatment planning. Many patients with TOS are symptomatic with arm elevation. The therapist can investigate the impact on symptoms with arm elevation while providing supportive elevation and correction to the shoulder girdle, ribcage, and pelvis position. Examples of this include elevation, protraction, or retraction of the shoulder girdle; repositioning the ribcage over the pelvis; repositioning the cervical spine through retraction, traction, or a lateral shift; facilitating scapular upward rotation; and glenohumeral stability or manual stabilization to the cervical spine. The immediate impact on symptom reduction through repositioning is considered a favorable prognostic indication in the authors’ experience. If mechanical resistance to corrective positioning is experienced, the examiner will need to investigate the source of restriction related to muscle length, strength, or joint mobility. The use of functional testing with modifications to load and tension helps the therapist prioritize the plan of care. It also gives the patient an opportunity to experience improved movement patterns and provides insight into the relative sensitivity to pain, palpation, and the ability to change the overall pain experience by mechanical means. In some cases, it can guide the patients’ understanding of the pain triggers and what changes they will need to make to better control them.

Treatment approaches

This section will address evidence and considerations for individual treatment interventions and will be followed by a commonly used phased treatment progression in which interventions are integrated. The primary goal of mechanical treatment is limiting the tensile or compressive loads across the thoracic outlet region and maintaining patency during functional arm use. The selection of manual treatment, exercise, and postural education for positioning and functional activity retraining should include an understanding of this space and the forces applied through it.

Manual techniques are commonly used to address restrictions in joint mobility and soft tissue length. If irritability levels are low, addressing soft tissue and joint restrictions that directly contribute to compromise of the thoracic outlet, such as first rib mobility and scalene and pectoralis minor length, can be attempted. Additionally, restrictions affecting the ability to achieve optimal postural alignment or restrictions contributing to altered movement mechanics across the cervical spine and shoulder should be addressed. Manual therapy may also have an influence on pain modulation and desensitization. Considerations to support the patency of the thoracic outlet region may include, but are not limited to first rib mobilizations, anteroposterior mobilizations of the second and third ribs, and flexion mobilizations of T2 to T5. Lateral lower cervical glides on the nonpainful side, aiming to decrease the tension on the overlengthened side, upper cervical flexion, and sternocleidomastoid lengthening. Manual cervical traction may be beneficial in a patient with compressive loading sensitivity and low-tension sensitivity, but should be done from a position of a neutral ribcage, which often includes a flexed or depressed sternum. This technique would decrease the concern for overtensioning of the plexus. Posterior glenohumeral mobilizations can be considered to aid in restoring glenohumeral positioning, mobility, and function.

Strengthening exercises are an important component of care but must be designed with caution in relation to load and with attention to alignment, supporting patency in the thoracic outlet. Inhibiting the overuse of the anterior neck and chest muscles, especially with arm use, is sought by improving the core and diaphragm. Improving alignment of the ribcage over the pelvis and elevation of the shoulder girdle are reinforced to optimize core function and load distribution through the body. From this position, upper extremity strength training can often begin, with a focus on scapular stabilization.

A variety of exercises focusing on improving glenohumeral and scapula stability are important. Strengthening a lengthened and depressed shoulder girdle can be done with shrugs, often without weight, using high repetitions and guided by irritability. Glenohumeral and scapular stability exercises are done with a properly positioned clavicle and shoulder girdle, being careful not to retract or depress the clavicle in tension sensitive patients. This can be done in supine, sitting, standing, wall sit, or hip hinge.

External support

Although the long-term goals aim for patients to gain better strength, endurance, and postural awareness to support the shoulder girdle, short-term goals often include better self-management strategies to control symptoms. Some examples of this could be using a pillow or towel roll to lift the shoulder girdle while resting, driving or working at a desk, and taping the shoulder girdle on the painful side for elevation. ^, Patients can have partners help apply tape with the goal of supporting overlengthened, weak muscle. This technique can be used over a few weeks to assist in symptom control and weaned as strength improves.

Stretching

Lengthening shortened tissues found on examination such as pectoralis and latissimus can be challenging in this population and can easily reproduce symptoms. Classic pectoralis stretches involve a doorway or supine over a ball or foam roller, they both put the arm in the EAST position and bring the clavicle into the first rib. Manually lengthening the pectoralis can be initiated in supine, with arm support, and transferred to a specific home technique. Lengthening scalenes with stretching exercises in a patient with a tensile sensitivity can also be challenging and is more often effective manually before attempting home stretches.

Posture education is a general term that should be individualized to the patient’s structure and postural habits. It involves identifying a neutral posture. Assumed neutral posture for function is based on alignment relative to gravity as well as the functional testing results on examination. If a patient can move their neck, shoulder, and arm with less pain for functional activities after postural readjustment, that positioning becomes a starting point for where their neutral should be. A common posture “correction” of a retracted and depressed shoulder girdle over an extended thoracic spine can reduce the space between the first rib and clavicle. ^, Patients with NTOS commonly benefit from the following postural corrections: bringing the thoracic spine and ribcage centered over the pelvis, shoulder girdle elevation, sternal depression, and shoulder protraction.

Function and ergonomics

Once an improved static postural alignment is identified, postural training for function becomes critical for carryover to activities of daily living. Taking a learned position and linking it to a previously painful task can help integrate a new pattern, and train muscle endurance.

Ergonomic considerations are also highly important, because many patients tolerate static positions poorly. The use of arm rests or pillows to unweight the shoulder girdle at a computer, varying position and task can be helpful. Standing desks and dictation software can work for some individuals. Occupational therapists can manage this population from many perspectives, and consultation can aid in management.

Helpful positioning for sleep can be side lying on the nonpainful side with significant (multiple pillows) arm support for the painful limb, as well as cervical support and leg, and pelvis support as needed.

Neural glides

Given that this population is experiencing neural irritability, it makes sense that neural gliding is considered. The concept of neural glides is that there exists a tensioning or scar tissue from a compressive internal force. It is often neural tensioning in this population that is also an irritant. Depending on the sensitivity of the individual, frequent reproduction of the symptom can increase rather than decrease sensitivity. Exercise creating thoracic flexion and rotation rather than a specific repeated neural glide or tensioning encompasses the concept and avoids the potential for heightened response.

Psychologically informed physical therapy

Woven throughout the treatment techniques chosen is the concept of pain neuroscience. Cognitive–behavioral therapy or motivational interviewing approaches have demonstrated effectiveness in helping patients manage pain. ^, The key components are listening to a person’s experience and reinforcing positive health-driven behaviors. How well the patient understands the problem, their degree of self-efficacy, ownership, and willingness to participate in change contributes to the clinician’s ability to aid in their recovery. Addressing central sensitization directly can be approached multiple ways. Pain reduction can begin with assigning an aerobic exercise activity for 30 minutes per day. ^, Meditation and relaxation activities can assist in decreasing sensitivity, controlling pain, and reinforcing optimal breathing patterns. Conversations around emotional triggers can emerge, including how they can be identified as intensifiers, and conversely how a change in emotional states, including reframing thoughts, can decrease pain intensity.

We are uniquely positioned as physical therapists to integrate our detailed examination outlining the mechanical triggers, with our positive, listening intensive approach to aid an individual back to improved function.

Treatment progression

As mentioned elsewhere in this article, standardized treatment programs for patients with NTOS have not been established and optimal treatment planning at this time remains highly individualized. Optimizing strength, mobility, and position to allow for improved functional use of an individual’s upper extremity is the goal of care. This process requires careful examination and progression in concert with the individual patient. Resumption of activities may require alteration in method and position.

There are, however, guidelines that can be created based on available evidence (expert opinion) and common patterns and experiences observed from treating patients with this condition. Walsh originally described approaching treatment for patients with NTOS in 3 stages. Although there has been progress in understanding and treating this condition since this writing, the general framework for organizing interventions still applies. We describe the general phases of treatment and examples to guide decision making. Stages 1 and 2 are best subdividing in to early and late phases to help delineate the gradual nature of the progression. Patients may enter at different points on the continuum based on their chronicity, irritability, and mechanical presentation.

In stage 1, the focus is on controlling symptoms and is of critical importance in patients with higher irritability levels. Botox of the scalenes and pectoralis minor can be extremely helpful in improving symptoms. This treatment can facilitate the ability to initiate physical therapy.

Supine core exercises with arm movements (think 90° of shoulder flexion, often a position these patients cannot achieve against gravity without pain) can allow for developing shoulder girdle stability and trunk rotation and thoracic mobility. Advancing core function and pelvic acceptance strategies to standing may include standing against a wall and reaching, with trunk rotation, or standing with arm support on a counter. The goal is to create the trunk and pelvic neutral positions with thoracic outlet patency. This process may include shoulder elevation and sternal depression. Eventually pectoralis length is needed but to be done without sternal elevation. Walsh has advocated for a staged program approach; this strategy is consistent with that initial stage.

Attempting to begin strength training, large postural corrections, and especially direct stretching or manual therapy across the tissues in the thoracic outlet before control of symptoms and irritability is achieved is often not tolerated well by the patient and is more effective in later phases of rehabilitation. Early considerations in stage 1 include providing strategies to unweight and elevate the shoulder girdle intermittently throughout the day and before bedtime for at least 30 minutes to decompress the thoracic outlet and aid in sleep. Taping strategies can be initiated for supporting and elevating the shoulder girdle, as well as stabilizing the glenohumeral joint. Positioning and small postural adjustments can be used that facilitate space in the thoracic outlet or relaxation of the provocative tissues such as scalene and pectoralis minor. Optimizing core function to allow for pelvic support of the ribcage and improved diaphragmatic function should begin in this stage as well. Activity modifications to decrease repetitive stress, overhead activities, and other provocative activities identified in the history are attempted to be removed, altered, or minimized along with promotion and reinforcement of activities that are neutral or alleviating to symptoms. Many times, walking, use of a stationary bike, or an elliptical trainer (no arms) can be beneficial in early management. These exercises can be done with taping or supportive arm positioning. Pain neuroscience education is initiated, in concert with the patient’s understanding and goals.

Later phases in stage 1 begin when the irritability level begins to reduce, and the patient has a set of established positions, postural adjustments, and exercises that help to manage symptoms more effectively. The therapist can then consider addressing biomechanical impairments contributing indirectly to tensile and compressive loads across thoracic outlet region. Examples include mobilizations and exercises that promote mobility of the thoracic spine, often promoting flexion and sternal depression. Manual therapy for glenohumeral restrictions such as posterior capsule tightness can be done. Core activation to address ribcage support in the context of postural corrections can begin. Active shoulder shrugs through moderate range without weight are often tolerated well. The primary goal is to begin to create patency of the thoracic outlet with minimal direct load or tension through tissues in this region.

It is important to include an against gravity activity incorporating the same principles with arm movements as early as possible. This activity can be undertaken in a sitting, wall sit, or hip hinge with upper extremity support, again with core engagement, inhibition of anterior neck musculature.

Once the secondary impairments are demonstrating signs of improvement, the treatments are tolerated well, and the patient has a good understanding of strategies for managing symptom reactivity, stage 2 treatment can begin. In stage 2, treatments can have a more direct impact on tissues involved in the thoracic outlet compression. It is critical that this phase be tailored according to the tissue reactivity level. Early stage 2 approaches would include first rib mobilizations, soft tissue work to the sternocleidomastoid muscle and suboccipital fossa. In the authors’ experience, direct manual therapy to the scalenes and pectoralis minor need to be performed with caution and best served when irritability levels are lower, because they can be highly provocative. Exercises that load the upper extremities must be gradually introduced and are often best started in supine with support of the cervical spine and shoulders in neutral positions before moving to upright. Postural corrections are reinforced and encouraged in more functional movement patterns to promote motor learning. Lower extremity and trunk exercises can often be progressed at a more rapid pace, allowing for functional movement patterns such as squats, lunges, and so on from an adjusted postural alignment. This process reinforces pain-free motion, movement, and exercise. Upper extremity exercises are often best slowly progressed and with an emphasis on maintaining postural adjustments that support patency. Trunk rotation and mobility is important. Patients typically need training on bringing the ribcage more centered over the pelvis. An extensor chain dominance is consistent with latissimus overuse and shoulder girdle depression. Exercises that retract and depress the shoulder girdle such as rows and lateral pull downs are typically tolerated poorly unless these corrections are learned and implemented.

Later phase 2 exercises bring upper extremity strengthening into upright postures. Standing latissimus pull down, row without depression or retraction of the shoulder girdle, resisting external rotation with combined elevation of the extremities, scapular wall clock, and wall pushups are all examples of later phase 2 exercises. Scapula and glenohumeral stability and mobility are key. The primary goal is reinforcing optimal movement patterns while using the upper extremities and to begin building strength, stability, and endurance.

In stage 3, the patient is progressed to more dynamic multiplanar movement patterns. It is important to note that not all patients with TOS reach this level of training. Patients attempting to return to sport can begin sport-specific drills in this phase. A continued emphasis on the glenohumeral stability over an improved ribcage position and core function is emphasized. Cervical extensibility in the vertical and frontal planes may be needed and easier to obtain as the ribcage and shoulder girdle have improved position, strength, and length.

Summary

NTOS remains a challenging condition to diagnose and manage conservatively. Examination requires detailed history and physical assessment of the mechanical factors that contribute to compression or load across the thoracic outlet, the irritability level of the condition and the presence of centralization of symptoms. Treatment approaches are individualized and examination driven, but ultimately aim to create space between the first rib and clavicle and decrease the tensile load of the limb. Postural retraining and optimizing diaphragmatic breathing patterns are essential for reducing overuse of accessory muscles that can contribute to compressive forces. There is a need for future studies with high-quality designs evaluating the effectiveness of conservative treatment approaches.

Clinical care points

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  Individualized examination of cervical, shoulder and thoracic spines to determine influences on the thoracic outlet region is critical.

  
  
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  Neural tension and compression points are identified in order to prioritize and plan treatment.

  
  
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  Maintaining patency of the thoracic outlet region through all planes of motion is important in designing an exercise approach, developing a proper postural set and planning manual intervention.

  
  
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  Treatment of a chronic neural irritability requires a knowledge of central sensitization and benefits of a cognitive behavioral approach.