Medication Summary
Muscle relaxants (eg, Flexeril, Soma, Robaxin, Parafon forte) are options to help decrease muscle tightness and restriction, thereby facilitating conservative treatment with exercise and manipulation. Tizanidine (Zanaflex) is being used for muscle tension cephalgia and may hold promise for thoracic outlet syndrome (TOS).
Anti-inflammatory medication can decrease irritability and pain and enhance conservative treatment results. Long-acting preparations often are most effective and are tolerated better (eg, Relafen, Daypro, Celebrex). Voltaren or Arthrotec and Celebrex are relatively long-acting alternatives that are less irritating to the GI tract than Naproxen or Clinoril.
Some internists or rheumatologists may recommend vasodilators and calcium-channel blockers, if significant vascular and vasoconstrictive involvement exists. These agents are not primary drugs of choice for TOS but should be considered ancillary or secondary options to be considered and integrated into treatment as clinically indicated.
Muscle relaxants
Class Summary
Used to relax and loosen the tight musculature involved in TOS, facilitate stretching and manipulation treatments, relieve pain, and assist with sleep.
Cyclobenzaprine (Flexeril)
Muscle relaxer of moderate duration, centrally acting, related to TCAs chemically. This drug often produces a "hangover" effect, which can be minimized by taking the nighttime dose 2-3 h before going to sleep.
Carisoprodol (Soma)
Short-acting medication with significant potential for addiction, that works at the spinal cord level.
Methocarbamol (Robaxin)
Short-acting muscle relaxer that probably works through CNS mechanisms.
Chlorzoxazone (Flexaphen, Paraflex, Parafon Forte)
Short-acting muscle relaxer, working via central pathways (spinal cord and subcortical).
Nonsteroidal anti-inflammatory drugs
Class Summary
Have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but may inhibit cyclo-oxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.
Nabumetone (Relafen)
Nonacidic NSAID rapidly metabolized after absorption to a major active metabolite that inhibits cyclo-oxygenase enzyme, which in turn inhibits pain and inflammation.
Oxaprozin (Daypro)
For relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of cyclo-oxygenase, which is responsible for prostaglandin synthesis.
Celecoxib (Celebrex)
Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited thus GI toxicity may be decreased. Seek lowest dose of celecoxib for each patient.
Naproxen (Anaprox, Naprelan, Naprosyn)
For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclo-oxygenase, which results in a decrease of prostaglandin synthesis.
Sulindac (Clinoril)
Decreases activity of cyclo-oxygenase and in turn inhibits prostaglandin synthesis. Results in a decreased formation of inflammatory mediators.
Diclofenac (Voltaren, Cataflam)
Inhibits prostaglandin synthesis by decreasing activity of enzyme cyclo-oxygenase which in turn decreases formation of prostaglandin precursors.
Diclofenac and misoprostol (Arthrotec)
Inhibits prostaglandin synthesis by decreasing activity of enzyme cyclo-oxygenase which in turn decreases formation of prostaglandin precursors.
Misoprostol is prostaglandin analog that protects lining of GI tract by replacing depleted prostaglandin E1 in prostaglandin-inhibiting therapies.
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Progressive postural decompensation with neurovascular compression. A: Normal resting posture. B: Shoulder protraction beginning; the sternomastoid muscles are shortening, drawing the head anteriorly and inferiorly. C: Advanced deformity with adaptive shortening of scalene and pectoralis minor muscles. Also note narrowed costoclavicular space (ribs 1-5 have been relatively elevated). Neurovascular compression is evident at all 3 sites.
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Scalene focal (left) and regional (right) stress tests for thoracic outlet syndrome. Both tests can be easily combined to enhance the stress effect (may be helpful in mild cases).
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Pectoral focal (left) and regional (right) stress tests for thoracic outlet syndrome.
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Stretching technique for the pectoralis minor muscle. Left: The patient has taken the slack out of the muscle. Center: He then rotates the body away from the side being stretched, increasing traction. Right: Maximum rotation and stretch effect are achieved slowly. Image courtesy of The Journal of the American Osteopathic Association
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Sagittal plane posture of patient with thoracic outlet syndrome before (left) and after (right) treatment. Notice the release of the pelvis that occurred with the reduction in hyperlordosis, which allowed the shoulder girdle to drop back and open the thoracic outlet. Image courtesy of The Journal of the American Osteopathic Association
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Myofascial release technique for the scalene muscles. Left: Side-lying approach. Right/top: Supine approach with pillow under thorax. Right/bottom: Supine approach with head extended off the table and supported by the operator's knees. Image courtesy of The Journal of the American Osteopathic Association
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Stretching technique for the scalene (anterior and middle) muscles. Left: The arm on the side to be stretched is secured down (hooked under the seat) to allow more control and effective stretch. Center: The opposite hand wraps partially around the head for good control to assist with the stretch. Right: After proceeding as far as tolerated, the patient leans the whole trunk away from the side being stretched, creating additional traction (downward) on the muscle by the arm that is secured. Image courtesy of The Journal of the American Osteopathic Association
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Algorithm for the treatment of nonprogressive thoracic outlet syndrome (TOS). Anti-inflammatory medication, muscle relaxants, and activity modifications all are used as indicated and tolerated in all cases. Values for very severe TOS are greater than those for severe TOS, and the patient probably should be referred for surgical evaluation.
