Treatment of Neck and Shoulder Pain from Thoracic Outlet Syndrome with Chinese Medicine

Neck and shoulder pain is one of the most common health concerns that lead patients to my door. Acupuncture and other modalities of Chinese Medicine (CM) are effective at providing relief of neck and shoulder pain. This has been shown through thousands of years of practice and, more recently, through the results of scientific research [1].

There are many conditions that can cause neck and shoulder pain. In an effort to delve into details regarding how CM can help I thought it best to focus upon one biomedical diagnosis. I’ve chosen Thoracic Outlet Syndrome (TOS) as this condition varies in presentation and etiology making diagnosis controversial due to resemblances to other conditions [2]. Effective treatment of neck and shoulder pain with CM doesn’t require a biomedical diagnosis. And those with TOS, diagnosed or not, find relief with acupuncture and other CM treatment modalities such as herbal medicine, gua sha, tui na massage, cupping, and moxibustion. Additionally, I have worked with patients diagnosed with this condition and can speak to how the use of CM helps.

What is Thoracic Outlet Syndrome?

TOS is a chronic condition that I have seen presenting as pain, numbness, tingling and weakness in the arm, hand, neck and back of the head. TOS results from the compression of blood vessels and nerves by neck muscles, rib or collarbone [2]. Specifically, the brachial plexus, subclavian artery, and subclavian vein exit through an area known as the thoracic outlet, located between the clavicle and the first rib [3; 4]. A thorough medical history, physical exam, electromyography, ultrasound, nerve conduction studies, and imaging of the cervical spine can all contribute to proper diagnosis [5].

97% of all TOS cases are neurogenic, and involvement of the C7 nerve root, the brachial plexus (C5-C6), and the C8-T1 distribution are most commonly responsible [3]. The main cause of neurogenic TOS symptoms is muscular dysfunction in the cervical and scapular regions leading to intermittent brachial plexus compression in the thoracic outlet [3].

Typically, those with TOS have challenges doing activities that involve elevating one’s arms [3]. Pain tends to worsen with activity [6]. Pain at rest, feelings of numbness, and decreased strength are other possible symptoms of neurogenic TOS [3]. A clinical update paper reported neurogenic TOS symptoms from 50 patients that included paresthesia (98%), trapezius pain (92%), neck pain (88%), shoulder pain (88%), arm pain (88%), supraclavicular pain (76%), occipital headache (76%), chest pain (72%), paresthesia in all five fingers (58%), and paresthesia in the fourth and fifth fingers (26%) [7].

A TOS pathology can be caused by: 1) trauma, commonly high velocity such as in motor vehicle accidents; 2) repetitive motions, related to overuse, physical, and mental stress; 3) anatomic variations, such as the presence of a cervical rib or fibromuscular abnormalities; 4) poor posture; 5) joint pressure, causational examples include obesity and routinely carrying heavy bags; and 6) pregnancy, associated with the loosening of joints [4; 3; 6]. There are cases in which the cause of TOS is undetermined [6].

TOS in Traditional Chinese Medicine

Traditional Chinese Medicine (TCM) utilizes a complete, self-contained diagnostic system to categorize illness and disease and how it relates to the world around us. The most simplistic explanation is that the harmonious balance of qi (life force energy) within ourselves and between us and our environment is equated with health. When there is an imbalance in qi flow, one can see symptoms of illness and disease. Licensed practitioners of Chinese Medicine are educated to understand how the functional activity of the body, mind and spirit are affected by patterns of disharmony in terms of qi. By identifying these patterns, licensed practitioners are able to determine an appropriate, individualized diagnosis and treatment plan for each patient.

Symptoms of TOS can have many diagnoses within TCM depending upon the signs and symptoms presenting. Numbness and tingling from a TCM diagnostic perspective may be caused by invasion of evil qi, internal stagnation of qi, malnourishment of blood, weak spleen qi, and heat consuming body fluids [8]. Nerve entrapment in TCM is viewed as traumatic injury that may cause blood and qi stagnation, overuse leading to malnourishment and stagnation, and wind cold damp invasion obstructing the flow of qi and blood [8]. Qi flows throughout the body in meridians that can be thought of as rivers of energy. Proper TCM treatment considers which meridians are affected. Therefore, patients should be evaluated by licensed TCM practitioners for correct differential diagnosis and individualized treatment plans.

Chinese Medicine offers treatment modalities that can increase blood circulation, decrease muscle tension, modulate neurotransmitters, and induce analgesic effects which all contribute to reducing pain and inflammation, promoting relaxation and facilitating healing [9].

Integrative Approach to TOS Treatment

Conventional treatment of neurogenic TOS typically starts with exercise and physical therapy, followed by consideration for surgery if conservative non-invasive therapies fail [5].

Pharmaceutical pain management of TOS may include anti-inflammatory medications, muscle relaxants, anticonvulsants, and antidepressants [4; 10]. NSAID medications carry a risk of adverse effects that include ulcers, hypertension, acute renal failure, and can exacerbate preexisting heart failure [11]. Muscle relaxants can be potentially addictive [12]. Antidepressants can potentially cause gastrointestinal distress, blurred vision, sexual dysfunction, weight gain, headaches, and insomnia [13].

Pain relief provided by CM therapies are a safe alternative to long term medication use.

Treatment plans that utilize exercise, stretching, postural corrections, muscle recruitment, and education about relaxation and a healthy lifestyle will absolutely benefit from inclusion of Chinese Medicine. Acupuncture, herbal medicine, tui na, gua sha, moxibustion, and qi gong are some of the therapies of CM that can support the effects of other efforts and reduce a reliance upon medication use for TOS patients. CM therapies help reduce muscle tension, oxygenate tissues, increase resiliency towards stress, and increase circulation to reduce pain and decrease compression.

Conclusions

The best conventional treatment for TOS hasn’t been determined, but there is agreement that it should involve a comprehensive and multidisciplinary approach [14]. Chinese Medicine is used clinically to manage TOS symptoms but there is little research on its effectiveness and safety specific to this condition [14]. However, there is evidence for the effectiveness and safety of acupuncture to manage neck and shoulder pain [1; 15]. And I myself have seen the benefits of integrating acupuncture and other modalities of CM into TOS treatment plans.

Patients with TOS are ideal candidates for Chinese medicine. TOS presentation varies wildly and this contributes to the difficulties conventional medicine has in agreeing upon guidelines for generalized treatment protocols [16]. CM prioritizes an individualized approach towards diagnosis and treatment; standardized therapy guidelines shouldn’t be generally applied to patients based solely upon a biomedical diagnosis. Diagnosis of TOS can be challenging to obtain in biomedicine and this can interfere with patients getting access to proper treatment. However, a diagnosis of TOS is unnecessary for appropriate and beneficial CM therapies.

CM helps provide relief of pain and facilitates healing, therefore, therapies such as acupuncture, cupping, gua sha, tui na, and herbal medicine can provide safe alternatives to NSAIDs, muscle relaxants, antidepressants, and surgery that all pose potential adverse effects [9; 11; 12; 13]. I believe a multidisciplinary approach utilizing a holistic perspective is ideal. Individualized integrative treatment plans may include exercise, stress management, education, physical therapy, postural therapy, and CM modalities.

Feel free to contact me if you have any questions and if you are interested in scheduling an appointment.

References:

[1] Trinh, K. & Graham, N. & Irnich, D. & Cameron, I. D., & Forget, M. Acupuncture for neck disorders. Cochrane Database of Systematic Reviews. 2016, vol. 4: 5. P. CD004870. Available at: doi: 10.1002/14651858.CD004870.pub4.

[2] John Hopkins Medicine. 2021. Thoracic Outlet Syndrome. Available at: https://www.hopkinsmedicine.org/health/conditions-and-diseases/thoracic-outlet-syndrome

[3] Laulan, J. & Fouquet, B. & Rodaix, C. & Jauffret, P. & Roquelaure, Y. & Descatha, A. Thoracic outlet syndrome: definition, aetiological factors, diagnosis, management and occupational impact. Journal of Occupational Rehabilitation. 2011, vol. 21: 3. P. 366-373. Available at: doi: 10.1007/s10926-010-9278-9.

[4] Jones, M. R. & Prabhaker, A. & Viswanath, O. & Urits, I. & Green, J. B. & Kendrick, J. B. & Brunk, A. J. & Eng, M. R. & Orhurhu, V. & Cornett, E. M. & Kaye, A. D. Thoracic outlet syndrome: A comprehensive review of pathophysiology, diagnosis, and treatment. Pain and Therapy. 2019, vol. 8: 1. P. 5-18. Available at: doi: 10.1007/s40122-019-0124-2.

[5] Huang, J. H. & Zager, E. L. Thoracic outlet syndrome. Neurosurgery. 2004, vol. 55: 4. P.  897-903. Available at: doi: 10.1227/01.NEU.0000137333.04342.4D.

[6] Mayo Clinic. 2021. Thoracic outlet syndrome. Available at: https://www.mayoclinic.org/diseases-conditions/thoracic-outlet-syndrome/symptoms-causes/syc-20353988.

[7] Sanders, R. J. & Hammond, S. L. & Rao, N. M. Diagnosis of thoracic outlet syndrome. Journal of Vascular Surgery. 2007, vol. 46: 3. P. 601-604. Available at: doi: 10.1016/j.jvs.2007.04.050.

[8] Flaws, B. & Sionneau, P. The Treatment of Modern Western Medical Diseases with Chinese Medicine: A Textbook and Clinical Manual. 2001. Blue Poppy Press.

[9] Cheng, K. J. Neurobiological mechanisms of acupuncture for some common illnesses: A clinician’s perspective. Journal of Acupuncture and Meridian Studies. 2014, vol. 7: 3. P. 105-114. Available at: doi: 10.1016/j.jams.2013.07.008.

[10] Kuhn, J. E. & Lebus V. G. F. & Bible, J. E. Thoracic outlet syndrome. Journal of American Academy Orthopedic Surgery. 2015, vol. 23: 4. P. 222-232. Available at: doi: 10.5435/JAAOS-D-13-00215.

[11] Vonkeman, H. E. & van de Laar, M. A. F. J. Nonsteroidal anti-inflammatory drugs: Adverse effects and their prevention. Seminars in Arthritis and Rheumatism. 2010, vol. 39: 4. P. 294-312. Available at: doi: 10.1016/j.semarthrit.2008.08.001.

[12] Levine, N. A. & Rigby, B. R. Thoracic outlet syndrome: Biomechanical and exercise considerations. Healthcare (Basel). 2018, vol. 6; 2. P. 68. Available at: doi: 10.3390/healthcare6020068.

[13] Hoang, M. & Deng, Y. & Hilmi, Y. & Langland, J. Treatment of anxiety and insomnia with acupuncture and Chinese herbs: A case report. Journal of Chinese Medicine. 2018, vol. 118. P. 32-35.

[14] Hwang, J. H. & Ku, S. & Jeong, J. H. Traditional medicine treatment for thoracic outlet syndrome: A protocol for systematic review of randomized controlled trials. 2020, vol. 99: 27. P. e21074. Available at: doi: 10.1097/MD.0000000000021074.

[15] McDonald, J. & Janz, S. The acupuncture evidence project: A comprehensive literature review (revised edition). 2017. Australian Acupuncture and Chinese Medicine Ltd.

[16] Vanti, C. & Natalini, L. & Romeo, A. & Tosarelli, D. & Pillastrini, P. Conservative treatment of thoracic outlet syndrome: A review of the literature. Europa Medicophysica. 2007, vol. 43: 1. P. 55-70.