Physical therapy and desensitization therapy post first rib resection surgery

for venous thoracic outlet syndrome

Dame Emily Robinson
Central Michigan University Doctoral Program of Physical Therapy

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Abstract
Background and Purpose: The purpose of this case study was to describe the physical therapy
interventions for a female patient post-surgical resection of her first rib following venous
thoracic outlet syndrome.

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Case Description: The case report described a 37-year-old female patient who participated in
physical therapy twice a week for 6 weeks with a total of 12 sessions as part of rehabilitation for
post-surgical resection of her first rib. Each session was 45 minutes long with a combination of
neuromuscular reeducation, therapeutic exercise, therapeutic activity, and manual therapy. The
sessions consisted of physical therapy interventions to address deficits in strength as well as
exercises to return to function. The therapy also included desensitization techniques to address
heightened sensitivity at and around the surgical scar.
Conclusions: The patient met all her long-term goals earlier than anticipated and showed gains
in strength, range of motion, postural alignment as well as reduction in pain and decreased
sensitivity at and around the surgical scar. Therefore, physical therapy and desensitization
therapy may be beneficial to support post-surgical venous thoracic outlet syndrome patients.
Recommendations for Clinical Practice: Physical therapy and desensitization therapy may
serve as adjunct treatments to surgical interventions for thoracic outlet syndrome to reduce
recurrence.
Key words: Thoracic outlet syndrome, rib, resection, surgery, desensitization therapy, case
report

Background and Purpose

Thoracic Outlet Syndrome (TOS) is defined as multitude of symptoms derived from compression
of the brachial plexus and the subclavian vasculature in the thoracic outlet primarily by the first
rib and anterior scalene muscles amongst other structures in this anatomical area.1 The incidence
of TOS is not completely known. According to the literature, neurogenic thoracic outlet
syndrome is the most common form, comprising of over 95% of cases, whereas venous thoracic
outlet syndrome makes up 2-3% of cases and arterial thoracic outlet syndrome 1% of cases.1
Research estimated that venous thoracic outlet syndrome affects 1 per 100,000 population.2
Difficulty in diagnosis suggests uncertain prevalence of TOS as a myriad of symptoms may lead
to many potential differential diagnoses.3
Individuals who present with symptoms of TOS have several options for treatment. The first
treatment option is a more conservative approach that includes physical therapy and other similar
modes of treatment. The second option is a surgical approach to remove structures or
decompress the area causing impingement, secondary impairment, and other symptoms.
According to the literature, individuals who present with neurogenic TOS in general begin with a
conservative intervention, yet this may be due to the fact that the majority of cases are
neurogenic which are more conducive to conservative treatment.4 However, if TOS is causing
severe edema in distal structures and diminishing the vascular supply to the upper extremity, it
may require the surgical approach to mitigate issues of potential tissue damage and further
complications.5 Rib resection is a surgical approach utilized to alleviate the TOS with positive
outcomes.6,7 In addition, decompression surgery has also been shown to be beneficial for patients
with chronic or acute TOS.8,9 However, if there are additional causes that contributed to the TOS

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that are not alleviated by surgery, physical therapy may act as an adjunct treatment to address
physical, functional and postural causes post-surgery so that patients may attenuate any further or
future complication and recurrence of TOS.
Research indicates that physical therapy is an important component of managing TOS by
instructing patients on modifying daily activities, minimizing repetitive motion that may be
exacerbating the condition as well as stretching and strengthening structures of the shoulder,
scapula, thoracic spine, and cervical spine.10-12 Literature has shown desensitization techniques
for the scar and surrounding tissue produce positive outcomes for patients post-surgery. 13,14
While there are numerous studies that look at treating TOS through conservative or surgical
methods, there are few studies that examine the contribution of physical therapy for a post-
operative TOS patient. In conjunction with TOS surgery, a patient may benefit from physical
therapy to address posture, body mechanics, exercise implementation, as well as home and
environment modifications to mitigate any future recurrences of TOS. For patients with
increased scar tissue sensitivity, desensitization techniques may offer further benefits. Therefore,
the purpose of this retrospective and prospective case report is to describe the outcomes of
physical therapy and desensitization therapy for a patient post-surgical resection of the first rib
for venous TOS.
This case report was completed under the direction of the Department of Physical Therapy with
oversight of the College of Graduate Studies at Central Michigan University.

Case Description
Patient History and Review of Systems
The patient was a 37-year-old female who presented to physical therapy 1-month post-surgical
resection of her right first rib. According to the medical chart review, she presented to the
emergency department 1 month earlier with the insidious onset of the compression of the right
subclavian vein in the thoracic outlet between the right clavicle and right first rib. The arterial
doppler found diminished arterial flow and subsequent edema in the right upper extremity. The
onset of the pain and myalgias was gradual with moderate pain that had occurred 2 days prior to
the emergency department visit. The patient displayed induration and bruising over the upper
arm with no associated numbness or tingling. The diagnostic x-ray was positive for thoracic
outlet syndrome. The patient had no previous history of thoracic outlet before this occurrence.
The patient did not have a history of cancer, swollen lymph nodes, or clotting disorders. The
patient had no documented recent surgeries, hospitalizations, or other procedures prior to the first
rib resection surgery for TOS. In addition, the patient did not report a recent history of an
overuse or exertion type injury.
Surgical notes for the patient were unavailable. Typically, the 3 different surgical approaches for
first rib resection include transaxillary, supraclavicular, and infraclavicular. The type of TOS as
well as the surgeon’s preference will determine the most appropriate approach.15 The patient’s

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scar indicated the infraclavicular approach which limits potential contact with the brachial plexus
as in other TOS surgeries and accesses the first rib and subclavian vein through the
costoclavicular region.16,17

Clinical Impression #1
The patient presented to physical therapy with loss of strength, range of motion, and postural
deficits as well as pronounced scar tissue and skin sensitivity at and around the surgical site. The
patient’s goals are detailed in Table 1 and included improving range or motion and strength of
the right upper extremity to match the left, establishing a home exercise program that would
support her rehabilitation as well as improvement in performance of functional tasks and
mobility without any increase in pain or difficulty of the tasks. Based on the patient’s physical
therapy goals the patient was an appropriate candidate for physical therapy to support her
rehabilitation for post-surgical resection of her right first rib to relieve symptoms of venous TOS.
Examination
Patient examination revealed increased forward head position, rounded shoulders and the right
shoulder presented slightly elevated. The forward head position was measured with a ruler in
millimeters with the patient’s heels and buttocks to the wall. The measurement was taken from
the patient’s right tragus to the wall on both the right and left sides. The patient’s right shoulder
was compared with her left shoulder in standing with the patient in her normal standing posture.
Research suggests that cervical, thoracic and shoulder positioning may predispose an individual
to TOS and targeted exercise may be advantageous to reduce TOS.11
Many of the strength standardized measures and special tests were deferred due to the post-
surgery protocol and the lifting restrictions of the surgeon at the time of the initial evaluation.
The patient’s gross upper extremity range of motion was within functional limits. During the
evaluation, the patient’s self-report of her pain was 5/10 on a 0 to 10 scale with 0 being no pain
at all and 10 being the most unbearable pain imaginable. The patient stated that the pain was in
the region of the surgical incision. At the time of the evaluation, the incisional scar appeared to
be closed with minimal increased erythema. The patient was sensitive to light touch and
myofascial release at and around the surgical scar.
The patient reported being right hand dominant and the surgery and subsequent surgical
protocols were limiting her ability to write for long periods of time.
The written form of the QuickDASH for Disabilities of the Arm, Shoulder, and Hand
Questionnaire Score was used to establish a baseline at the evaluation. The QuickDASH is a
functional outcome measure that uses 11 items with a 5-point Likert scale to measure a person’s
self-reported ability to complete functional tasks as well as the level of disability that may be
present.18 The greater the number on the test the higher degree of disability is present with 0
being no disability and 100 being the greatest level of disability. This test was administered
because of its high reliability and validity. According to Gummesson et al., QuickDASH has

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excellent test-retest reliability (ICC=0.93) and construct validity.18,19 The patient’s initial score
was over 50 on the QuickDASH (exact score unavailable).

Clinical Impression #2
The patient responded well to the initial therapy sessions. However, she was not compliant with
her home exercise program and complained of persistent fatigue and weakness during therapy.
During week 4 of therapy, the patient integrated therapeutic activities and exercises that were
part of her home exercise program and demonstrated gains in pain reduction, reduced fatigue,
and improved strength. Yet, the patient continued to struggle with simple daily tasks and had not
returned to full participation in work and home activities after the surgeon’s surgical protocols
were lifted. Therefore, at 4 weeks, the patient continued to be an appropriate candidate for
physical therapy to address limitations in functional and daily activities. In addition, the patient’s
home exercise program needed to be updated and adjusted to foster more compliance and
implementation.20At 4 weeks, the patient reported the desensitization techniques were tolerated
better in clinic and at home than the physical therapy exercises. However, she was still reporting
heightened sensitivity at and around the surgical scar to light touch and myofascial techniques.
Therefore, therapy continued to be appropriate to address scar tissue and surrounding tissue
sensitivity.

Intervention
The physical therapy interventions were structured to address the patient’s goals of equal
strength in both upper extremities, the development of a supportive home exercise program as
well as desensitization for the scar and surrounding tissue as well as an improvement in the
QuickDASH score.18 The patient was seen twice a week, for 45-minute sessions, for 6 weeks for
a total 12 sessions. The interventions included neuromuscular reeducation, therapeutic exercise,
therapeutic activities, and manual therapy. The initial sessions emphasized therapeutic exercise
while staying within the surgical protocol and the surgeon’s lifting restrictions.
The patient began each session with a total of 4 minutes on the upper body ergometer with 2
minutes in each direction (forward and backward). In the beginning of therapy, the patient began
at a level 1.5 and progressed over the course of therapy to a level 2.0. In addition, in the
beginning of therapy, the desensitization and manual therapy addressed the scar tissue and
surrounding tissue sensitivity. Over time, various textures of cloths were introduced to the scar
and surrounding tissue. The first therapeutic exercise interventions that were introduced at
evaluation to the patient to mitigate pain and to gently warm up the tissue were Codman’s
pendulums in all planes. In addition, the patient was instructed on postural alignment with the
use of a lumbar support pillow and pillows in the lap to elevate electronic devices to lessen
forward head position and flexion in the torso. These exercises were given as part of the patient’s
home exercise program to enhance the benefits of physical therapy sessions. These therapeutic
exercises were given as the research supports the benefits of Codman’s pendulums for shoulder

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rehabilitation and TOS rehabilitation to modulate pain.21 The patient was instructed to use the
pendulums throughout the day to encourage movement in the shoulder joint. Lastly, the patient
was given scapular retraction exercises to do for 10 repetitions with a 3-5 second hold while
seated with proper postural alignment. In the subsequent weeks, the patient was given more
progression of therapeutic exercises. Due to a 1-lb weightlifting limitation, the lightest resistance
bands were used. The patient used the unweighted pulleys in a seated position. As therapy
progressed, the patient was given a sequence of cervical, scapular and shoulder strength
exercises supine over the half foam roller to warm up and strengthen the muscles around the
shoulder. The sequence began with chin tucks and scapular retraction exercises followed by a
pectoralis stretch. These exercises were added to increase tissue extensibility to counter the
forward head and rounded shoulders. This was followed by scapular depression and shoulder
flexion exercises. The series of exercises was given to the patient as part of her home exercise
program.
During the initial session, the patient began with 6 repetitions with 3-5 second holds. Over the
course of therapy, the patient progressed to more repetitions, resistance, and exercises. In
addition, after the surgeon’s weight restrictions were lifted, the patient was able to slowly add
weight to therapeutic exercises and activities. During weeks 3 and 4 of therapy the patient was
given a series of resistance band exercises to increase strength. These activities included pull
downs, high rows, low rows, as well as external and internal rotation exercises. The patient
began with the level 1(yellow) resistance band and over the course of the next therapy sessions
increased to the level 2 (orange) resistance band. After the surgeon’s lifting restrictions were
removed, the physical therapy sessions gradually increased resistance in the exercises from level
1 to level 3 resistance bands. The patient displayed fatigue and weakness initially with the
increased resistance and repetitions, but by the 10th session she demonstrated increased stamina
and less fatigue. During week 4 more therapeutic activities were integrated into therapy sessions.
The West frame was used to mimic shelves in the patient’s home. The patient practiced reaching
and lowering objects of assorted shapes and sizes off the varying heights of the shelves. The
heights were adjusted each therapy visit to offer the patient more challenge. In addition, the
finger ladder was used to increase the endurance of the patient’s right arm. After the early weeks,
manual therapy was used on days when the patient displayed fatigue, pain, and increased
stiffness. As therapy progressed more therapeutic and functional activities were included to
challenge the patient. A ball toss to replicate the patient’s activity of playing ball with her young
son was employed toward the end of therapy.

Outcomes
After 6 weeks of physical therapy, the patient displayed signs of improvement in observed
postural alignment as well as self-reported reduction in pain and tolerance to light touch and
myofascial release techniques at and around the surgical scar. In addition, the patient
demonstrated improved gains in range of motion and strength with the right upper extremity
matching the left upper extremity. Furthermore, the patient showed an improved score of less
than 20 on the QuickDASH functional outcome measure. There were multiple therapeutic

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approaches that potentially contributed to the patient’s improvement. Due to improvements as
well as meeting the physical therapy goals, the patient was discharged from physical therapy
sooner than anticipated. The patient was equipped with a thorough home exercise program to
potentially mitigate further exacerbation of symptoms and recurrence of TOS in the future.

Discussion
The patient improved self-reported pain measures, increased ability to participate in functional
activities, household chores and work, as well as improved sleep upon completion of physical
therapy. Patient results were ahead of anticipated schedule, which was based on prior research
for individuals with neurogenic TOS who pursue physical therapy or other conservative therapy
options. It is possible that combining surgical intervention for venous TOS with physical therapy
and desensitization therapy may offer quicker recovery in addition to decreased occurrence of
TOS. As this case study only presents single patient results, future research may explore these
findings systematically.
The emphasis on postural re-education as well as strengthening of the cervical, shoulder girdle
and scapular muscles and structures may have contributed to the patient’s progress throughout
therapy. The incorporation of desensitization and manual therapy techniques jointly to decrease
tissue and scar sensitivity may have contributed to improvements regarding sensitivity.
Furthermore, employing therapeutic activities that emulated the patient’s home and work
activities within the therapy sessions may have also contributed to the progress in therapy.
In future clinical practice, in cases where TOS surgery has been performed, a combination of
physical therapy and surgery may yield greater outcomes than each intervention independently.
The findings for this specific case provide an opportunity for future research. The patient
reported moderate improvement in sensitivity of tissue at and around the surgical scar. Given the
somewhat limited research on scar sensitivity and desensitization techniques, this also represents
an area of potential future research.

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Table 1: Patient long-term physical therapy goals:
Goal Number Long-term physical therapy goals
1. The patient will be provided with a home exercise program for stretching,
strengthening, decreasing pain, increasing functional mobility and strength
and for the patient to self-manage and prevent exacerbation of symptoms.

2. The patient will have an improved range of motion of the right shoulder equal
to that of the left shoulder or better. Strength will be a 4 out of 5 or better
throughout for improved ability to perform functional tasks and mobility to
return to work tasks, obtaining a comfortable sleeping position, and
performing household chores.

3. The patient will have a QuickDASH (written copy) assessment of no greater

than 20 for an improved ability to perform functional tasks and mobility
without increased pain or difficulty.

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