Understanding the 'Thoracic Outlet Syndrome' as per Ayurveda and its Ayurveda management. An effort by Department of Kayachikitsa, Government Akhandanand Ayurveda College, Bhadra, Ahmedabad, Gujarat, India.

1. A
Presentation
on
Thoracic Outlet Syndrome
Ayurveda approach
1
Presented by:
Dr. Miss Kailas S. Dabhi
M.D. IInd Year Scholar
Under the Guidance :
Dr. Surendra A. Soni
M.D., Ph.D (Kayachikitsa)
Prof. & Head
Upgraded P. G. Dept. of Kayachikitsa
Govt. Akhandanand Ayu. College, Ahmedabad, Gujarat, India.

2. Thoracic Outlet Syndrome
2
 INTRODUCTION:
 The term thoracic outlet syndrome was originally coined in
1956 by RM peet.
 TOS is group of disorders that occur when vessels or nerves in
the space between collarbone and 1st rib (thoracic outlet) are
compressed.
 This can cause pain in shoulders and neck and numbness in
fingers.

3. 3
 Definition:
 The simple definition of thoracic outlet syndrome is
neurovascular symptoms in the upper extremities due to
pressure on the nerves and vessels in the thoracic outlet area.
 The specific Structures compressed are usually the nerves of the
brachial plexus and occasionally the subclavian artery or
subclavian vein.
 Prevalence:
3 to 80 cases/1000

4. EPIDEMIOLOGY
 Incidence 1-2 %
 Age – usually seen 20-50 yrs of age
 Sex – Female : Male – 3 : 1
 No Racial Predilection
Neurogenic TOS >95%
Venous TOS > 4%
Arterial TOS – 1 %
4

5. Thoracic Outlet Space:
 Thoracic outlet
space between
collarbone
(clavicle) and 1st
rib.
 These narrow
passage way is
crowded with
nerves, blood
vessels and
muscle.
5

6. ANATOMY
 Interscalene Triangle ( Most Commonly Involved )
 Inferiorly : 1st rib
 Ant : Scaleneus anterior
 Post : Scaleneus medius.
 Costoclavicular Space
 Ant : Clavicle, subclavius muscle
 Post Medial : 1st rib
 Post Lateral : Superior border of scapula
 Pectoralls Minor Space
 Anteriorly by Pectoralis minor and posteriorly by chest wall
6

7. 7

8. CONTENTS
8

9. 9

10. Causes :
 1. Anatomical defects :
 Inherited defects that are present at birth (congenital) may include
an extra rib located above the first rib (cervical rib) or an
abnormally tight fibrous band connecting your spine to your rib.
2. Poor posture:
 Drooping your shoulders or holding your head in a forward
position can cause compression in the thoracic outlet area.
10

11. Causes cont…
3. Trauma:
 A traumatic event, such as a car accident, can cause internal
changes that then compress the nerves in the thoracic outlet.
 The onset of symptoms related to a traumatic accident often is
delayed.
11

12. Causes cont…
4. Repetitive activity:
 Doing the same thing repeatedly can, over time notice symptoms of
thoracic outlet syndrome if to repeat a movement continuously, such
as typing on a computer, working on an assembly line or lifting
things above head, stocking shelves etc. Athletes, such as baseball
pitchers and swimmers, also can develop thoracic outlet syndrome
from years of repetitive movements.
12

13. Causes cont…
5. Pressure on joints :
 Obesity: Obesity can put an undue amount of stress on joints,
as can carrying around an oversized bag or backpack.
 Pregnancy: Because joints loosen during pregnancy, signs of
thoracic outlet syndrome may first appear during pregnancy.
13

14. 14

15. Pathogenesis
 1. Neurogenic thoracic outlet syndrome:
 This condition is related to abnormalities of bony and soft
tissue in the lower neck region (which may include the
cervical rib area) that compress and irritate the nerves of the
brachial plexus, the complex of nerves that supply motor
(movement) and sensory (feeling) function to the shoulder,
arm and hand.
15

16. Neurogenic TOS
 Cervical outlet syndrome (Upper TOS) :
 When brachial plexus nerve roots are compressed in the scalene triangle, Upper
nerve roots ( C5 C6 C7 ) are most forcefully compressed.
True thoracic outlet syndrome (Lower TOS) :
 When the compression of brachial plexus in the costoclavicular space,
usually lower roots ( C8 -T1 ) of the brachial nerve plexus are
compressed.
16

17. Symptoms of Neurogenic TOS:
 Weakness or numbness of the hand.
 Decreased size of hand muscles, which usually occurs on one side
of the body.
 Tingling sensation
 Prickling pain
 Numbness and weakness in the neck, chest, and arms.
 Weakening of grip.
17

18. Pathogenesis cont…
 2. Venous thoracic outlet syndrome:
 This condition is caused by damage to the major veins in the lower neck
and upper chest. The condition develops suddenly, often after unusual and
tiring exercise of the arms.
 Symptoms of venous TOS :
 Swelling of the hands, fingers and arms,
 As well as heaviness and weakness of the neck and arms.
 The veins in the anterior (front) chest wall also may appear dilated
(swollen).
18

19. Pathogenesis cont…
 3. Arterial thoracic outlet syndrome :
 The least common, but most serious, type of TOS is caused by
congenital (present at birth) bony abnormalities in the lower neck
and upper chest.
 Symptoms of arterial TOS -
 Cold sensitivity in the hands and fingers.
 Numbness, pain or sores of the fingers.
 Poor blood circulation to the arms, hands and fingers.
19

20. Investigation :
 X-ray:
 Chest X-ray, Cervical Spine X-ray
 X-ray for the affected area, which may reveal an extra rib (cervical rib).
 Ultrasound:
 For vascular thoracic outlet syndrome or other vascular problems.
Tomography (CT) Scan:
 ACT scan may identify the location and cause of blood vessel
compression.
20

21. Investigation cont...
 Magnetic resonance imaging (MRI) :
 An MRI may reveal congenital anomalies, such as a fibrous band
connecting spine to rib or a cervical rib.
 Angiogram:
 An X-ray of blood vessels to identify blockage.
21

22. 22

23. Diagnosis Test:
Roos test/Elevated arms stress test
Wright’s hyper abduction test
Costoclavicular maneuver
23

24. Root Test / Elevated Arms Stress Test (EAST) :
 Patient seated with arms above 90 degrees of abduction and full
external rotation with head in neutral position. Patient opens and
closes hands into fists while holding the elevated position for 3
minutes .
 Positive test : Pain and/or paresthesia and discontinuation with
dropping of the arms for relief of pain.
 Sensitivity : 52-84 %
 Specificity : 30-100
24

25. Roos Test / Elevated arms Stress Test
25
False +ve in,
Carpal tunnel syndrome,
Ulnar neuropathy,
Fibromyalgia.

26. Wright’s Hyperabduction test :
 Arm hyperabducted to 180° -
diminishing radial pulse.
 Neurovascular structures
compressed in subcoracoid region
by pectoralis minor tendon, head
of humerus or coracoid process
 Sens. -70 -90
 Spec. -29 -53
26

27. Costoclavicular Maneuver :
 Patient sits straight with arms at the side. Radial pulse is
assessed . Patient retracts and depresses shoulders while
protruding the chest. Position is held for up 1 minute.
Positive test : Change in radial pulse and /or painand
paresthesia.
Sens : NT
Specs : 53 - 100
27

28. Treatment :
Physical measures:
 Stretching, occupational and physical therapy are common non-
invasive approaches used in the treatment of TOS.
Medication:
 Clot-dissolving medications:-If have blood clots in venous or arterial
thoracic outlet syndrome, administer clot-dissolving medications
(thrombolytic) into veins or arteries to dissolve blood clots.
28

29. Non Operative Treatment :
Posture improving exercises.
Breathing exercises.
Avoid aggravating activities.
Avoid repetitive upper extremity mechanical work and
muscular trauma.
Analgesics ,muscle relaxants,antidepressants.
Physiotherapy.
29

30. Surgery:
 Surgical approaches have also been used successfully in TOS.
 Microsurgery can be used approaching the area from above the collar
bone followed by neurosis of the brachial plexus, removal of the
scalene muscle (scalenectomy), and the release of the underlying
(subclavicular) blood vessels. This approach avoid the use of resection
and has been found to be effective treatment.
 In case of extra rib is compressing a vein, artery or the nerve bundle,
part of the extra rib and any compressive fibrous tissue, removed in
the first rib resection surgical procedure.
30

31. Ayurvedic Concept:
 TOS is not exactly correlate with any Ayurvedic description but it
can be correlated with following ayurvedic topics:
1. Amsaphalaka Marma Vedhana
2. Amsa Marma Vedhana
3. Vishvachi
4. Snayugata Vata
5. Siragranthi
31

32. 1. Description of Amsaphalak Marma:
 पृष्ठ उपरि पृष्ठवंशम् उभयतः त्रिक संबद्धे अंसफलके नाम,ति बाह्वःस्वापवापशव । (सु.शा.६).
Location :
 Amsaphalaka Marmas are located one on either side of the upper part of the
Prushta Vamsha (Spine, Backbone). They are located in the region of Trika
(scapula). Trika is a place where 3 bones meet i.e. Scapula (triangular, wing
shaped bone at the back of shoulder), Humorous (arm bone) and Clavicle (collor
bone).
32

33.  i) According to Sthana: Amsaphalaka Marma is Prushta Gata
Marma (Prushta - Back).
 ii) Asthi Marma – Amsaphalaka marma is predominantly made up
of Asthi i.e. bones, which form the structural component of this
Marma. The other elements namely Snayu (ligaments), Siraa
(blood vessels, veins), Sandhi (bony joints) and Mamsa (muscles)
are also present but in a lesser proportion.
 iii) Vaikalyakara Marma: (Vaikalya kara – deformity forming)
Amsaphalaka Marmas when injured produce deformity of the body
or part of the body where in the marma is damaged.
33

34. 34

35. Effect of Injury Amshaphalaka Marma:
 ति बाह्वः स्वापवाप शव ।
(सु.शा.६)
 Bahu Swaapa: Numbness or loss of sensation in the upper limbs.
 Bahu Shosha: Emaciation or thinning of the upper limbs.
35

36. 2. Amsa Marma:
 बाहु मूर्ध ग्रीवा मध्ये अंसपीठ स्कन्र् निबन्र्ौ अंसौ िाम, तत्र स्तब्र्
बाहुता।(सु.शा.६/२७)
Location:
 Ansa Marma are located one on either side of the upper part of the Prustha Vamsha
(Spine,Backbone). They are located at center of Bahu Murdha and Greeva.
 i) According to Sthana: Prushta Gata Marma (Prushta - Back) Amsa Marma is
located in the back, upper back region, shoulder and scapular region to be precise;
they are classifie under Prushta Gata Marmas.
36

37. ii) Snayu Marma –
 Amsa marma is predominantly made up of Snayu i.e. ligaments
and tendons, which form the structural component of this
Marma. Therefore it is classified under Snayu Marma. The other
elements namely Asthi (Bones), Siraa (blood vessels, veins),
Sandhi (bony joints) and Mamsa (muscles) are also present but
in a lesser proportion.
iii) Vaikalyakara Marma: (Vaikalya kara – deformity forming)
Amsaphalaka Marmas when injured produce deformity of the
body or part of the body where in the marma is damaged.
37

38. 38

39. Effect of Injury Amsa Marma:
 ति स्वापतब्ध बाहुता। (सु.शा.६/२७)
 बाहु त्रियाहि । (अ.शा.४/२६)
Injury of Amsa Marma leads to Stabdha Baahutaa
i.e. stiffness or rigidity of the shoulder or arm.
Injury of Amsa Marma causes deformity.
39

40. 4. Vishvachi
तलं प्रत्यङ्गुत्रलनां तु कण्डिा बाहुपृष्ठतः |
बह्व: कममक्षयकिी त्रवश्वाचीत्रत त्रह सा स्वापमृता |
( सु. त्रन. १/७५ )
 Chikitsa:
 Siravedha
 Vatavyadhi chikitsa: Abhyang, Svedan, Basti, Nasya etc.
40

41. 4. Snayugata Vata:
 Lakshana:
 Stambha, Kampa, Shoola, Akshapa.
(Su. Ni.1/27)
 Chikitsa:
 Sneha, Upanah, Agnikarma, Bandhan, Mardan.
(Su. Ni.5/8)
41

42. 5. Siragranthi:
42
Various type of Vyayam
Vata Prakopa
Siraptratan
Sira Sankochya
Sira Vishoshya Sira Granthi
 Chikitsa: Chikitsa of Siragranthi- Raktamokshan

43. 43
 Common Ayurvedic Treatment Of Neurological TOS:
• Common Vata Vyadhi Chikitsa used in neurogenic thoracic outlate
syndrome.
 SNEHAN:
 के वलं त्रनरुपस्वापतम्भमाद स्वापनेहैरुपाचिेत्||
वायुं सत्रपमवमसातैलमज्जपानैनमिं ततः|
स्वापनेहक्लान्तं समाश्वास्वापय पयवत्रभः स्वापनेहयेत् पुनः||
यू ैर्ग्ामम्याम्बुजानूपिसैवाम स्वापनेहसंयुतैः|
पायसैः कृशिैः साम्ललवणैिनुवासनैः||७७||
नावनैस्वापतपमणैश्चान्नैः (च. चच. २८/७५-७७ )

44. 44
 SVEDAN:
 सुत्रस्वापनग्धं स्वापवेदयेत्ततः|
स्वापवभ्यक्तं स्वापनेहसंयुक्तै नामडीप्रस्वापतिसङ्किैः||७८||
तथाऽन्यैत्रवमत्रवधैः स्वापवेदैयमथायवगमुपाचिेत्| स्वापनेहाक्तं [२]

45. 45
 MODE OF ACTION OF SVEDAN:
 स्वापतम्भग िवशीतघ्नं स्वापवेदनं स्वापवेदकािकम्||
( च. सू. १४/११ )
 त्रस्वापवन्नमङ्गं तु विं स्वापतब्धमथात्रप वा||
शनैनाममत्रयतुं शक्यं यथेष्टं शुष्कदारुवत्|
ह मतवदरुगायामशवथस्वापतम्भर्ग्हादयः||
त्रस्वापवन्नस्वापयाशु प्रशाम्यत्रन्त मादमवं चवपजायते|
( च.चच.२८/७८-८१ )

46. 46
 NASYAAND GHRUTPAN:
 बाहुशी मगते नस्वापयं पानं च त्तिभत्रक्तकम्||
(च. चच. २८/९८)
 PATHYA FOR VATA VYADHI:
 सत्रपमस्वापतैलवसामज्जसेकाभ्यञ्जनबस्वापतयः ||
त्रस्वापनग्धाः स्वापवेदा त्रनवातं च स्वापथानं प्राविणात्रन च|
िसाः पयांत्रस भवज्यात्रन स्वापवाद्वम्ललवणात्रन च||
बृंहणं यच्च तत् सवं प्रशस्वापतं वातिवत्रगणाम्|
(च. चच. २८/१०४-१०६)

47. 47
 Ayurvedic Treatment Of Venous And Arterial TOS:
• Venous TOS can be correlated with Grathita-Rakta Janya Shotha.
 Chikista:
 For Swelling due to truama-Raktamoksan
 For Raktasrava-Hima Ghruta Lepa and Seka (Parisheka)
 For Thrombus: Shonita-sanghatahar Chikitsa
Sroto shodhan Chikitsa
Kaphahar Chikitsa

48. 48
Case presentation
Thoracic outlet syndrome

49. 49
IPD Case detail
• Ward: Male-2
• Source of History: By patient
• Consult Doctor: Dr. Surendra A. Soni
• OPD No. 34780
• IPD No: 1471
• Case taken on: 25-11-2019
• Address: Odhav,Ahmedabad.

50. 50
Pradhana vedana (Chief complaints)
At the time of admission patient complains following…
Ubhaya Hasta pradeshe kampan
Ubhaya Skandha pradeshe Sphuran
Ankushan, prasaran, Bharvahne Kampan vruddhi
Shirahshoola evum Shirogaurav
Adhika Udgarpravruti
Atopa
Adhman

51. 51
Koutumbika vrittanta
All family member are said to be healthy.

52. 52
History of present illness:
According to patient he was doing diamond labour
work from 15 years. He was doing work in closed arm
position repeatedly over time and noticed symptoms
like numbness and tremor in both hand for last 5 years.
Symptoms gradually worsened. He had taken allopathy
medicine for 1 year but he didn’t get symptomatic
relief. After that he was admitted in Govt. Akhandanand
Ayurved College under RMO and started ayurvedic
treatment. After 5 week RMO referred patient to
kayachikitsa department.

53. 53
Personal History
 Diet: Vegitarian
 Appetite : Alpa
 Bowel: 1 time / day
 Micturation: Day- 3-4 times
Night – 1-2 times
 Sleep: Alpa
 Addiction: Not any additions

54. 54
Ashta Vidha Pariksha
 Naadi:70/min
 Mutra: Samyak
 Mala: Savibandha Malapravruti
 Jihwa: Sama
 Shabda: Samyak
 Sparsha: Anushna sheeta
 Dreek: Samyak
 Aakriti: Vyathita, dukhita

55. 55
Dashavidha Pariksha
1. Prakriti: Vata Pitta
2. Vikriti: Lakshya nimitta
3. Sara: Ras, Madhyama sara
4. Samhanana: Madhyam
5. Pramana: Madhyama
6. Sattva: Madhya
7. Saatmya: Madhyama
8. Ahara shakti: Madhyam
-Abhyavarana shakti: Madhyama
-Jarana shakti: Madhyama
9. Vyayama shakti: Pravar
10. Vaya: Madhyam

56. 56
General Examination
 Built: Moderate
 Nourishment: Moderate
 Facial symmetry: Normal
 Pallor: Present
 Cyanosis: Absent
 Oedema: Absent
 Icterus: Absent
 Nails: normal
 Lymphadenopathy: Absent
 B.P.: 110/70 mmHg
 R/R : 18 cycles/min
 Tongue: coated and cracked

57. 57
Nidana panchaka
Nidana-
Repeated activities: Diamond work
Aharaj : Vata vardhaka ahara and vihara
Abhighat: Fall down 2 yr ago

58. 58
 Purvaroopa -
 Ubhay Hasta Suptata evum Gauravta
 Roopa
 Ubhaya Hasta pradeshe kampan
 Ubhaya Skandha pradeshe Sphuran
 Ankushan, prasaran, Bharvahne
 Kampana vruddhi
 Shirahshoola evum Shirogaurav
 Adhika Udgarpravruti
 Atopa
 Adhman

59. 59
Samprapti Ghataka
1. Dosha: Vata pradhana & Kapha
2. Dushya : Rasa, Rakta, Majja
3. Vyaktisthana: Amsa, Urahpradesh
4. Strotasa : Rasa-Rakta-Majjavaha
5. Strotodusti Prakarara : Sanga, Sira granthi
6. Agni sthiti : Vishamagni
7. Vyadhi prakara: Chirakari
8. Sadhyasadhytva : Krichchhrasadhya
9. Sama-Niram: Sama
10. Udbhavsthan: Pakwashaya
11. Adhishthana- Amsha-pradesha

60. Diagnostic Criteria:
 Clinically Diagnosed
 Venous and Neurogenic TOS
- Engorged veins on both shoulder region and arms
- Tremor in both hands
- Numbness in both hands
- Wright’s test positive – Arm hyperabducted to 180
degree- diminishing radial pulse
60

61. Engorged veins:
61

62. Wright’s test-
62

63. 63
Date Chikitsa Observation
25-11-2019 1.With Goghrita before meal
Ajmodadi choorna 5 gm
Sarjika ksara 1gm
Trikatu 1gm
2 times
2.With warm water after meal2 times
Rajahpravartini vati 2 tab
Sudarshan Ghanvati 2 tab
2 times
3. Sihnaada guggulu 3 tab
Agnitundi vati 2 tab
Sanjivani vati 2 tab
2 times
4. Kshirpak 2 time
Ashwagandha churna 10 gm
Sunthi Churna 3 gm
2 times
• Ubhaya Hasta pradeshe
kampan
• Ubhaya Skandha pradeshe
Sphuran
• Ankushan, prasaran,
Bharvahne Kampana
vruddhi
• Shirahshoola evum
Shirogaurav
• Adhika Udgarpravruti
• Atopa
• Adhman
Treatment given

64. 64
25/11/2019 5. Dashamool Kwath 100 ml
Prakshep madhu 2 tsp
6. Haritaki churna 5 gm
HS with warm water
7. Nadi Svedan only
17/01/2020 Rep. 1 to 7
8. Ashvagandharishta 4 tsp
2 times
After meal
Treatment given

65. Images of original Case-record
Next Slide Number 66 to 79 show original case records.
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79. 79

80. After treatment:
80

81. Relief in Signs & Symptoms
 After clinically diagnosis treatment started and patient
gets marked relief :
 - engorged veins become normal on both shoulder
regions and arms.
- Decrease numbness in both hands.
- Decrease Tremor in both hands.
- Visible tremors disappear.
- Generalised improvement in health overall with
improvement in appetite, bowel, sleep and body
strength.
- Wright’s test negative – Arm hyperabducted to 180
degree- Appear normal radial pulse.
81

82. Discussions
 The present case was treated on the basis of
Vat-vyadhi esp Kaphanubandhi & Grathit-
rakta line of Treatment and Patient got
marked improvement. Visible tremors in
right hand get cure & there is mild tremor
on initiation of any act is only.
82

83. Conclusions
Thoracic outlet syndrome
(Vaso/neurogenic) can be
managed vary well if there is no
structural damage with basic
principles of management of
Ayurved esp Vat-vyadhi/Grathit
Rakta-chikitsa.
83

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