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The most important statement I can make is that symptoms that seem minimal in nature and include numbness, tingling, and aching pain following use of the arms need to be treated early and intensively. Of course, this is true for virtually any disorder, but I feel this is even more important here because of the consequent disability and suffering that occurs when, as happens all too often, these symptoms are ignored.

Given the difficulties many of my patients have encountered in obtaining appropriate treatment, it is important to remember not to follow any advice or perform any activities that result in increased symptoms, taking into account the frequent delay time. Damaging movements or postures can often take hours to a full day to result in increased symptoms and include activities such as driving, doing laundry, pulling weeds, opening difficult doors or jars, stirring pots, or using a keyboard or mouse even minimally. These and similar activities need to be avoided or compensated for. Initially, rest and avoidance of such activities bring about regression of symptoms relatively quickly; however, over time, symptoms appear more rapidly and recovery times lengthen. This is perpetuated by several factors, including personality type (mentioned under “Diagnosis”) and the need to continue to make money.

Individuals whose minimal symptoms (numbness, tingling, and aching pain) resolve with rest will continue to push past their not-so-obvious limitations due to previous commitments and a drive to progress in their careers, which leads to an increase in pain and sensitivity with eventual serious disability.

The first step is to obtain appropriate physical therapy with an individual who has significant expertise in this disorder. I usually recommend Dr. Peter Edgelow (510.732.7881), who has developed a technique that is effective. I encourage you to find someone with expertise in and knowledge of the techniques so ably described by David Butler in his “Mobilization of the Nervous System” and “The Sensitive Nervous System". If your physical therapist asks you to perform exercises that increase your symptoms consistently, find another one.

Pharmaceuticals, unfortunately, are of minimal-to-moderate help. When appropriate, diazepam (more so than its congeners) helps in reducing the irritability and attendant trapezial and scalene muscle spasm. Other muscle relaxants, such as Flexoril or Soma, can be of benefit as well. Opiates are usually of minimal benefit and have obvious problems in select individuals. Antiepileptics and vasoactive agents play an even lesser role but can often be effective, again in select individuals.

Nonsteroidal or steroidal anti-inflammatories are rarely helpful, and usually only when there is a bursal tenderness or muscular local inflammation. Nitroglycerin patches, in individuals who don't react with severe headaches, can be of benefit. Side effects from these drugs are not infrequent and include increased headaches, stomach pain, tiredness, etc.

My experience in prescribing hyperbaric oxygen therapy, although limited, has shown significant improvements in the ten or so individuals who have had access to it, although this requires a large number of treatments.

Heparin has been found to have a specific anti-inflammatory effect that can dramatically decrease this kind of severe nerve pain, and I use it frequently to quell unresponsive flare-ups and to generally decrease pain levels.
In many patients, infrared treatment (using an appropriate photon source) helps with hypersensitivity and pain when applied over the affected skin areas.

If the above combination of modalities proves to afford no relief, then surgical decompression becomes an important consideration.

As mentioned previously, in cases of severe blanching or swelling, this is a priority (if lasting and severe) and should prompt an immediate consultation with a vascular surgeon. For historical reasons, vascular surgeons also have the most experience in decompressing the brachial plexus. Because of the factors outlined above (in “Causes”), the best approach, generally, is a direct one above the clavicle, rather than through the axilla, for two reasons. The axillary approach usually involves resection of the 1st rib. The remaining stump, produces reactive oxygen species for a long time, often causing further scarring around the area of the nerve trunks. In addition, the field of view obtained by the surgeon makes it difficult, if not impossible, to perform a neurolysis or complete resection of the scalenes, which is much more easily performed with the supraclavicular approach. Results are highly variable and, in my experience, depend greatly on the expertise and number of cases performed by the surgeon. Generally, individuals with obvious anatomical defects, such as extra ribs or serious fibrotically induced deformations, do the best. Overall, when operated on by competent hands, approximately 50% of the patients report that the surgery was worthwhile.
However, one should bear in mind that resumption of deleterious activities will rapidly result in a recurrence of the original symptoms.

Regardless of the modalities used, the individual afflicted has to go through a significant characterological change and become much less of a type A personality and more of a tai chi practitioner, who practices all activities slowly, smoothly, and gradually. This change usually takes several years.

In summary, avoiding reinjury is imperative; finding appropriate physical therapy and treatment modalities is often difficult but obviously necessary for improvement; and surgery should be considered a problematic last resort with the exceptions noted above.