Physical Therapy in the Management of Patients with Neurogenic Thoracic Outlet Syndrome: In Reply to Gambhir and colleagues.

We must congratulate the John Hopkins team for their excellent outcomes after transaxillary surgical decompression of thoracic outlet syndrome (TOS). We note that surgery was offered to patients with neurogenic TOS (NTOS) after failure to respond to 8 weeks of physical therapy (PT). Can you tell us what PT protocol was followed for these 8 weeks? In our own practice, we normally ask patients to commit to 3 to 6 months of PT before proceeding to surgical decompression, and our preferred approach is supraclavicular. One of the most neglected areas of TOS management is the role of PT, and we would be grateful if you could share your PT protocol. A set of 6 exercises described by Peet and colleagues are now no longer popular, and most TOS surgeons leave it to the physiotherapists to decide what they think is the best. In our practice, we give patients a typed list of exercises to do beginning preoperatively and continuing for 6 weeks postoperatively. In their recent publication, the Stanford group has actually been offering surgery to patients who respond to PT, which seems counterintuitive. But the logic is understandable because compliance with PT is always an issue. Regarding your investigation protocol, do you routinely do nerve conduction studies and MRI scans of brachial plexus for your NTOS patients?