Treatment

As has been stated, fully thirty methods of treatment, many of them surgical, have been recommended. When the diagnosis has been made and the anatomy of the condition is understood, treatment should follow rational lines. The long thoracic nerve will recover spontaneously in the great majority of cases in from three to six months. Therefore, during this period, therapy should be directed toward guarding the serratus anterior and its protagonists from overstretching, and toward strengthening these muscles as rapidly as possible. Similarly the contracted and often painful antagonist muscles should be stretched to prevent scapular fixation in the abnormal position.

The use of a shoulder spica, as advocated by Berkheiser and Shapiro, or the elevation and derotation brace method, as described by Horwitz and Tocantins, are sound procedures but rather severe, as they incapacitate the patient for a number of months. The scapular cup devised by Wolf and used by us in several cases seemed theoretically to be the best ambulatory treatment, as it allowed freedom of both arms. However, we found this brace quite difficult to fit satisfactorily and many patients would not tolerate it. After a number of alterations, a brace has been evolved (Figs. 2B, 2C, 2D, and 3) which is light, comfortable, and gives better

Figure 3. The brace itself weighs little over a pound. It is made of tempered, slightly springy brace steel, three-sixteenths of an inch thick and five-eighths of an inch wide. The padded steel cup and the disks are covered by leather. The cup is fitted to the individual scapula, with the patient's arm lying in full passive abduction.

Figure 3. The brace itself weighs little over a pound. It is made of tempered, slightly springy brace steel, three-sixteenths of an inch thick and five-eighths of an inch wide. The padded steel cup and the disks are covered by leather. The cup is fitted to the individual scapula, with the patient's arm lying in full passive abduction.

scapular support than any we have previously used. Its main virtue is that the patients like it and will wear it constantly. With it they can lead a normal life, provided that heavy use of the affected arm is not required, yet they seem to get as good support as from a shoulder spica and the results are as good. Its use is also recommended in other conditions, such as poliomyelitis, in which serratus anterior weakness is a major factor.

Before this brace was perfected we used a reinforced canvas shoulder brace (Fig. 4) in some of the cases with milder involvement; we still recommend its use for the later stages of the condition when tests of the serratus show only slight weakness. This canvas brace partially limits the winging and rotation of the scapula, but obviously cannot prevent the adduction in cases in which the serratus anterior has been severely weakened.

The indications for operation seem meager in a condition in which there is such a relatively good prognosis on a conservative regimen. Some of the cases reported in the literature in which operation was performed seem to have been inadequately or impatiently treated. The fact that several of our patients were seen a year after the onset of symptoms indicates that failure to provide protection will frequently prevent recovery, while institution of protection will promote recovery even at a late date. Many of the good results attributed to operations, such as fascial fixation or muscle transplantations, have been due, it is believed, to the mere reinforcing of a

Figure 4: Photograph of the canvas shoulder brace. Heavy steel stays on each side of the back and tight straps across the chest hold the scapula to the chest wall. The buckle on top of the shoulder can be tightened and tends to derotate the scapula. Adduction of the scapula is not prevented.

muscle the function of which was already returning. On the other hand, operations seem indicated when there is proved irreparable damage to the long thoracic nerve, when a thorough and adequate conservative course of treatment has failed, or sometimes when the serratus anterior palsy is part of another disease, such as poliomyelitis.

Enthusiasm for conservative treatment is not to be understood as a condoning of inadequate treatment. Admittedly the course of therapy is long and arduous and requires specialized care. Although only one muscle is originally and primarily involved, there is produced a definite effect upon its antagonists and protagonists. Antagonists, such as the rhomboids, relieved of the duty of balancing the normal serratus pull, become contracted and excessively strong. The trapezius, especially its lower and middle thirds, although a competitor as an adductor, is an assistant in the complex rotatory control of the scapula (Fig. 1) and tends to become stretched and weakened. However, it is possible to strengthen the trapezius sufficiently to resist this stretch (Fig. 5) and even to compensate partly for a weak ser-ratus anterior in obtaining full abduction. This strengthening of the lower fibers of the trapezius is one of the major aims in therapy and does much to minimize the continuous elongation of the serratus anterior which so delays its recovery. Patients are cautioned to forego any strenuous activity which abuses the weakened structures. Careful stretching of contracted and often painful antagonist muscles, such as the rhomboids and the pectoralis minor, completes the plan of treatment.

The outline of treatment here presented is a combination of physical therapy and brace protection, which has proved satisfactory in our more recent cases.

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Dealing With Back Pain

Dealing With Back Pain

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