DIAGNOSIS ARTERIAL COMPRESSION

test. However, an investigation to determine the false positive rates of vascular thoracic outlet syndrome (vTOS) diagnostic arm manoeuvres reported pulse alteration to be an unreliable measure (9). The reported lack of reliability for such tests highlights the importance for clinicians to use reproduction of the patient’s symptoms, in addition to pulse and blood pressure measurements and advanced imaging technology, to confirm a positive test. However, the use of advanced imaging technology in diagnosis is not without error. Diagnostic tests for vascular compression have been shown to reproduce vascular occlusion not only in symptomatic patients but also in asymptomatic individuals. Previous research by our team revealed that approximately 20% of healthy asymptomatic facipsustie v individuals demonstrate clinically significant (more than 50% diameter reduction and/or a doubling of PSV) compression sum euis nulla at, corerciduis aliqui esto del il ullam ipit praessed eumsandre vel dolessequi lluptatum vel dunt amcon ero odolorperate exerit nos endreraestis dionsed dionsed

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conulla ad molendrem zz iuscilis nm erosto er of the third portion of the axillary artery with the arm positioned at 120 degrees abduction, 30 degrees horizontal etxt uension and 90 degrees external rotation (10). This was in keeping with the findings of Mochizuki et al., who investigated modolor peraessit inisi te commolo reetum qui the false-positive rate of the hyperabduction diagnostic manoeuvre with magnetic resonance (MR) angiograms for occlusion of the posterior humeral circumflex artery (a venisi. branch of the axillary artery) and found occlusion in 80% (eight shoulders) of healthy asymptomatic controls (5). SUBHEADING 1 ONE HERE

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n the throwing positi Hon (EREextreme abduct Pute dolut am vion and external I rotation) in baseball pitchers, athletes and non-athletes (11). Out of 92 shoulders tested, 83% showed a reduced internal diamet HEAer of the axillary artery on duplex ultratsound, 56% showed a drop in blood pressure of 20mmHg or greater when placed in the throwing position, and in 13% blood pressure was undetectable. These results indicate that normal asymptomatic subjects react to the test in such a manner that could clinically be defined falsely as positive. It is uncertain whether this induced intermittent compression is a true false positive and should be considered as an incidental and innocuous finding or whether it is has pathological significance that could predispose the individual to arterial Rud te con veniam enismodignim doloboreet Another dilemma for diagnosis concerns patient positioning. It is unclear whether the patient should be positOioned in a seated or supine postbore consectem quat. Suscidunture during performance of these manoeuvres. Textbook descriptions and illustrations dignim in volore commodo lendre mincilit nim quisciliquam velisit ulla con velismo dolore volumsan hendiate core volutpatisim del doluptate tatetuer sit utatet aliqua tum acipsum do dolutem zzriliq uipisi te feugiamet adit lum iure con vent ea faci euguerc ilismodit a adignit lute tin hent ut wis do consequat, consecte del utat. Ut augait nulla con utpat. Tat. Ro consecte dolesequip el iusto er se et aliquam commodionum zzriusc illuptatue

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ulluptatet lor in eros nonulpu tpatetum exeros of the various diagnostic arm manoeuvres for arterial compression syndromes have depicted the subject in a seated position, with the therapist detecting changes in pulse pressure or blood pressure. However, the positioning of patients in studies using ultrasound or MR angiography to investigate blood-flow characteristics in patients with l thoracic o

let syndrome are inconsistent, utilising either

the supine position or the seated position. The problem with positioning the patient in the seated position is that, as the t arm is elevated above the level of the heart, due to changes commy nisi. in orthostatic pressure, pulse pressure and blood pressure diminish slightly, even if no arterial compression exists. However, the seated/upright posture is a more functional position and therefore more likely to reproduce the subject’s symptoms. To detect clinically significant arterial narrowing, a difference of more than 15mmHg in brachial blood pressure between arm positions is classified as clinically

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www.sportEX.net

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References 1. Department of Health. At least 5 a week: Evidence on the impact of physical activity and its relationship to health. A report from the Chief Medical Officer. Department of Health 2004

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and haemodynamically significant (8,12); however, this figure does not take into account changes in orthostatic pressure. To date, no published studies have investigated the effect of changing posture on upper-limb blood-flow characteristics, such as pulse pressure, blood pressure or PSV, during diagnostic arm manoeuvres. It would be beneficial for clinicians to know the most appropriate subject positioning for sensitivity and specificity of the test manoeuvre, or at least to have available a diagnostic criteria for blood-pressure changes that take into account the effects of orthostatic pressure. Finally, the criteria used to detect clinically significant arterial compression with ultrasound are based on the vascular demands of activity levels in the average individual. It should be noted that athletes demand much more than their sedentary counterparts from the vascular system; therefore, smaller limitations to blood flow become more significant during high-intensity activity, presenting as symptom production or deterioration of performance (8). Schep et al. suggested that a 10–30% reduction in the vessel diameter may prove to have significant implications on an elite athlete’s performance (13). However, smaller limitations to blood flow may not be detected at rest. As with the detection of external iliac artery endofibrosis in the lower limb (14), the addition of exercises (eg. handgrip or elbow flexion exercises) may be required to increase blood flow and, therefore, to increase the blood pressure drop should an arterial lesion exist (15). Roos and Owens suggested the addition of handgrip exercises to the abducted, externally rotated arm position (16); however, as yet, there is no standard protocol for blood pressure or ultrasound that incorporates exercise, standardises the workload of the upper limb muscles, or provides a criterion for diagnosis. It should be highlighted that this article covers only one aspect of upper-limb vascular assessment. The outcome of diagnostic arm manoeuvres with or without advanced imaging equipment must be interpreted with the subjective history and other physical findings in order to exclude differential diagnoses and to determine whether a positive result should be considered clinically significant. In summary, arterial compression syndromes affecting

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2. Stratton G, Ridgers ND, Gobbii R et al. Physical Activity Exercise, Sport and Health: Regional Mapping for the North-West 2005 www.nwph.net/pad/accessed 13/3/07) 3. Ridgers ND and Stratton G. Physical activity during school recess - The Liverpool Sporting Playgrounds Project. Pediatric Exercise Science 2005; 17:281-290

THE AUTHORS

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References 1. Fechter JD, Kuschner SH. The thoracic outlet syndrome. Orthopedics 1993;16:1243–1251 2. Wright I. The neurovascular syndrome produced by hyperabduction of the arm. American Heart Journal 1945;29:1–19 3. Roos DB. New concepts of thoracic outlet syndrome that explain etiology, symptoms, diagnosis, and treatment. Vascular Surgery 1979;13:313–32

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the subclavian artery, axillary artery and posterior humeral circumflex artery have been identified in young, fit and healthy athletes. In order to aid localisation of the specific anatomical site of arterial compression, suggestions were made to separate the component parts of common diagnostic arm manoeuvres. However, diagnosis has proved difficult, with clinically significant levels of arterial compression recorded for both healthy, asymptomatic individuals and patients with proven vascular injury, inconsistent patient positioning affecting arterial pressures, and reports of unreliable clinical measures. Many questions remain unanswered, and thus more research into these areas would develop our understanding and enhance our clinical practice.