So now, with the first rib, the cervical thoracic area that I'm talking about with the thoracic inlet, try to look at the assessment, and there's two areas of the assessment to look at. First, I'd like to go through some general ideas to think about. When you're approaching any patient, first of all, you need to make sure that you're probably, that there's no other major problems. So in history, you would have picked up all kinds of red flags, questions around radiculopathy, infection, fracture, and tumor. One of the reasons you make sure, especially novices are working with this, to make sure they don't do any harm. So anyone has the use of manipulation, you're considering that, you want to make sure you're not dealing with something that's more significant, and so asking questions around that are very important. So always think of RIFT. It also has your differential diagnosis. I think especially novice learners get kind of, it's kind of challenging, because they're like, wow, you know, there's so many things to think about, and say, look, ask questions around this, RIFT. If you do that, you've taken all the major problems there can be, you're pretty much going to narrow it to what's kind of a biomechanical, you know, functional, mechanical, structural problem, primarily. Now you say, well, it may not hit connective tissue disease, and a few zebras, but yeah, but the vast majority of things, radiculopathy, infection, fracture, and tumor, that RIFT will get it. The other thing that's a major important thing, and we try to instill in people early on, is looking at the idea of you assess, you treat, and you reassess. And that's very important. So as we're going to go through any assessment, is that we have to make sure whenever we assess someone, we find something else. You know, one thing about here, using manipulation, you're going to get an immediate response, and you can reassess it immediately, see where is that improvement going through it. When you're thinking of looking for somatic dysfunction, it comes down to TART. So look at that, you know, tenderness, you know, where does it hurt? The self. The asymmetry, or is there a change in the structure on one side? The range of motion, restriction of motion, less motion, and tissue texture changes, where tissues feel tight. So again, when you put it in these kind of terms, when you're teaching, you're giving a safety net for the person you're teaching. You're saying, okay, is it safe to do this? Because a lot of them are very nervous about the idea. Say, look, did you ask about red flags? Yeah, is there any problem? No, no, okay. Remember, we're going to assess something, you're going to treat it, we're going to reassess it, we go through it, and when you're looking at things, think of this TART. Think it's a tender, you know, asymmetry, this restriction of motion or range of motion of the self, and this tissue texture change. Those are the things you're looking at to determine. That determines if there's somatic dysfunction. I'm finding those things. Well, yeah, that's because you're finding somatic dysfunction. So it helps them get barriers. Those are general things we're going to do in every part of the body going through it. In this area of the first rib, this cervical thoracic area, there's a very common condition. So there's one major common kind of structural condition, it's thoracic outlet syndrome. So same with this. And again, it's a common condition. So what I'll try to do with an area is take something that's very common, make sure they feel comfortable, understand that concept. If they do that, they say, well, why are we learning something here? It's relevance. And saying, well, you know, this is the key area where problems with thoracic outlet come through. And again, you know, common condition, the anatomic structural, the cervical thoracic junction, the first rib. And the idea is this area of manipulation is beneficial. And what they look at with this, the key thing, the point you get across, and sometimes this is where having a picture or showing something to themselves that says, hey, look, you know, can you see this? You know, it's out of the structure. We've got, you know, the vasculature. We can see the nerves in the arteries and veins coming through this area and how that, if the structure's tightened on there, it can impact going into the upper extremity. And you think about it, the key vasculature are these subclavian blood vessels and also neurologically, the brachial plexus. So again, this neurovascular component. So that's neurovascular bundles, the big thing for themself. And that leads to, well, the symptoms. There are several key anatomical areas that impact this. And, you know, the scaly muscles, we kind of talked about themself. The other thing you acknowledge themself is the pectorals muscle, especially pectorals minor, that come in front of the ribcage themselves. This one also impacts the area themselves and the clavicle. And these are key structures when we look at it, and there are different ways to test for this, but those are the kind of key things that we look at, the key muscles, the key structures that impact it. So when you're looking at here, you're looking at where the problem is. A lot of times patients, you know, we mentioned we got this brachial plexus, so that's that neurologic component. People describe this tingling or notice themselves. So when you're taking a learner, so can you explain how do I see these things? You want to tell them how it presents and say, well, the brachial plexus, if they get a neurologic symptom, you might expect tingling. You know, if you get a problem with the subclavian themselves, blood vessels, then all of a sudden, they may get some things. Maybe there's some coolness themselves, decreased pulses, fatigue. So kind of hit those points of things they can see, and then all of a sudden, I think it illustrates in their mind, oh, yeah, it's that brachial plexus, so it's that nerve, and that's why I'm getting that tingling. You know, subclavian, obviously, that's why I'm getting some, you know, this themself, this edema. I'm getting this decreased pulse, and after using it a while, you know, it kind of bothers me, and that fatigue, and that fatigue can be both from vascular insufficiency, but also it can be from, you know, impacting the brachial plexus, too. So, and those are background things to go through for them to understand it, but when it comes down to it, you know, just say, look, the key thing we're looking at is this neurovascular bundle. It's around the brachial plexus, subclavian blood vessels. This, what's interesting I found about this area, the number one kind of, you know, diagnostic maneuver is called the Adsense. Now, in medicine, it's interesting, but a lot of times there's a technique or an approach that, you know, has, in some ways, different people do it different ways. So this is a classic, and, you know, again, sharing kind of a story, and again, I try to tell stories, and I'm trying to teach things along with it, is I had one of my previous residents when I was a family medicine program director who was an orthopedic surgery resident, and he stepped out, didn't like it, came to family medicine, and we were going through this, and I was talking about the Adsense maneuver, and he goes, well, that's not the right way to do it. I said, well, Paul, what do you mean it's not the right way to do it? He goes, no, no, it's not this way. What it was is that around more of the sports medicine circles, when they talked about Adsense maneuver, they would do a technique where they put the person's arm out and back, and they would look away and test it, and they'd be testing the pulse and sensation to see what they'd feel. He goes, no, you look towards it. So I started looking at literature, and I found that I had books that said yes, what I was teaching was right. Then I found an ortho book, and my gosh, what I was teaching wasn't right. It was different. And then I started doing a deeper dive, and when you really look at the literature, Adsense really had two methods it was described, and the real classic Adsense was method one, where you just have the patient, you know, sitting, put the arm back, and you look towards the side you're testing. And the second method is you'd have them look away from that. It was also referred to as the Halstead maneuver or some people call it the reverse Adsense. So the teaching point there, sometimes if we're teaching someone, someone says, you know, I don't think that's right, something else, you may both be right and not knowing it. So I think obviously it's humility as a structure because sometimes you may not think, you know, that you think that you have all the answers, but sometimes there are different things. In medicine, different groups do different, kind of different approaches to that. So in just kind of a fast summary of assessment, this thing about is first of all, generally, we think of RIFT, radiculopathy, infection, fracture, tumor. Remember that whenever we evaluate something, we assess it, we'll treat it, we'll reassess it. And when we're assessing things, think of TART, tenderness, asymmetry, ulcer, range of motion, tissue texture changes. When we think of thoracic outlet, remember this is basically a condition that affects the neurovascular bundle from that affects to the upper extremity. It's a very common thing to myself, involves key structural things, the scaly muscles, pectoralis minor, and the clavicle. When we look at that, the symptoms we get from the brachial plexus is mostly pain and numbness and tingling. And from the subclavian vessels, there's some edema, some decreased pulse with that. The maneuver to test it is something called the Adsense Maneuver. There's two variations. One, the Adsense himself, when a patient is looking towards the side we're testing. And the second method, sometimes referred to a Halsted or reverse Adsense, where they're looking away. So in this lab, we're looking at assessment in the first rib, the cervical thoracic area, around the thoracic inlet. We're also going to focus on a common clinical problem, which is thoracic outlet syndrome. Adsense Maneuver is probably the one maneuver that you should learn and teach. So when you're teaching this one here, the interesting thing is to say there are two methods to do this. But both basically want to get the same point. They want to determine, is there a neurovascular compromise to the upper extremity? Is there a problem with the brachial plexus? Subclavian occurs with that. So when we're looking at that, the key thing we're trying to do is how do we narrow that? So when you're teaching it, a lot of the idea is we can show a maneuver, but I always try to give an idea of what I'm doing. I say, look, there are several structures here. And I'll point out the clavicle, the pectoralis, and the scalene, all these structures, you can see where it impacts both the neurovascular structures that are going into the upper extremity. So take advantage and point those areas out to them when they're going through, and they'll get a better idea of what's going on with it. To test that, there's a few things. One is, the point is that, gee, I'm going to check an area that involves a vascular compromise. What will do it? Something that may decrease pulse. So you're going to feel the radial pulse when you're going through it. When it comes to neurologic, say, ask them about any sensation, any changes there, because this is called a provocative test. Look at it. So to do this, there's a few components. One is that there's a position you're having. So the one method, looking at the absence maneuver themselves, is you're going to bring the arm back, and the method one is have the patient look towards the side. So bring the arm back. You're going to be palpating. You're going to be feeling the pulse. You're going to ask them, tell me if you feel anything in your hand. You don't want to lead them on too much, but you do want to ask them if they feel that sensation. Now, to make the technique effective, though, you ask the patient to bring their chest out and take a deep breath in and hold their breath. And hold that for as long as they can. And the reason you're doing that is sometimes that just little change, by doing that, will impact and decrease the pulse than it would otherwise. So that's the key caveat with this. Make sure the patient breathes. But the idea I wanted to do with this is that's the part that's provocative, too. It's that little extra step. So in doing it, it's not just the position and holding it, but it's asking them again to bring their chest out, kind of a military thing, bring their chest out, deep breath in, hold their breath. You may have to do it a few times for them to do that. And just again, feel that pulse and see if you can feel that going through it. Now, the second method is honestly the same step. The only difference is you turn your head away. And this is referred to as sometimes the reverse Adsense or Halstead maneuver. Some areas they call it Adsense maneuver in areas of literature, but it's more formally referred to again as the Halstead maneuver or reverse Adsense. So again, the same kind of thing. Bring your chest out, take a deep breath in, hold your breath, and look away. And again, feel. Do I feel a decrease in the pulse? Do I feel? And ask the patient if they're feeling things. And again, with the learner, when you're teaching them, you can breathe again here, and say, look, there's a couple different ways we can do this, and let's go through this. But the key idea you're going to hit on when you're talking about it is that there are structures here. And when you do that, usually you're going to point out the things so they get a better visualization of it themselves, that clavicle, that pectoralis, the scaling. So that way, sometimes those points we talk about is one thing, but when you're showing it and you're letting them see that, then I think they get the point across a lot better. And then go through maneuvers because now they're thinking, boy, there's a problem in this area. So it makes sense when you say, I'm going to bring this arm back here, this provocative test. Also you say, oh yeah, you're kind of stretching out the area. And then again, go through and say, hey, there's two different ways. Head towards, head away. Not the one Adsense, reverse Adsense, Halsted, but the same thing. Deep breath in, bring your chest out, and that actual maneuver kind of helps us with that. Okay? So now we've gone through the first part of our assessment that we've done for the first rib, this cervical thoracic junction on the thoracic inlet. And we're going to go through to the tables for us to kind of discuss this thoracic outlet syndrome, but also to go through the Adsense maneuvers, to go through the first method and the second method, also for the Halsted, reverse Adsense, and do that at tables right now. So in this lab we're doing right now, I ground the thoracic outlet syndrome, kind of a model for this. And this is kind of a good clinical case to get a first rib and, you know, in this cervical thoracic junction, thoracic inlet. So thoracic outlet syndrome is one. So this is a good opportunity to kind of really work with learners. And key things you want to get a point across, when you're teaching, again, is get them an idea that, you know, the conditions, you have a neurovascular bundle problem. So, you know, brachial plexus, you know, the subclavian. But also we need to get a point to them, say, hey, look, you know, what are the key structures? Is this clavicle, pectoralis through here, and the scalene? So sometimes, again, I'll touch, I'll look through the area themselves, and I'll talk about it for them, because then they get a better visualization. They understand, oh, yeah, it impacts that. And then say, well, to test it, we do these provocative tests. So when you're going through, remember, there's two kind of techniques we do with the Atsin. So there's the Atsin's kind of method one, more traditional. And with that one, we're looking at the impact to the vasculature and this neurologic. So, you know, when they talk about brachial plexus, you put them in a certain position, they feel numbness, a tingling, and going through that. You know, it's vascular, it can decrease the pulse, they may see medema, other kind of symptoms like that. So with learners, hey, look, you know, bring out common things for them, say, you know, just prompts for them. Or you can ask them to say, when you think of, you know, neurologic things, what things do you think you might feel? So you can also get them to do, especially if someone needs to be more engaged in doing it. It's always good to be active with that. You know, the key things you're going through is make sure, you know, that they're conscious that they're going to feel the pulse, you know. So when you're holding the pulse, you're taking it back. So when you're behind, you know, make sure that they're in a position when you're teaching it that they hold the pulse, they leave the arm back, you know, and have them, you know, the first one, the method one, you know, when you're feeling that pulse, just say, okay, turn your head towards the area. Now, the clincher, you want to remind them when you're teaching learners is, kind of bring your chest out, take a deep breath in. Now, and point out to them, you say, by doing that, we've just changed the space of the blood vessels and the nerves coming through, and that's why it may demonstrate the symptoms you may not see normally. That's why it's provocative. Okay, you can breathe out, you know. Now, turn your head away. So the other thing is, the other way, repeat the same thing, chest out, deep breath in, because again, that narrows that, the neurovascular bundle themselves, and this is called the Halsted or the reverse Adsense. So you're going to have a chance for them to feel that pulse, ask for the patient to feel that sensation going through it, and breathe out. So with Thoracic Outlet Syndrome, we are checking neurovascular compromise, and so the two structures that we're going through, that we're looking at, are the subclavians and the brachial plexus. And you look at the area, so the three components of Thoracic Outlet that we're looking at here are the clavicle, basically is the clavicle, the pectoralis, and the scaly. So we're looking at here, and we're using the Adsense technique as a provocative test to see if there is a neurovascular compromise, and the patient would be able to actually testify by telling us if they're experiencing any numbness or tingling, or, as you're doing the Adsense technique, you're checking the pulse also to see if there is any vascular compromise. So I'm just going to go ahead and demonstrate that. As I check your pulse, I'll be putting you in this position, and then I'll have you look toward me, to this side, and then take a deep breath in, and blow your chest out, and then I'll be checking for pulse and asking to see if you have it here. Symptoms of non-certain rates. Go ahead and breathe out. The other technique to check is also the same thing, but the head would rotate to the other side. So let me demonstrate that as well. So again, I will be checking for the pulse. You'll be looking the other side. Go ahead and blow your chest. Take a deep breath in, and hold it. All right. Thank you. Kind of bring it up and say, Oh, you know, we're talking about, you know, we're looking at assessing clinical problems here with the first rib, cervical-thoracic junction, common condition is thoracic outlet syndrome. Well, that affects this neurovascular bundle. There's two key things, the brachial plexus and the subclavian. And these are key structures. Here, there's two methods for this Adson maneuver. So first one, and then you can go through it. So those help out. So that way, because all these things are right, but sometimes the extra framing all of a sudden gets clarity. Because the idea with the novice learner is they need just some clarity with how things run, you know? Okay. How are you doing? Good. How are you feeling? Do you need to pee? No. No. 14 minutes. Okay. So I will bring her back to neutral. For Addison's test, in both methods, one is the tour, one is the medication. So what you want to do, if we're in the exam, is to readily test, take a drill seal. If you can see, you know, let's say something that shows common lines, again, the Addison's maneuver is to assess the thoracic outwards. Which implies the restriction in your vascular bundle, the adrenals versus the thoracic outwards. There's a lot of things going on. So you have the clavicle, you've got scalenes, you've got pectoralis, and your things you want to assess are, is there any kind of vascular issues going on? And, or, are there any neurologic issues? Because the vasculature and the nerves, the praguial plexus, run through some of these. There's obviously, there's going to, I would also remind the person that you're teaching that there's anatomic variance. So just because it looks like one way in the textbook doesn't mean it's going to be like that for everyone. There might be some variance. But just keep that in mind. So the big things, make sure you at least think about and rule out the RIFT, you know, the RIFT things. Which would be, you know, the radiculopathy infection fraction tumor. And then what you want to do for an exam to readily, a provocative test to see if there is, if you can elicit something that shows compromises in the vasculature or the neurologic portion would be like the AdSense. And so there's two ways to do it. There's a regular AdSense and there's a reverse AdSense. And it's pretty easy. What you need to do is you just tell them to grab the, get ahold of the arm of the patient and then have them sit straight up, off of their chest, kind of like they're in the military. And have them look toward the arm that you're pulling back and then take a big deep breath in and then hold. And try to assess if you can feel a decrease in their pulse. Go ahead and breathe. And you can do this several times to best ascertain whether, if you can feel a difference. Okay, and the other way, you can have them with the, on the same arm, have them look away. And you can bring this up a little bit. And then have them take a big deep breath in, stick out their chest, hold it. And then breathe. Again, assessing to see if there's a decrease in the pulse, the radial pulse, and also to see if there's any kind of paresthesias or tingling or numbness that are going on. Did you feel any of that? Okay. So those are the big things that you want to really emphasize when you're teaching this to a resident or a student. Is, again, red flags, and then a provocative test, the Adsense and or reverse Adsense. The first thing when assessing a patient with a head or upper back, or excuse me, a neck or upper back complaint, is to roll out red flags using the monogryph, RIF standing for radiculopathy, infection, fracture, tumor. And once those are rolled out via questions on their HPI, and physical exam, you can do provocative tests such as the Adsense to look for neurovascular insufficiency from thoracic outlet syndrome. So what we're looking for here is decreases in pulse and or paresthesia or numbness on the test. So I'll go ahead and perform the exam. Okay. So you're just going to take the patient's arm, put it behind their body, extending it through, monitoring their pulse. Then I'm going to have you look towards that arm. Good. Good. I'm going to have you puff out your chest. Take a big deep breath in and hold it. And I'm looking for any pulse changes, any, you can go ahead and exhale, or any numbness or tingling in the arm during the maneuver. No? Yes? No. Okay. And then I can go ahead and do a reverse Adsense. I can have you look in the other direction. Raise the arm up while monitoring the pulse. I'm going to have you puff out your chest again. Take a big deep breath in and look for the same thing. So any pulse changes and or paresthesia, numbness, tingling? No. All right.

thoracic outlet syndrome

thoracic inlet

RIFT acronym

TART framework

Adsense maneuver

neurovascular bundle