Physiotherapeutic approach in thoracic outlet syndrome in pregnancy

Sav proces dijagnosticiranja torakalnog outlet sindroma, odnosno sindroma gornjeg torakalnog otvora jest kompliciran, dugotrajan i težak te je potrebno veliko znanje i vještine važne za pravilnu i pravovremenu provedbu određenih testova i ostalih postupaka s ciljem utvrđivanja ovog sindroma. Prvi korak jest određivanje točnih simptoma, komplikacija i ostalih tegoba trudnice te uvid u njezino trenutačno stanje. Zatim se na temelju otkrivenih simptoma isključuje pogrešna i postavlja pravilna dijagnoza. Do pravilne dijagnoze dolazi se pomoću testova koji pokazuju svoju pozitivnost ili negativnost i samim time pokazuju karakteristike torakalnog outlet sindroma na temelju vidljivih simptoma. Testovi koji se primjenjuju su Adsonov test, Allenov test, Edenov ili Kostoklavikularni test, Roosov ili Elevated Arm Stress Test (EAST) test, Wrightov ili Hiperabdukcijski test i Upper Limb Tension Test (ULTT). Svaki od njih ima svoje specifičnosti koje pokazuju radi li se o sindromu gornjeg torakalnog otvora te o njegovoj razvijenosti i mogućnostima liječenja istog. Potom je potrebno nastaviti s detaljnijim pretragama i pregledima da se utvrdi odgovarajuća rehabilitacija i liječenje. Rehabilitacija počinje intervencijom fizioterapeuta. U intervenciju fizioterapeuta spada pozicioniranje i edukacija trudnice te određene vježbe. Važno je pravilno pozicioniranje i u tu skupinu rehabilitacijskih procesa spadaju posturalni mehanizmi, kontroliranje tjelesne težine, tehnike opuštanja te načini izvođenja i nastavak svakodnevnih aktivnosti. Trudnici prvo treba dati sve informacije o sindromu gornjeg torakalnog otvora, o mogućnostima prilagodbe različitih aktivnosti ovisno o stanju trudnice. Važno je paziti na određene pokrete tijela. Javlja li se mogućnost neispavanosti i nedostatak sna potrebno je dati trudnici informacije o prilagodbi na različito pozicioniranje. Nakon toga slijede rehabilitacija pomoću različitih vježbi. Provode se primarno vježbe disanja, a nakon toga vježbe za mobilnost i jačanje svih mišića, osobito onih koji su oslabljeni zbog prisutnosti sindroma gornjeg torakalnog otvora. Kod vježbi disanja bitno je spomenuti da se prakticira dijafragmalno disanje i prvi korak jest stjecanje navike da se vrši takvo disanje. Vježbe za mobilnost i jačanje mišića uključuju razvoj mobilne torakalne kralježnice i područja ramenog pojasa za kvalitetnije pokrete trudnice. Bitna je opuštenost mišića, vraćanje pravilnih respiratornih obrazaca i ispravljanje lošeg držanja. Vježba se sporo, laganim ritmom uz pratnju disanja trudnice (početna pozicija udah, izvođenje pokreta uz izdah). Cilj je postići rehabilitaciju torakalnog outlet sindroma koja će imati dugoročne pozitivne posljedice.The whole process of diagnosing thoracic outlet syndrome, ie upper thoracic orifice syndrome, is complicated, time-consuming and difficult, and requires great knowledge and skills important for the proper and timely implementation of certain tests and other procedures to modify this syndrome. The first step is to determine the exact symptoms, complications and other problems of the pregnant woman and an insight into her current condition. Then, based on the detected symptoms, the wrong one is ruled out and the correct diagnosis is made. A correct diagnosis can be made using tests that show their positivity or negativity and thus show an accurate diagnosis of thoracic outlet syndrome based on visible symptoms. The tests are Adson's test, Allen's test, Eden's or Costoklavicular test, Roos' or Elevated Arm Stress Test (EAST) test, Wright's or Hyperabduction test and Upper Limb Tension Test (ULTT). Each of them has its own specifics that show a diagnosis that will show that it is a syndrome of the upper thoracic opening and its development and treatment options. It is then necessary to proceed with more detailed examinations and examinations to determine appropriate rehabilitation and treatment. Rehabilitation begins with the intervention of a physiotherapist. The physiotherapist's intervention includes positioning and educating the patient and certain exercises. Proper positioning is important and this group of rehabilitation processes includes postural mechanisms, weight control, relaxation techniques and ways of performing and continuing daily activities. The patient should first be given all the information about the upper thoracic orifice syndrome, about the possibilities of adapting different activities depending on the patient's condition. It is important to pay attention to certain body movements and there is also the possibility of insomnia and lack of sleep, so information should be given on adjusting to different positioning that will contribute to the patient's condition. This is followed by rehabilitation using various exercises. Primary breathing exercises are performed, followed by exercises for mobility and strengthening of all muscles, especially those that are weakened due to the presence of upper thoracic opening syndrome. In breathing exercises, it is important to mention that diaphragmatic breathing is practiced and the first step is to acquire the habit of performing such breathing. Exercises for mobility and muscle strengthening include the development of a mobile thoracic spine and shoulder girdle area for better movements of the pregnant woman. Muscle relaxation, restoring proper respiratory patterns and correcting poor posture are important. Exercises are performed slowly, at a light rhythm, accompanied by the patient's breathing (starting position inhale, performing movements with exhalation). The goal is to achieve rehabilitation of thoracic outlet syndrome that will have long-term positive consequences