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Introduction: Thoracic outlet syndrome (TOS) is a complex condition that causes pain, tingling sensation, hypesthesia, muscle atrophy, weakness, and edematous changes in the upper quadrant (UQ) and down upper extremity (UE). 3,7,8,16,17 TOS is due to compression of neurovascular bundles in the interscalene triangle, costoclavicular space, and under pectoralis minor and caused by trauma, congenital malformations such as a cervical rib, and abnormal/poor postures from muscle imbalances.3,7,8,16,17 Interventions for TOS can consist of correcting posture by addressing muscle imbalance, decreasing tone and muscle tightness and rib mobilization, and in rare cases, rib resection. 3,7,8,13,16,17 However, there is limited research on the effectiveness of heart rate variability biofeedback (HRVBF) for the treatment of TOS.

Purpose: The purpose of this case report is to find the effectiveness of HRVBF in conjunction with traditional treatment for a 25-year-old female with TOS who was referred for Physical Therapy (PT) services prior to rib resection.

Case Description: An ectomorphic right (R)-handed female patient (pt) with complaints of constant numbness, pain, pins and needles sensations from R UQ from scapula/trapezius and R upper chest into R UE for the past year after a traumatic chiropractic treatment. Initial Electromyography found radial neuritis in R UE. Magnetic resonance imaging found a small SLAP tear of R superior labrum adjacent to bicep anchor. Pt comorbidities include asthma and a history of chronic depression/anxiety disorder and panic attacks.

Interventions: The treatment included ten sessions over seven weeks by a student PT under the supervision of a certified PT. A plan of care (POC) was implemented which included HRVB, myofascial release, trigger point release, 1st rib and thoracic spine mobilization, corrective stretching, nerve glides, neuromuscular education, strength/motor control training, positive reinforcement to movement, and pt education to include a home exercise program (HEP).8,16,17

Outcomes: The pt made progress completing most of her goals in decreasing her pain from 8/10 at worst and 4/10 at best throughout the day to 0/10 based on a numerical pain scale. The pt increased range of motion (ROM) in cervical spine and in R shoulder, increased strength, and normalized sensation in R UQ. Upper Extremity Functional Index initially scored 47/80 and after 71/80 scores, showing an increase in physical function with activities of daily living and life participation. The pt was able to improve her quality of life (QoL) based on the SF-12 QoL13, which initially scored at 31.03 physical score (PCS) and 40.86 mental score (MCS) that improved to PCS 40.43 and MCS 52.73. Pt also has less fear and avoidance of movement based on her Fear-Avoidance Beliefs Questionnaire (FABQ)10 score, which initially scored at 28 for physical activity FABQ (PA) and 37 for work FABQ (W) improved to FABQ(PA) 12 and FABQ (W) 7.

Discussion: Depression, anxiety, and asthma have impacted this pt’s posture and muscle tone, and the assault from the traumatic experience manifested TOS, which has impaired her ROM, sensory system, strength/motor control, and increased fear and avoidance of movement. Implementation of HRVBF in relaxing the pt through her day and not utilizing accessory muscles to breathe was found to be beneficial in diminishing pt symptoms.1,2,5,6,9 Pt was set for a 1st rib resection and was thought to have possible nerve damage but was able to recover with conservative treatment in conjunction with HRVBF. More studies need to be conducted to see if there is a relationship with asthma and depression/anxiety disorders with TOS and the impact of HRVBF in a POC for TOS.

Publication Date

Summer 8-19-2020


University of St. Augustine for Health Sciences


San Marcos, CA


Thoracic Outlet Syndrome, Physical Therapy, Anxiety, Depression, Neck/Shoulder Pain, Posture, Heart Rate Variability Biofeedback (HRVBF)

Medical Subject Headings

Thoracic Outlet Syndrome, Physical Therapy Modalities, Heart Rate, Biofeedback, Psychology, Posture, Neck Pain, Shoulder Pain, Depression, Anxiety


Orthopedics | Physical Therapy | Physiotherapy


Poster accepted for the Summer 2020 Campus Research Day on the San Marcos, CA, campus of the University of St. Augustine for Health Sciences on August 19, 2020.


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The Effectiveness of Heart Rate Variability Biofeedback in Conjunction with Traditional Treatment for Thoracic Outlet Syndrome in a 25-year-old female: A Case Report