This condition also has an altered sensation and temperature in the arm and hand. without contrast , MSKT agiography with contrast)) URL https://drive.google.com/drive/folders/180G0B9Ev6UWbGuFIdXjjcgFiqFmJggud . PT probably made you worse. Saxton EH, Miller TQ, Collins JD. Talk to our Chatbot to narrow down your search. Thoracic outlet syndrome (TOS) is a symptom complex attributed to compression of the nerves and vessels as they exit the thoracic outlet. 1994;90:179185. What are your general thoughts on having a rib-sparing scalenectomy, especially in TOS-CVH? Deep vein thrombosis is more common in the legs. Symptoms include pain, tingling or weakness in the shoulder and arm, especially when raising the arms. Was very impressed by how much the article made sense and then seen you wrote it! Thoracic outlet syndrome symptoms include. As I have said already, the key to solving forward head posture is correcting pelvic and thoracic alignment. 3) on the symptomatic side compared to the other side (in unilateral TOS) and to the normative data in cases of bilateral TOS (Kai et al., 2001). Provocative pressure testing is a very reliable way of diagnosing thoracic outlet syndrome, because it shows the therapist exactly where the nerves are irritated. I was diagnosed with Essential Thrombocythemia at a very young age and we just assumed it was linked with that disease but now we will be testing for TOS. Upper back and chest pain are related to the misalignment of the muscles that attach to the thoracic ribs and cause compression of the rib cage. Sympathetic comorbidity such as tremors, Reynauds syndrome or causalgia may develop. We get treated like lab rats being sent from one 15 minute appointment to the next. Result of this one was post op horners syndrome and lower trunk damage. Since I started exercises and posture correction changes listed in these 2 articles 1 month ago, I have absent or barely any pain if I keep my L shoulder up but it definitely still has to be conscious act. Org. The treatments are of course the same; the scalenes and SCM requires significant strengthening over a period of time. If the shoulders appear relatively symmetrical in resting height after surgery, this suggests that an inadequate amount of rib was removed. These safe (read: relatively healthy) muscles are usually not relevant to the patients complaint, in my personal experience, which is why I dont perform releases all that often (many may, of course, disagree with this). No, thats futile. The subcoracoidspace-compression (beneath pectoralis minor) is rarely a big player in the dysfunction, and will almost always resolve on its own when the posture, scalenes and clavicle have been corrected. 3. When trying to hold my shoulders up (as you recommended in your TOS video) I notices a fatty bump right where my collar bone is. Extreme muscular inhibition will cause severe abrasiveness and tightening, greatly increasing its potential of irritating / compressing nearby structures such as nerves and blood vessels. Your SCM would not affect your arm, only to some extent the subclavian vein. 2009;4(4):170-181. I have also addressed this topic in my lumbar plexus compression syndrome article. Although, perhaps, a less popular topic, it must be stated that a lot of TOS cases develop secondary to stress (Scaer 2011, Korn 2021). /Anna. I have been trying to follow some of your programs and it seems to be affecting my vagus nerve and causing a lot of anxiety. Thus relative weakness of the fifth finger with regards to opposition and abduction (Selmonosky 1981, 2002, 2008) is a good criteria for detection of TOS. Elevation of the shoulder girdle can alleviate these stressors and potentially lead to decompressing the thoracic outlet (Kitamura et al., 1995). Learn more about the tranaxillary first rib resection surgical approach to treat TOS from the Johns Hopkins Thoracic Outlet Syndrome Clinic. TOS exceeds the competence of PT. Make a donation. Subclavian steal syndrome. Fig. In some cases, however, your doctor may recommend surgery. Heres an ultrasound image of a patients scalenes, clearly showing atrophy (degeneration w. fatty infiltration) of the muscle, especially the anterior scalene. Is there another way I could do this exercise? Yeah what do you think about this Kjetil? Is this 10 reps for each of the middle and anterior scalene exercises, or 10 reps total (eg 5 each). Relative value of electrophysiological studies. symptoms/signs. The nerve passes through the coracobrachialis, and then between the biceps and brachialis muscles. Subclavius muscle 6. About how long does that worsening last and at what point do you decide that the worsening symptoms indicate that the TOS is getting worse, not better? j. surg. Having a cervical rib (an extra rib extending from the neck) increases your chance of developing thoracic outlet syndrome. The scapula should be located between the T2 and T7 vertebrae, with its superior angle levelled with T2 on the longitudinal line. Amazing write up. PMID: 7266064. Neurosurgery. Tingling or numbness in your fingers, hand or arm. AllScripts EPSi. For patients with venous or arterial TOS, it is important to seek urgent medical attention to make the correct diagnosis and implement appropriate treatment. 4. But problem hasnt gone away. Other treatments include: Medication:blood thinners to treat clots, Reconstructionorreplacement of the arteryif the artery has an aneurysm or contains a clot. But first, some elaboration with regards to swayback posture and breathing dysfunction is necessary. 2004, Four patients with elevated creatine phosphokinase (CPK) values and recurrent chest pain were found to have thoracic outlet syndrome. I have spent up to 10 sessions with certain clients until theyve got it right. Nothing else really makes it do this. A single copy of these materials may be reprinted for noncommercial personal use only. Demondion et al., 2006. Urschel HC, Razzuk MA, Hyland JW, et al. Reading your article really shed light on that as I assume its because I was doing a lot of back and down motions trying to fix it, which compresses the thoracic outlet even more. Fig. This is why public health care is good if you have a simple medical problem but a tragedy if theres any complexity to the matter. This cycle will need to be practiced over and over until it feels more normal or occurs automatically. All rights reserved. Neuroradiology. chest pain, headaches, and dizziness are some of the symptoms that can be found in a case of TOS. Make sure that the person doing it starts very, very easy. Elevate the arm and squeeze into the musculocutaneous nerve. Severe slouching habits will inhibit this pattern as well as proper cervical (axial) rotation, causing degeneration of the involved muscles. Weakness and hypotonus of the teres minor, lateral & long heads of the tricep will usually be present for the posterior shoulder. Accuracy of MRI in diagnosing peripheral nerve disease: a systematic review of the literature. A few questions. What are the symptoms of venous thoracic outlet syndrome? I get tingling sometimes and weakness. Our heart health checklist can help you determine when to seek care. Therefore, the authors believe that abnormalities in this muscle may cause sympathetic cardiac hyperactivity. Whenever a weak muscle is forced to work beyond its capacity, it will tighten and, therefore, be more subject to stress and strain. This animation illustrates how physicians at the Johns Hopkins Thoracic Outlet Syndrome Clinic perform interscalene brachial plexus blocks using botulinum toxin type A injections to provide temporary pain relief for patients. Mayo Clin Proc. Shrugs have helped but my pain is back. In this case, the clots are formed as the result of overhead motions (efforts) that compress the vein. Coumel, 1994, Pathways of pain in angina pectoris and afferent stimuli originating from brachial plexus compression at the thoracic outlet stimulate the same autonomic and somatic spinal centers that induce referred pain to the chest wall and arm. I dare to say its one of the few ones that dont insist on obssesive stretching before there is even a muscle mass to begin just overstreched tissue that wasn t really able to do that in the first place. Research has demonstrated a connection between compression of the subclavian artery and compromise of the vertebral artery, an artery that supplies the posterior brain with blood. Treatment for thoracic outlet syndrome usually involves physical therapy and pain relief measures. Stretch daily, and perform exercises that keep your shoulder muscles strong. I started psychotherapy, no exercises just massage ultrasound therapy, neck traction, and heat therapy. Ive written more about the scapular positioningtopic in this shoulder pain article. Surgical exploration revealed entrapment of the left vertebral artery by a tight anterior scalene muscle, release of which resulted in complete resolution of her symptoms. More specifically, the anterior scalene and the clavicular portion of the sternocleidomastoid muscle. Botox (scalenus, whiplash, etc) is generally not a good idea unless one is already awaiting surgery. 1981;74:974-949. In most cases, the vertebral artery arose at the level of the thyrocervical trunk and the compression was relieved by section of the scalenus anticus muscle and by division of the inferior thyroid artery. The patient attributed his symptoms to TOS. Bodybuilding: Built-up muscles in the neck may grow too large and compress nerves or the subclavian vessels. Surgeryis usually recommended for venous TOS. Would the strengthening of scm and scalene make this go away? Evaluation of the axillary nerve under the teres minor, suprascapular nerve under the supraspinatus muscle, musculocutaneous nerve within the coracobrachialis, etc., must be done and treated accordingly. The compression may be due to a normal or an accessory first rib or fibrous band (thoracic outlet syndrome) or occur during strenuous arm activity (effort thrombosis, or Paget-Schroetter syndrome, which accounts for 1 to 4% of upper extremity DVT cases). I am in the middle of trying to figure out what is causing my symptoms. Turned head to the right, i.e. She was also very, very stressed, worked 10 hour days (with a horrible posture as a dentist), almost without breaks, for 30 years. Do you know if it can be difficult to see a vascular TOS with ultrasound, even be false negative? For most people experiencing symptoms of TOS, the recommended treatments are: Surgery might be recommended for patients who are diagnosed with an anatomical abnormality They also start saying that this is fibromyalgia. However, the vagus and phrenic nerves have a different course than the above-mentioned, yet are also related to the scalenes. You can keep your scapula up in the proper position, if conscious of it, regardless of your pelvic or TVA status. Except in the more Thank you very much for your educational and specific information. NINDS thoracic outlet syndrome information page. 11-12 Scalenus anterior (left) & medius (right) MMT. Beware that normalization of breathing should be reintroduced slowly, often over the course of years, in patients with TOS, especially in those whom symptoms are severe. The vein itself must also be treated. 1988;11:571575. I want to do your Scalenus anterior & medius exercises, but can not lie on my side, because I have Ehlers Danlos Syndrome, and my shoulders sublux/dislocate in that position. 5 reps for 1-2 sets twice per week is usually a safe start. This generally means that the compression is stemming from another structure, and that the area thatyoure working on is not that important. In result, intermittent or sometimes even chronic hyperperfusion of the carotid and vertebral arteries may occur (Larsen et al. Meanwhile i was having some complaints about my other side with different kind of symptoms which were 4th 5th finger weakness loss of grip power, wrist ache etc. Because ultrasound is not quantitative, meaning that it can not reliably quantify blood volume, it is generally used for qualitative assessments, meaning that evaluation of flow speeds and waveforms are used to estimate whether or not the flow is normal. Again, a strong pressure will usually be required. The SCJ dislocation is a separate issue. Additionally, the scalenes and sternocleidomastoid will need strengthening, along with any relevant compression you may find in the extremities. Symptoms of thoracic outlet syndrome relate to the compression of blood vessels and nerves. Scapula depression will lead to. How could thoracic outlet cause face pain? I see some of the Mews instructions are absolutely detrimental after reading your stuff. Thoracic outlet syndrome (TOS) occurs when nerves or blood vessels are compressed by the rib, collarbone or neck muscles at the top of the outlet. Dadsetan & Skerhut, 1989, Rotational positioning of the head showed vertebral obstruction in one direction, and unobstructed filling of the vessel when the head was turned to the opposite side. If significant weakness is discovered, it is an utmost high priority to decompress the CCS. can confirm or rule out TOS. Are there any possible ligaments implications that mighr further compress the structures. thoracic outlet syndrome compression as previously rec-ommended. Triggering the symptoms may be a little challenging. A branch of the subclavian artery include a key vessel, the vertebral artery. In Memory Of DeAnne Marie. The Annals of Thoracic Surgery Volume 16, Issue 3, September 1973, Pages 239-248, Xi Y, Cheng J. Dysfunction of the autonomic nervous system in atrial fibrillation. Compression of the superficial C8 to T1 cutaneous afferent fibers elicits stimuli that are transmitted to the brain and are recognized as integumentary pain or paresthesias in the ulnar nerve distribution. Between 1 and 3 percent of the population has a cervical rib, which may grow on one side or both, and may reach down to attach to the first rib or may not be fully formed. I have to assume this is from what you said, that it further compresses the thoracic outlet. The reason the strengthening makes it feel worse, is because the muscles are so utterly weak that any stimulus will cause exacerbationof the symptoms. You might be called a malingerer, and Is this a sign of fatty-atrophy? 2015;7(2):193-198. doi:10.3978/j.issn.2072-1439.2015.01.12. Symptoms are worse when you use your arm and better when you rest. lumbar plexus compression syndrome article, David Weinstocks book Neurokinetic Therapy, Vestibular impairment and its association to the neck and TMJ, https://www.youtube.com/watch?v=dCI-Qa6Fu-Y, https://drive.google.com/drive/folders/180G0B9Ev6UWbGuFIdXjjcgFiqFmJggud, Do you really have atlantoaxial and craniocervical instability? They include: Pain in the neck, shoulder, or arm Numbness and tingling Swelling Weakness Discoloration. This leaves only 5% left that have any potential of causing dizziness. 2005;92:25-7. doi: 10.1007/3-211-27458-8_6. As Ive said many times now, this is a postural and breathing related issue. Muscle twitching. That the main compression occurs in the interscalene triangle, a well as the costoclavicular passage. several tests developed to detect TOS. The same assessment protocol applies to thecoracobrachialis. 2010 Apr;4(2):27-35. doi: 10.4103/0973-6042.70817. When I press on my left scalenes, I can induce nystagmus. Wearing heavy gloves can help also. Continued bracing / severe psychological distress. Amazing article, and so informative. Warren Hammer, 1990. Is there any way to know if this is a styloid problem, or scalenes/SCM? In my experience, its a great and even potentially dangerous myth to assume that these tight muscles are over active and mandate release. throat, trachea, major blood vessels and many nerves. Keep up the good work. 16-17 Supinator MMT (left), Teres minor MMT (right). https://www.uptodate.com/contents/search. It may also be the most underrated, overlooked, misdiagnosed, and probably the most important and difficult to manage peripheral nerve compression in the upper extremity. It may potentially lead to tractional stress being placed on the nerve, vascular and muscular elements as well as compression as the clavicle descends closer towards either the first rib or any other bony element present. Surgeons should be aware that any PT that cues their patients to depress their claviculae will WORSEN the patients symptoms and screw up the surgical results. Worsening of pain means youre doing too many reps. Pretty much wide spread pain, much of which was nerve pain stemming from the thoracic outlet. 1994;81:6179, Larsen K, Galluccio FC, Chand SK. Two patients had bilateral fascial band obstruction, one patient had left only, and the remaining 10 were obstructed on the right side. As we have already seen, SBP will affect our breathing strategy. Korn LE. Will that be good for a first appointment? Any of these abnormal formations can compress blood vessels or nerves. Accessed July 6, 2021. Four operations were used: transaxillary first rib resection (26); supraclavicular first rib resection with neurolysis (15); scalenectomy with neurolysis (58); and brachial . Use MMT, palpation and provocative pressure tests to find the answers. Symptoms of Thoracic Outlet Syndrome Symptoms indicating TOS can include: Numbness, tingling, cold, or weakness in the arms and hands Wwelling or discoloration (blue, white) of the hands and fingers Pain, tiredness, or heaviness in the upper arm cCest pain Headaches "Funny feelings" in the face or ear Dizziness, lightheadedness, or vertigo Orthopedic physical assessment, 2014). The next day she did 7 reps, still no symptoms. For me, this has been caused by the alignment of my head and neck, and the way the skull sits on the spine. One of the consistent objective findings that we have observed and measured in cases of sTOS is that the scapula can be depressed at rest (Fig. Was trying to figure out a connection between dizziness issues and this exact area feeling like it was the culprit. To check for entrapment within the costoclavicular passage, Iuse a clavicular depression test. The shoulders must be held up in this patient group. Somatosensory evoked potentials: lack of value for diagnosis of thoracic outlet syndrome. Does thoracic outlet syndrome cause cerebrovascular hyperperfusion? When strengthening the upper traps, can this worsen nerve pain? National Institute of Neurological Disorders and Stroke. At exploration, the phrenic nerve was found adhered to the brachial plexus. For the anterior scalene, resist above the eyebrow while client the head toward the shoulder. What if they somehow get this kind of scalene weakness or injury, let s say, from inappropriate return to activity after a long pause. Known to include pain and muscle spasm frequently extending to the upper arm, neck and back. Not unless youre as crooked as Quasimodo (ie., extremely crooked). Postoperatively, the patient could elevate his right arm without coughing. Usually, people with ATOS don't have any symptoms in their neck or shoulder. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). The cell bodies of the two types of neurons are situated in the dorsal root ganglia of the corresponding spinal segments. Hold it for at least 30 seconds, and look for tingling or frank pain in your arm, hand, chest, neck or scapula. I had my Tos surgery 20th august 2022. A sagittal plane CT (post-surgery) will help in detecting this. What youll likely come to notice is that carpal tunnel syndrome and similar issues are often just a secondary TOS-symptom. The best way to evaluate myotomes are to look for relative weaknesses, as utter paralyzation is usually not present. Even in incidences of successful surgery, residual entrapment in the periphery may forelie. More so, once the patient does engage the scalenes properly during their homework, their symptoms will exacerbate. You'll soon start receiving the latest Mayo Clinic health information you requested in your inbox. It is the least common form of thoracic outlet syndrome but is potentially dangerous as it can result in significant morbidity. There are a lot of 5-minute-experts out there that insist on a lot of things, interetingly without any genuine results with patients. 2007 Sep;46(3):601-4. doi: 10.1016/j.jvs.2007.04.050. Forensic medical aspects. Pre surgery i had some range of motion issues on my related side tight scm, scalene muscles and trap pain. 1990;32(6):514-5. doi: 10.1007/BF02426468. The anterior scalene is a muscle located in the neck that attaches to the first rib in the area known as the thoracic . This content does not have an Arabic version. Diagnosis and Tests How is venous thoracic outlet syndrome diagnosed? Hi Kjetil, amazing articles on TOS, Winged Scapula, subluxing clavicles and TMJ/D. Emotional release. In addition to usual migraine triggers, symptoms were triggered by neck extension and by arm abduction and external rotation; paresthesias and pain preceded migraine triggered by arm and neck movement. The American Journal of Orthopedics. The muscles that entrap the nerves and vascular structures must be strengthened significantly, so that they no longer reflexively tighten due to the unduly stress theyre exposed to. The carpal tunnel is a little different than the rest of the compression points in this article. Thoracic Outlet Syndromes are resulted by compression of the neurovascular structures. The two most useful MMTs are provided here, for the teres minor and supinator muscles. Feeling so thirsty that no water can saciate me is one of the symptoms I started to develop as a pre adolescent when breathing became a problem. Numbness in the fingers is another major symptom of thoracic outlet syndrome to watch out for. These symptoms occur because compression of the vein may cause blood clots. See my reps and sets video on youtube. Thoracic Outlet Syndrome Symptoms Symptoms of this condition can depend on which type of TOS you have. I was diagnosed with nTOS and vTOS a year ago but now I have purplish hand and sometimes swelling in my TOS arm when its by my side, which I didnt have before. Its hard work, but well worth it. Thus one needs to evaluate changes between the foraminal levels, as well as with rotation in both directions while in cervical extension. However, there is still some question as to whether EMG is adequately sensitive to detect changes in NTOS patients with milder symptoms.42,45 Sanders et al., 2008, Somatosensory evoked potentials (SEPs) are used in the diagnosis of thoracic outlet syndrome (TOS), even as an indication for surgery. 2015; doi:10.5435/JAAOS-D-13-00215. Kjetil, thank you very much for the detailed article. (4 months after surgery). When the pelvis is tucked down and in (posterior pelvic tilt, lumbosacral flexion), it causes a shift in the bodys gravitational points so that the mid back hyperextends and the shoulders and head comes forward. Remember that the clavicle shouldelevate gently as you breathe in, and gently depress as you breathe out. Epub 2007 Feb 16. Five percent of cases are venous. Drowsy eyed? In TOS, the rib elevation caused by scalenus tightness also causes rib rigidity. I have had neck pain since my teen years, and now at 32 it has gotten unbearable and general UK physio is not fit for a complex case. Lack of sensation or awareness of certain muscles. My apologies, I dont have the capacity for free back and forths on email. Biceps short head muscle 7. The body knows that firing off that muscle will cause pain and irritation, and often doeseverything it can to avoid using it. Aug. 18, 2021. To help this, it will be beneficial to strengthen the muscles that assist in thoracic inspiration: The sternocleidomastoid, scalenes, (and sometimes the pectoralis minor, but this will absolutely requireproper scapular stability first). The white hand sign. An anterior scalenotomy was done with preservation of the phrenic nerve. TOS problems occur when blood vessels or nerves passing through the thoracic outlet If your lat was so tight that it altered your scapular mechanics, you wouldnt be able to lift your arm. will also remove the troublesome symptom. The hypertrophied scalenes you are talking about, are fatty-atrophied. Weakness in . it is the only attachment between the axial skeleton and the arm, if there is movemnet dysfuction at the scm, of course that would play out in arm function! EMG for thoracic outlet syndrome. If neurogenic thoracic outlet syndrome is suspected: Brachial plexus block: Local anesthetic is injected into the scalene muscles of the neck. Increased discomfort or weakness when you raise your arm for extended periods of time. Clin Orthop Surg. DISCLAIMER: This article is written for educational purposes only. Kwee RM, Chhabra A, Wang KC, Marker DR, Carrino JA. Signs That You May Have Thoracic Outlet Syndrome Regardless of what type of TOS a person may be suffering from, there are several tell-tale symptoms that could indicate that they have TOS, including: Pain, numbness or tingling in the arm, forearm or fingers Loss of pulse in the wrist Swollen, bluish arm Clumsiness of the affected arm It is important to be aware of how psychological factors lead to tension which can lead to TOS. The superior scapular angle is significantly inferior (lower than) the T2 vertebrae, and they rest in considerable anterior and downward rotation. For example: Doctors are quick to point out, however, that none of these diagnostic procedures 2003 Nov;53(5):1053-58; discussion 1058-60. doi: 10.1227/01.neu.0000088738.80838.74. found to be an anatomical abnormality or variation, such as a deformed rib or a fibrous However, with proper conservative treatment, such risks are not present, and we need to be so wary of false positives. privacy practices. Thanks for your helpful artikle about TOS. Surgery and anticoagulation therapy!! Youll have to book a session. @discovery33 I have had these symptoms too, ear pain, sometimes pain on the side of my face or jaw, and my ear turns beet red too. PM R. 2015;7(7):746-761. doi:10.1016/j.pmrj.2015.01.024. If it does, MMT it by having the client resist your attempt to supinate their wrist. 2020). This is called a positive Tinels sign. The name thoracic outlet syndrome suggests chronic irritation (compression) of the brachial plexus and the subclavian vessels, as mentioned initially. Possible symptoms are: Pain. Thoracic outlet syndrome. there is a difference of opinion if its VTOS or NTOS. Hardin & Poser, 1963, Subclavian steal symptoms presents secondary to arterial insufficiency, created by a retrograde flow that steals blood from the brain circulation, more specifically from the basilar artery via the vertebral artery. This triangular tunnel consisted of the hypertrophied ligament of the longus colli muscle and the anterior scalene muscle. Laulan J, Fouquet B, Rodaix C, Jauffret P, Roquelaure Y, Descatha A. Thoracic outlet syndrome: definition, aetiological factors, diagnosis, management and occupational impact. Sometimes, a congenital (from birth) abnormality can cause thoracic outlet syndrome, but it is more likely to occur after injury or bodybuilding. Compression of C7,C8,and T1 nerves fibers is responsible for the neck pain. This is a very unique case and Ive never experienced something so dramatic before, and Ive treated manysevere TOS sufferers, but thats also why I bring it up so that youre aware that this may occur. But it also seems like I could alleviate a lot of my symptoms from the exercises outlined above based on what I was reading. Bilateral functional thoracic outlet syndrome in a collegiate football player. Moreover, it is sometimes strongly denied by those who have not had the opportunity of identifying it as a disease or even when they have not dealt with TOS patients. Symptoms of thoracic outlet syndrome differ depending on the type of TOS someone has. Also I never knew what the neck hinge was called but I asked my doctor about it and he said it looked normal which I knew it didnt cuz just felt like it folded rather than extended. Should I reduce the exercise intensity? Most TOS patients have high stress or anxiety levels and concomitant bracing habits. For example, a person who works in a warehouse and has to lift on heavy [] In particular, in cases of TOS where the scapula mechanics are poor and the patient presents with the dropped shoulder condition (scapula depressed and/or downwardly rotated, and/or anteriorly tilted) (Ranney,1996). Accompanied by localized tenderness in the base of the neck. Grunebach H, et al. 914 390 028 However, the amount of first rib being removed varies greatly. It has potential to cause numerous types and areas of pain,such as neuralgiain the arms, chest, between the shoulder blades and in the back (figure 1), dizziness, brain fog, migraine, headaches, a feeling of being heavy-headed, etc. KL TRENING & REHAB Different types of thoracic outlet syndrome call for different treatments. She also exhibited other less severe brainstem symptoms.
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