Halstead Maneuver

The Halstead maneuver serves as a provocative test used in the clinical evaluation of thoracic outlet syndrome (TOS), a condition characterized by compression of neurovascular structures as they pass through the thoracic outlet. Originally described by Dr. William Halstead in the early 20th century, this maneuver specifically assesses for compression within the costoclavicular space and potentially the interscalene triangle.

Understanding the physiological basis and proper execution of this maneuver is essential for accurate clinical assessment of patients presenting with symptoms suggestive of TOS, including pain, paresthesia, and vascular compromise in the upper extremity.

How to Perform the Halstead Maneuver?

The Halstead maneuver requires careful attention to patient positioning and precise execution to ensure accurate results. The test is performed with the patient in a seated position on the examination table with arms initially in a neutral position alongside the body. The examiner should stand beside the patient, positioned to simultaneously monitor the radial pulse and guide the patient through the required movements.

The test proceeds through the following steps: First, the examiner locates and palpates the radial pulse at the patient’s wrist, establishing a baseline for pulse quality and amplitude. Next, the patient is instructed to extend their neck while maintaining the arm position. This neck extension movement is crucial as it potentially narrows the costoclavicular space. Throughout this movement, the examiner continuously monitors the radial pulse for any changes in amplitude or quality.

As a modification to enhance sensitivity, gentle longitudinal traction may be applied to the patient’s arm while maintaining neck extension. This additional traction potentially increases the compression of neurovascular structures within the thoracic outlet. The examiner should carefully observe for both changes in pulse characteristics and the reproduction of the patient’s reported symptoms.

See Also: Adson Test Maneuver

What is a Positive Halstead Maneuver?

A positive Halstead maneuver is characterized by specific vascular and neurological changes during the test procedure. The primary indicator of a positive test is a noticeable diminution or complete obliteration of the radial pulse amplitude during neck extension. This change in pulse characteristics suggests compression of the subclavian artery within either the costoclavicular space or the interscalene triangle.

Beyond pulse changes, the reproduction of the patient’s symptomatic complaints during the maneuver significantly strengthens the clinical suspicion of TOS. These symptoms may include pain radiating down the arm, paresthesia in the C8-T1 distribution, or sensations of heaviness in the affected limb. The combination of pulse changes and symptom reproduction provides more compelling evidence for neurovascular compression than either finding alone.

Imaging studies have provided anatomical evidence supporting the physiological basis of the Halstead maneuver. Research by Demirbag and colleagues utilized MRI to demonstrate that the maneuver significantly decreases the distance between neurovascular structures and the inferior border of the clavicle within the costoclavicular space, creating a mechanical basis for the observed clinical findings.

See Also: Wright Test

Halstead Test Reliability

Despite its widespread reference in clinical literature and common usage in practice, the Halstead maneuver presents significant limitations regarding its diagnostic reliability. To date, there have been no comprehensive clinical studies that have rigorously evaluated either the validity or reliability of the test for diagnosing thoracic outlet syndrome. This lack of empirical validation represents a notable gap in the evidence base supporting its clinical utility.

The test faces inherent challenges that potentially compromise its reliability. Pulse amplitude assessment remains largely subjective, introducing potential examiner bias and variability. Additionally, research has demonstrated that provocative tests for TOS, including the Halstead maneuver, often produce positive results in asymptomatic individuals, suggesting limited specificity.

Current clinical practice guidelines recommend against relying solely on any single provocative test for diagnosing TOS. Instead, a comprehensive approach incorporating detailed history, physical examination, and appropriate imaging studies is considered the standard of care. The Halstead maneuver should be viewed as one component within this broader diagnostic framework rather than a definitive standalone test.

For optimal diagnostic accuracy, clinicians should utilize the Halstead maneuver in conjunction with other established provocative tests, including the Adson test, Wright test, and Roos test, while correlating findings with imaging studies when clinically indicated.

Clinical Implications

The proper interpretation of the Halstead maneuver requires clinical context and correlation with other diagnostic findings. When positive in conjunction with other supportive clinical evidence, the test may help guide management decisions for patients with suspected TOS. Treatment approaches may include conservative management with physical therapy focusing on postural correction and strengthening of the shoulder girdle musculature, or in more severe cases, surgical decompression may be warranted.

It is worth noting that the diagnosis of TOS remains challenging due to the overlap with other neurovascular and musculoskeletal conditions that can produce similar symptoms. Therefore, a thorough differential diagnosis should always be considered even in the presence of positive provocative tests.

Ongoing research is needed to further elucidate the diagnostic accuracy of the Halstead maneuver and to establish standardized protocols for its execution and interpretation. Until more robust evidence emerges, clinicians should approach the results of this test with appropriate caution and clinical judgment.

Resources

1. Demirbag D, Unlu E, Ozdemir F, Genchellac H, Temizoz O, Ozdemir H, Demir MK. The relationship between magnetic resonance imaging findings and postural maneuver and physical examination tests in patients with thoracic outlet syndrome: results of a double-blind, controlled study. Arch Phys Med Rehabil. 2007 Jul;88(7):844-51. doi: 10.1016/j.apmr.2007.03.015. PMID: 17601463. Pubmed
2. Hooper TL, Denton J, McGalliard MK, et al. Thoracic outlet syndrome: a controversial clinical condition. Part 1: anatomy, and clinical examination/diagnosis. Journal of Manual & Manipulative Therapy. 2010;18(2):74-83. Pubmed
3. Povlsen B, Belzberg A, Hansson T, Dorsi M. Treatment for thoracic outlet syndrome. Cochrane Database of Systematic Reviews. 2010;(1):CD007218. Pubmed