T-Spine Manipulation- Cohen Flashcards
T/S Pain
- Viscera and T/S w/ shared innervation
- pts w/ primary c/o T/S pain should have ht’d awareness for non msk disorder
Visceral referral pain to the T/S
see pics
- Cardiac Ischemia
- Dissecting thoracic aneurysm
- Peptic ulcer
- Cholecystitis
- Renal infection and kidney stones
Serious Cond’s Causing T/S Pain
see pics
- Fx
- Neoplastic cond’s
- Inflammatory disorders
- Inflammatory or Systemic Dis’s
Pot sources of mechanical t/s pain
3
- Thoracic facet jts
- Thoracic IVD
- Soft tissue
Pot sources of mech. t/s pain
Thoracic facet jts
- pain local to jt
- may inc w/ closing
- EXT and ipsilat s/b
Pot sources of mech. t/s pain
Thoracic IVD
- more common in lower t/s, can refer to abdominals and hip
- diffuse pain, may radiate ant.
- thoracic nerve root lesions uncommon
- possible directional preference of EXT
- Thoracic disc herniation in imging is common in those W/OUT pain
Pot sources of Mech t/s pain
Soft tissue
trigger pts common in upper t/s and scapular region
NOTE about t/s mechanical sources of pain
Probably not possible, nor necessary to ID the exact structural cause of t/s pain and all MSK pain as multi-factorial causes
Mech sources of rib pain POSTERIORLY
2:
- Costovertebral jts
- Costotransverse jts
Mech sources of rib pain ANTERIORLY
2:
- Costosternal jts
- Costochondral jts
T/S pain referral patterns
- Pain mapping shows that thoracic facet and costotransverse jts refer pain locally OR @ most 1 lvl above or below
Cervical referral patterns:
- Cervical facet jts and discs refer pain to the thoracic and periscapular area
- Cervical radiculopathy→ pts often report periscapular area pain
Cervical radiculopathy
Pts often report pain referral to_______
Periscapular area
Can mechanical t/s pain mimic visceral pain?
- shared innervation and convergence of primary afferent into the spinal cord
- Sympathetic division of ANS originates from T1-L2 (big region)
- Viscera below diaphragm receive sympathetic innervation from below T5
Pseudo visceral pain
see pics
Pseudoanginal pain
- T4-T7 segs freq’ly implicated in this phenomenon
- 6 reports of anginal pain relived by manipulation of mid t/s segs
Mgmt of chest pain:
appraisal of most probable cause (“initial dx”)
- Ischemic heart dis→ 50%
- MSK pain→ 22%
- Psychiatric dis/anxiety→ 12%
- pulm dis→ 5%
- dyspepsia→ 5%
- GI dis→ 3%
- other (arrhythmia, HTN crisis)→ 3%
Chest Wall Syndrome
- Most common cause of Ant. chest pain in pts presenting to primary care is benign
- Usually loc’d in ant chest wall and is MSK in nature
- 20-45%
Abdominal pain of MSK origin
Responses to following questions predict that abdominal sx’s are likely of MSK origin:
-
YES to both:
- Does taking a deep breath aggravate your sx’s?
- Does twisting your back aggravate your sx’s?
-
NO to ALL 3:
- Has there been any change in B&B habit since onset of sx’s?
- Does eating foods aggravate your sx’s?
- Has there been any wt change since onset of sx’s?
T4 Syndrome
RARE
Most hypOmobile segment
Clinical features:
see pics
Assess of pt w/ T/S pain
- assess for red flags
- assess adj. regions
- c/s
- shoulder
- L/S
- ID t/s impairments
- mvmt impairs
- sensitivity to loading
More assess of pt w/ T/S pain
- Hx→ trauma vs overuse
-
Area of sx:
- t/s vs ribs, c/s referred pain, visceral
-
Aggravating factors:
- sustained postures vs dynamic acts.
-
Special ?’s:
- night pain
- chest pain
- abdom. pain
- neuro sx’s
T/S and Rib Composite Exam
- Observation/posture
- Screen C/S
- T/S AROM, AROM w/ overpressure
- palpation
- segmental mobility
- Thoracic central and U/L PA glides
- Rib PA’s and AP’s
- muscle length
- lats, pecs
- muscle strength
- mid/lower traps
- Serratus ant.
T/S Assessment
Mechanical T/S pain
*NOTE: usually rotation affected→ Facets, T/S
- painful + restricted t/s ROM and t/s seg. mobility
- AND/OR
- pain w/ sustained t/s loading
T/S Assessment
Mechanical Rib Pain
*NOTE: usually S/B→ rib issue, CV or CT jts
- painful + restricted t/s ROM +/- painful breathing
- painful + restricted rib seg. mobility
T/S pain evidence for mgmt:
- NO high qual evidence for mgmt of primary t/s or ribcage pain
- 1 low qual RCT suggests benefit of man tx + ex for pts w/ primary t/s pain
- Regional interdependence
- mod evidence for t/s manipulation in mgmt of indiv’s w/ neck pain
- conflicting evidence for shoulder disorders
T/S and C/S Connection
- Mvmt of C/S associated w/ mvmt of T/S
- T1, T6, T12 segs all move during C/S mvmts***
- excursion from full c/s protraction to retraction involves 30% and 10% contributions from lvls C4-T4 and T5-T12 respectively
Evidence for T/S Manipulation in Neck Pain
-
T/S manip usually included as part of multi-modal tx package
- diff to separate out effects
-
Cond’s studied:
- mech. neck pain
- C/S radiculopathy
- WAD
-
Majority studies show + effects compared to:
- competing intervents
- sham manip→ just putting them into pos.
- controls
T/S Manipulation for Neck Pain Rationale***
- Potentially safer than C/S manip
- tx neck pain w/out tx neck
- Can be used when neck is irritable
- acute c/s radiculopathy
- Acute WAD or neck pain
T/S Manipulation
Huisman 2013
10 studies (677 pts)
- 8/10 studies showed sig reduction in pain and disability for pts w/ mech. neck pain
T/S Manipulation for C/S Radiculopathy
Young et al and Cleland
- Included @ least one manual tx tech targeting upper and mid t/s in multimodal tx package for pts w/ c/s radiculopathy
Does the technique matter?
- All studies done on pts w/ neck pain
- TS manips may have greater short term effect compared to mobs
- TS manip + CS manip/mobs may have greater short-term effect compared to CS manip/mobs alone
-
Choice OR direction of tech. does not affect immediate outcomes
- seated, supine, prone
Regional Interdependence:
Thoracic spine and Shoulder
- Upper t/s Ext and ipsilateral s/b REQUIRED for end-range shoulder Flex
- Restricted t/s mobility→ subAC patho
- Restricted upper rib mobility→ s/s consistent w/ subAC impingement or TOS***
T/S and Shoulder Girdle
-
Incd T/S kyphosis leads to reduced shoulder elevation ROM
- assoc’d w/ pain?
- Full B/L shoulder elevation assoc’d w/ on avg 12 degs of t/s Ext (lower>upper)
- close to total amt of t/s Ext available***
T/S Kyphosis and Shoulder Elevation
- Taping to reduce t/s kyphosis lead to inc in shoulder flex and scap plane ABD in some people w/ and w/out shoulder pain
- Pain was unchanged in people w/ sx’s
- Deg of elevation where they reported pain was higher
T/S Manip and Shoulder Pain
- Part of multimodal program in pts w/ shoulder pain
- Pilot studies found immediate effects of TSM on shoulder pain and/or ROM
- No diff in indiv’s w/ SubAC impinge
Shoulder Pain and the Upper Ribs
see pics
T/S and Tennis Elbow
- 70% indiv’s w/ tennis elbow reported c/s or t/s pain compared to age match controls
- Local pain in elbow was elicited w/ TS spring testing in almost half pts w/ tennis elbow
T/S Neurodynamics **
- Phys health and mobility of TS may effect spinal neurodynamics
- Consider assess of TS in pts w/ sx’s brought on by neurodynamic testing
- Ex. Slump Test
Mech. Effects of TSM
see pics
Neurophysiological Effects of TSM
see pics
T/S Summary
- Primary T/S or Rib pain should alert clinician to possible Red Flags
- SCREEN!
- Lower c/s frequently refers to Upper t/s
- Mgmt of MSK t/s disorders→ focus on impairs w/ mobility deficits
- Regional interdependence of T/S and neck pain and shoulder pain
T/S PA’s
Spring Testing
see pics for instructions
Used for assessment and mobilization
T/S Manipulation
INDICATIONS (DO)
- Neck pain
- c/s radiculopathy
- c/s HAs
- WAD
- t/s pain
- shoulder pain
- Lat elbow pain
- stiffness w/ t/s testing
- restricted CS and TS ROM
TS Manips
CONTRAINDICATIONS (DO NOT DO)
- Osteoporosis (known or @ risk for)
- Hx of OR active neoplasm
- Fx of TS
- Spinal infection
Manual Therapy Clinical Decision Making
- Functional test/pain score/location of sx’s→ basic manual exam→ manual intervent→ reassess functional tests/pain score/loc of sx’s
- *Consider:
- safety
- irritability
- pt comfort
- pt expects
- clinician skills
- Baseline outcome measures→ reassess @ follow-ups
- PSFS
- NDI
- NPRS
Seated Mid-TS Thrust Manip
see pics
Prone TS Manip w/ Thrust
see pics
CTJ Distraction Manipulation w/ Thrust
*Full Nelson one
see pics
