NO MAN’S LAND:
PAIN AND DYSFUNCTION IN THE THORACIC
REGION
AJ Cushman, SPT
PURPOSE
•
Better understand of functional connection between c-spine and l-spine
•
Review red flags
•
Referral patterns (visceral vs joint)
•
Associated diagnoses
•
Involved structures affecting thoracic spine pain and additional treatments/exercises
•
The effect of thoracic spine dysfunction on other areas (shoulder, neck, low back, chest
wall)
•
Importance of proper breathing mechanics and exercises to consider
•
Is laughter really the best medicine?
EPIDEMIOLOGY
•
Prevalence of musculoskeletal origin ranges from 4.0-72%
• Evidence lacking in definitive answers
•
Most common cause = muscle irritation caused by decreased strength/poor posture
•
Association between cervical stenosis and thoracic stenosis
•
Associated with primary/secondary osteoporosis (esp vertebral fx/hyperkyphosis from
bone loss), ankylosing spondylitis, OA, and Scheuermann’s disease.
•
Common site for inflammatory, degenerative, metabolic, infective, and neoplastic disease
•
Higher prevalence in kid/adolescent, W>M
• Proposed: backpack weight/unilateral carry, heavy purses
•
Significantly associated with concurrent musculoskeletal pain; growth and physical;
lifestyle and social; backpack; postural; psychological; and environmental factors
RED FLAGS
•
Violent trauma
•
Minor trauma, even strenuous lifting, in people with osteoporosis
•
Age of onset less than 20 or over 50 (new pain)
•
Hx of cancer, drug abuse, HIV, immunosuppression or prolonged use of corticosteroids
•
Constitutional symptoms – fever, chills, unexplained weight loss
•
Recent bacterial infection
•
Structural deformity
•
Severe progressive neurological deficit in LE
•
Pain is:
• Constant, severe, and progressive
• Non-mechanical without relief from rest/postural changes
• Unchanged after 2-4 weeks of treatment
• Severe morning stiffness (rheumatoid arthritis and ankylosing spondylitis)
Condition
Data from interview/Hx
Data from Physical Exam
Stable vs Unstable Angina
Pectoris
Symptoms that occur w/
predictable level of exersion
vs unpredictable patterns
Alleviated w/ sublingual
nytroglycerin vs not
consistently alleviated
Myocardial Infarction
Reports chest pain, hx of
CAD, HTM, DM-2, smoking,
M>40, W>50
Palor, sweating, dyspnea,
nausea, palpitations, s/s last
longer than 30 min and no
relief w/ sublingual
nytroglycerin
Pericarditis
Sharp/stabbing chest pain.
May refer to lateral neck or
either shoulder
Inc pain w/ side-lying (esp L)
Dec pain w/ fwd lean in
sitting (arms supported)
Spinal fx
Hx fall/MVA (trauma),
osteoporosis, prolonged
steroid use, >70, loss of
func/mobility
Midline tenderness at level of
fx, bruising, LE neuro
deficits, increased thoracic
kyphosis, heel drop test,
percussion test
Pneumothorax
Recent bout of coughing,
strenuous ex, trauma
Chest pain intensify w/
inspiration, difficulty
expanding ribcage,
hyperresonance upon
percussion, dec breath
RED FLAGS
Condition
Data from Interview/Hx
Data from Physical Exam
Chest, shoulder, upper
abdominal pain, dyspnea, hx
of, risk of DVT (Wells
Prediction Rule)
Dyspnea, tachynea,
tachycardia
Pneumonia
Pleuritic pain- can refer to
shoulder
Fever, chills, HA, malaise,
nausea, productive cough
Neoplasm
Unexplained wt loss,
constant/progressive pain,
night pain
No relief w/ position changes
Pleurisy
“knife-like” pain w/
inspiration, hx of recent/coexisting respiratory disorder
Dyspnea-dec chest wall
excursion
Cholecystitis (gallbladder)
Right upper quadrant and
scapular pain. Fever, nausea
and vomiting. 1-2 hours after
a fatty meal.
RED
FLAGS
PE
REFERRAL PATTERNS
C-spine/T-spine
Visceral
JOINT REFERRAL PATTERNS
T-spine zygapophyseal Joint Pain
•
Deep/dull ache, nauseating, boring,
cramp-like
•
Trend for cephalad joints to be slightly
more painful
•
Consistent pain reproduction: one
segment inferior and slightly lateral
• All referred inferior (no more than
2.5 segments)
• No more superior than ½ segment
• Unilateral only – approached, but
not crossed midline
• No radicular pain to ant/lat chest
wall
Costotransverse Joint Pain
•
Similar distribution, quality, severity as
facet joints
• Patterns unreliable in diagnosis
•
All joint innervated by dorsal rami
• Facet = medial branches
• Costotransverse = lateral
branches
• Costovertebral = sympathetic
innervations from corresponding
levels
T4 SYNDROME
• Includes glove-like paresthesias
of one or both upper limbs,
referred pain into the neck and
scapular regions, and a dull,
aching generalized headache.
• Successful treatment has been
reported in case studies using
manipulation and exercise
intervention
• Both the thoracic intervertebral
disks and thoracic zygapophyseal
joints are thought to be primary
pain generators
costotransverse may play a
role as well.
OTHER DIAGNOSES RELATED TO T-SPINE
Costochondritis
•
Assess breathing patterns and correct
if necessary
•
Stretch/stabilize chest/scapulohumeral
structures
•
Mobilize
Thoracic outlet syndrome
•
Correct movement impairment
•
PROM for cervical musculature
•
Stretch!
• Levator Scapulae
• Scalenes
• Costovertebral
• Pec minor
• Costosternal
• Sternoclavicular
• Involved ribs (most common are
4th-6th)
•
Potential rib mobs/MET
Scheuremann’s Kyphosis
•
Exercise to decrease lumbar lordosis
through:
• Tilting of pelvis
Scoliosis
•
Stabilize
•
Bracing for curves > 25-40 degrees
•
Promote motions opposite to lateral
curvature
•
Postural education
•
Spine ROM
• Hamstring stretching
•
Correct kyphosis by:
• Foam roller
• Hyperextension of thoracic spine
•
Correct movement impairment
•
Mobilize
•
Education
•
Various bracing devices may be
required to help stabilize
JANDA CROSSED SYNDROMES
RIB INVOLVEMENT
•
Pump-handle vs bucket-handle
•
ER with elevation
•
Find depressed rib with inspiration – Find elevated ribs with expiration
•
Assess gross distraction and approximation by placing fingers between intercostal spaces
and then side-bend ispilaterally and contralaterally
•
Joints:
• Costovertebral, costotransverse, costochondral, sternocostal
•
Common problem areas: thoracic inlet/first rib
1ST RIB
Assessing 1 st rib symmetry:
•
First rib MET
• Scapula retraction
To mobilize L 1 st rib:
•
Clinician places his/her own R foot on
table beside patient’s R side
•
Patient drapes R armpit over clinician’s
thigh (Patient may need to sit side-saddle
with feet facing L)
•
Clinician places thumb on L 1 st rib
•
Clinician glides patient R by moving knee
laterally cause patient to L SB to
barrier
•
Pt L rotate to barrier
•
Pt extension barrier
•
Cue pt submax contraction in R fwd
diagonal for 4-5 breaths keeping
constant pressure on 1 st rib (May
continue w/ UT stretch while maintaining
pressure on 1st rib)
• Draw UT posterior
• Apply downward pressure
• Equal + non tender = normal
• Single side1/4-1/3 in higher
= elevated rib
• Single side 1/3-1/2 in =
subluxed rib (may notice
ulnar distribution neuro
signs)
• >1/2 in = cervical rib
STERNOCLAVICULAR JOINT
ASSESS
•
Place index finger at the proximal ends
of the clavicle (sides of the sternal
notch) to view symmetry
•
(In supines) Ask pt to shoulder
shrug observe for equal inferior
glide
•
(In supine) Ask pt to protract shoulders
observe for equal posterior glide
TREAT L SC jt
•
Bring supine pt to barrier of L shoulder
flexion w/ caudal pressure to proximal
clavicle
•
Ask pt to provide submaximal (1lb) of
resistance against shoulder elevation
while clinician proved caudal glide to
proximal end of clavicle
•
8 sec, 4-5x
Exercises for Mid-thoracic dysfunction
• The Brügger relief position: To
prevent the tendency to hyperextend
the lumbar spine with this exercise, it
should be performed with active
exhalation. Promotes upright posture
through entire chain.
• The back stretch on the ball. It
promotes improved respiration. Also
challenges balance. (Modification:
foam roller in vertical orientation
along midline while sliding arms down
to 90/90)
• Kolár's wall slide with arm
elevation combines arm elevation,
squatting and breathing. Patients may
also feel stretch in lattismus dorsi with
this exercise.
GENERAL
• MOBILIZE
• Extension
• Rotation
• P-A mobs along vertebral segments
• T-spine/C-T spine manips
• CV/CT mob/manip
• Stretch/strengthen where appropriate
• Address trigger points
• Dry needling
• Ischemic compression (30-60 seconds) > strumming
EFFECT OF INCREASED KYPHOSIS ON
SUBACROMIAL SPACE
•
Increased kyphosis  linked to scapular dyskinesis
• decreased posterior tilt, ER, and upward rotation of the scapula
• excessive scapular protraction/downward rotation
• prevents elevation of acromion and increases pressure on subacromial space.
• affect kinematics at glenohumeral joint
•
Increased kyphosis also associated with:
• Decreased physical function
• Respiratory function impairments
• Increased cervical pain
•
Wall-occiput test (WOT)
• Detect occult thoracic vertebral fractures
• (+): Unable to touch wall with occiput while head is neutral and back and heels are
against the wall.
•
Rib-pelvic distance test (RPDT)
• Detect occult lumbar vertebral fractures
• (+): <2 finger widths between inferior margin of ribs and iliac crest.
•
Findings:
• Prevalence of thoracic kyphosis was significantly higher in subjects with subacromial
impingement syndrome. Suggests influence of shoulder angle elevation.
• 15 degrees of thoracic extension required for full bilateral arm elevation (9
degrees for unilateral elevation)
• (+) WOT might indicate restriction in thoracic spine mobility (even though it does not
evaluate thoracic extension), but only reduction in shoulder elevation (RSE) was
significantly associated with SIS directly.
THE INFLUENCE OF THE MOBILITY IN THE
CERVICOTHORACIC SPINE AND THE UPPER RIBS
(SHOULDER GIRDLE) ON THE MOBILITY OF THE
SCAPULOHUMERAL JOINT
• Relation between Mobility in Shoulder Girdle and
Scapulohumeral Joint
• Importance of the function of the clavicle for the anteflexion
and abduction motions in the scapulohumeral joint.
• These motions depend on function of ligamentum
costoclaviculare and the musculus subclavius.
• The tension in these structures will change when the first
rib remains immobile  restriction in mobility of the first
rib can cause a restriction of mobility in the
scapulohumeral joint.
•
Relation between Mobility in Cervicothoracic Spine and First Rib (Shoulder Girdle)
• 1st rib mobility restriction during inspiration associated with Thoracic Outlet
Syndrome
• Costoclavicular, anterior/middle scalene, pectoralis minor, cervical rib
•
To test for restriction in mobility:
• Cervical rotation later flexion test (CRLF test)
• Expiration Inspiration test.
• In 28/32 patients with 1 st rib restriction, rotational restriction combined with twisting at
C7-T1 was detected
CRLF test
Expiration Inspiration test
• Relation between Mobility in the Spine and the Scapulohumeral
Joint
• Rotation between C6 and T4 toward the anteflexion side is
necessary for an anteflexion motion of the arm
• Restriction of mobility of the cervicothoracic spine 
disturbances in this anteflexion motion
• Observe a restriction in anteflexion and/or complaints
caused by a much stronger participation of the muscles
involved in the motion
CHRONIC NECK PAIN IN YOUNG ADULTS:
PERSPECTIVES ON ANATOMIC DIFFERENCES
•
To identify anatomical predictors for chronic neck pain (NP) using MRI
• Sagittal alignment
• Dimension of thoracic inlet (manibrium, first rib, T1, etc)
•
Depth of T1-manubrium arch (T1AD) (mm) = midsagittal distance between top of the
manubrium and the tip of T1 spinous process
•
Thoracic inlet inclination (TiI) (degrees) = Angle between lines drawn along top of
manubrium to center of superior aspect of T1 end plate and horizontal
•
Both T1AD and TiI were identified as predictors for NP in binary logistic regression
analysis
OTHER C-SPINE CONSIDERATIONS
Region-specific history
•
“Do neck movements improve your
symtptoms?” (+LR) of 2.2, (-LR) or 0.5
•
“Where is the pain most bothersome?”
If answer “shoulder/scapula area,”
(+LR) 2.3
EVALUATING KYPHOSIS AND LORDOSIS IN STUDENTS BY
USING A FLEXIBLE RULER AND THEIR RELATIONSHIP WITH
SEVERITY AND FREQUENCY OF THORACIC AND LUMBAR
PAIN
•
Lumbar arch was 34.46°±12.61° and 22.46°±9.9° in female students and male students,
respectively. Lumbar lordosis showed a significant difference between the two student
groups (p<0.001),
•
No difference in the thoracic curvature (p=0.288)
•
No significant relationship was observed between kyphosis and inter-scapular pain
(p=0.946)
•
Significant relationship between lordosis and lumbar pain severity (p=0.006).
THE EFFECTIVENESS OF NONINVASIVE INTERVENTIONS
FOR MUSCULOSKELETAL THORACIC SPINE AND CHEST
WALL PAIN: A SYSTEMATIC REVIEW BY THE ONTARIO PROTOCOL FOR TRAFFIC
INJURY MANAGEMENT (OPTIMA) COLLABORATION
•
Lehtola et al randomized females with thoracic spine pain (≤ 3-month duration, T3-T8).
Interventions performed 4x/week for 3 weeks
•
(1) high-velocity thrust spinal manipulation,
• (2) needle acupuncture, or
• (3) placebo electrotherapy with intermittent suction.
• Results: small statistically significant differences in pain reduction favoring
manipulation 1-week postintervention. No significant difference in long term
outcome.
•
Stochkendahl et al randomized recent-onset anterior chest wall pain (<7 days) to
• (1) Receive a multimodal program of care OR
• (2) Consultation with a chiropractor
• Statistically significant improvement in “worst chest pain” reduction favoring the
multimodal care, however, change was not clinically important. Also more likely to
report chest wall pain was “better or “much better” in short term.
• **(Study weakness: DOSAGE)
THE IMMEDIATE EFFECT OF THORACIC SPINE
AND RIB MANIPULATION ON SUBJECTS WITH
PRIMARY COMPLAINTS OF SHOULDER PAIN
•
Relative contribution of specific manipulative techniques applied to the cervical spine,
thoracic spine, and/or ribs.
•
Report the immediate effects only
•
Exclusion: diagnostic evidence of rotator cuff tear
•
VAS pain intensity scores decreased by 32mm post-treatment (p<0.01), thus surpassing
the MCID of 12mm 25.
BREATHING
•
Breathing glides the median nerve 1 inch
•
Influences sympatho-vagal balance
• Dysfunctional breathing can induce hypocapnia (from hyperventilaiton)
• Increased neural activity/synaptic tranmission
• linked to muscle tightness and resting tone
•
Breathing mechanics
• Diaphragmatic breathing benefits: relaxation, mobility, and core activation.
• Using breath with core in natural, more efficient pressurized stability than isolated
transverse abdominis.
IMPORTANT ANATOMICAL COMPONENTS
•
Diaphragm: RESPIRATION AND STABILITY…should be able to perform this dual function all
the time
•
•
Abdominals and pelvic floor
•
•
With poorly trained system, diaphragm loses stabilizing function to focus on respiration
with increased activity/exertion inability to control intra-abdominal pressure
(IAP)INJURY!
During inspiration these muscle contract eccentrically to increase intra-abdominal
pressure
Thoracic Cavity
•
Where the magic happens…
•
Must have enough mobility available to accommodate pressure change/molecule flow
•
Ribs ER and spine extends
•
Breathing hydrates thoracic disc with ribs acting as a lever to pry open thoracic spine with
each breath
CHECK YOURSELF
•
Ideal pattern at rest = slow, light, mainly abdominal breathing increases oxygenation of
human body.
• >12 diaphragmatic breaths per minute w/ about 500mL per breath OR deep
diaphragmatic breathing that causes CO2 losses = hyperventilation
• Reduces O2 delivery to vital organs
•
Test predominant automatic breathing technique: One hand over stomach and other over
upper chest. Observe pattern for 20-30 seconds.
•
Exercise 1: Same position, but breath so that your rib cage/upper hand don’t move
•
Exercise 2: In supine, place phonebook (or equivalent weight) and abdomen. Breath so
the books lift 2-3 cm without expanding the ribs.
•
Exercise 3: Breathing with belt around rib cage (cannot take deep inhalation with
ribcage/chest. Can be done for minutes/hours. Focus enhances nervous system links to
muscular control.
5 TECHNIQUES
•
Lateral shift correction
• Push on hip with arm against wall, hold end range for 3-5 breaths (should total to 2030 seconds with proper breathing technique)
•
Repeated extension in lying
• Improvement on “sag” overpressures, see hip drops closer to table
• Extend head/neck as well to put further slack on posterior chain muscles
•
Open book thoracic rotation
• Chronic cervical, glenohumeral, and lumbar issues
• Hold upper LE down with bottom hand, and place top hand on sternum and pull in
opposite direction for thoracic rotation.
•
Standing (or kneeling) psoas stretch
• Posterior pelvic tilt, hip IR, isometric glute contraction
•
Standing Hamstring/Sciatic Neurodynamic Tensioner
• Anterior pelvic tilt, hip adduction, IR, ankle dorsiflexion
LAUGHTER YOGA:
IS LAUGHTER REALLY THE BEST MEDICINE AFTER ALL??
•
Compare compare muscle activation between traditional low back stabilization
•
Overall mean activity at highest intensity laughter yoga was comparable to traditional
exercises
• Internal oblique exceeded abdominal crunch by 150%.
•
Stronger emphasis on self-organized muscular control, where traditional exercises are
controlled in a cognitive manner.
•
Laughter associated with presence of co-activation for back and abdominal muscles
•
Rhythmic, high frequency, less stereotypical
REFERENCES
•
Briggs, Andrew et al. “Thoracic Spine pain in the general population: Prevalence,
incidence and associated factors in children, adolescents and adults.” European Journal
of Medical Research. June 2009.
•
Lee, Ji-Hye et al. “Chronic neck pain in young adults: perspectives on anatomic
differences.” The Spine Journal. Vol 14, Issue 11, pages 2628-2638. 2014-11-01.
•
Religioso III, Erson. “5 Techniques to Try With Diaphragmatic Breathing.” The Manual
Therapist: The Blog of the Eclectic Approach. Jan 2013.
•
Sedigheh-Sadat Mirbagheri et al. “ Evaluating kyphosis and lordosis in students by
using a flexible ruler and their relationship with severity and frequency of thoracic
and lumbar pain.” Asian Spine Journal. 416-422. June 2015
•
Sobel, JS et al. “Review of the literature. The influence of mobility in the
cervicothoracic spine and upper ribs (shoulder girdle) on the mobility of the
scapulohumeral joint.” Journal of Manipulative & Physiological Therapeitcs. (7): 46974. (16 ref). Sept 1996.
•
Southerst, Danielle et al. “The Effectiveness of Noninvasive Interventions for
Musculoskeletal Thoracic Spine and Chest Wall Pain: A Systematic Review by the
Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.” Journal of
Manipulative and Physiological Therapeutics. National University of Health Sciences.
2015.
•
Strunce, Joseph et al. ‘” The immediate effect of thoracic spine and rib manipulation on
subjects with primary complaints of shoulder pain.” The Journal of Manual & Manipulative
Therapy. 17(4): 230-236. 2009.
•
Wagner, Helko et al. “Laughing: A demanding exercise for trunk muscles.” Journal of
Motor Behavior. Vol 46, Issue 1, pages 33-37, 2014.
•
Young, Brian A, et al. “Thoracic costotransverse joint pain patterns: a study in normal
volunteers.” BMC Musculoskeletal Disorders. Oct 2008.