Introduction
Most components of the interview with patients with thoracic spine problems are the same as that conducted when assessing cervical spine patients; therefore the history-taking is not presented in detail. A few points distinct to the thoracic spine are addressed in this chapter, but the detail of the history-taking is the same as that covered in Chapter 10 (cervical history). The physical examination involves the use of movements that are more specific to the thoracic spine. It is also important with symptoms that are located around the scapulae to distinguish between pain that is most influenced by cervical or by thoracic movements. The physical examination, including differential diagnosis, is considered in more depth.
Sections in this chapter are as follows:
• history
differentiating cervical and thoracic symptoms
• physical examination • flexion • • extension rotation repeated movements erect sitting flexion erect sitting extension erect sitting rotation extension in lying prone
supine
static mechanical evaluation
• role of palpation
conclusions following the examination further testing.
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1
CHAPTER TWENTY-EIGHT THE CERVICAL & THORACIC SPINE: MECHANICAL DIAGNOSIS & THERAPYHistory
As mentioned in the introduction, most items of history-taking are the same as those used for neck pain patients, and much of the detail in the chapter on cervical history is relevant here. However, some items that are relevant specifically to the thoracic spine need further comment.
In the thoracic spine the patients age may alert one to the possibility of Scheuermann's disease, which affects adolescents, whilst osteoporosis is a consideration in older patients, especially older women. These and other specific conditions that are relevant to the thoracic spine are considered in the chapters on serious spinal pathology (Chapter 8) and other diagnostic considerations (Chapter 9).
If clinicians wish to use an established functional disability ques tionnaire, as we are not aware of one developed specifically for the thoracic spine it is probably best to use one developed for low back pain rather than neck pain, as generally the functional questions are more relevant.
In non-specific thoracic spine problems symptoms are generally felt around the trunk. The narrowness of the thoracic spinal canal makes a spinal lesion such as a disc herniation at risk of causing an upper motor neuron lesion (Kramer 1990). This may produce lower limb signs and symptoms with minimal thoracic involvement. It is important to be aware of such serious spinal pathologies in the thoracic spine as in other regions; these are considered in more depth in Chapter 8.
Two other important considerations regarding symptoms are their distribution and site. Regarding distribution, a distinction should be made between symptoms that are central or symmetrical and those that are unilateral or asymmetrical. As in other spinal regions, these different types of distribution may require different management strategies.
Centralisation and peripheralisation do occur in the thoracic spine, but symptoms most commonly spread out from the spine laterally, with the pain referred in bands around the trunk. Thoracic pain syndromes can refer pain to the front of the chest, and also they may present as isolated patches of pain over the trunk - the symmetrical or asymmetrical distribution of symptoms should still be considered.
THORACIC SPINE ASSESSMENT
Thoracic presentation in isolated patches on the trunk is probably the reason why spinal problems have been mistaken for visceral disease in the past. Thus, when monitoring symptom response in thoracic spine problems, the most distal symptoms are usually those that are felt most anteriorly or laterally and centralisation is noted when symptoms move toward the spine.
In the thoracic spine onset may either be for no apparent reason or related to trauma, such as whiplash or sudden twisting movements, or sustained positions. Aggravating and relieving factors that may affect symptoms are similar to the lumbar spine: bending, sitting, standing and lying; rotating or twisting the trunk. Sleep is commonly disturbed, and activities that involve thoracic activity, such as laughing, coughing or deep breathing, are frequently painful.
Pain in the thoracolumbar region may be either from the upper lumbar or lower thoracic spines; however, both respond to the same repeated movements. Pain in the cervicothoracic region is more likely to originate from the cervical spine than the thoracic, but again the same repeated movements would produce similar responses wherever the origin of symptoms. In effect, these 'border' regions should be considered to be part of the functional lumbar and cervical spine respectively, and the examination proceeds as described for those regions with some minor adaptations to increase forces in the thoracic region. If symptoms and movement are being improved with, for instance,extension of the cervical and upper thoracic spines, it is not particularly important to pinpoint the segmental level that is causing the disturbance. However, sometimes it may be important to differentiate the origin of cervical and thoracic symptoms.
Differentiating cervical and thoracic symptoms
Since the classic study by Cloward (1959) in which he stimulated cervical discs at surgery and reproduced interscapular pain, several studies have confirmed that pain around the scapulae is commonly caused by cervical disco genic disorders (Roth 1976; Connor and Darden 1993; Parfenchuck and Janssen 1994; Schellhas et al. 1996);
it can also result from stimulation of cervical zygapophyseal joints (Dwyer et al. 1990; Aprill et al. 1990). Thoracic disc disease, at least
of a serious nature, is reported as being uncommon at the upper three or four segments (Arce and Dohrmann 1985; Singounas et al. 1992).
Pain provocation studies involving thoracic zygapophyseal joints suggest limited patterns of referred pain two or three segments inferior
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CHAPTER TWENTY-EIGHT THE CERVICAL & THORACIC SPINE: MECHANICAL DIAGNOSIS & THERAPYto the joint injected (Dreyfuss et al. 1994a). Given this background, pain above a line drawn at the inferior border of the scapulae should be judged to be of cervical origin until proven otherwise (McKenzie 1990). Any associated shoulder and arm pain and any sensory abnormalities in the arm are much more likely to be associated with neck problems.
Other clues to differentiate symptoms of cervical or thoracic origin can be found in the aggravating factors. If neck or arm movements are implicated the former is likely to be the origin; if coughing, deep breathing, laughing or trunk rotation is implicated the latter is likely to be the origin.
If symptom response to initial movements is uncertain and further clarification is necessary, the cervical spine should be examined whilst the thoracic spine is immobilised. This can be done with the patient adopting a slumped sitting posture with the head protruding and the thoracic spine and lumbar spines flexed. It may be necessary for the clinician to restrain or stabilise the thoracic spine in some cases. The location and intensity of pre-test pain should be established once the patient is in this position, and then cervical test movements are performed. If symptom response correlates with cervical movement for instance worse with flexion, better with extension - then this is the likely source. If cervical movements do not particularly affect symptoms, the thoracic spine is the more likely source. If symptoms gradually worsen whichever way the cervical spine is moving, the thoracic spine, being placed in sustained flexion, may be the source.
Physical examination
The principles of assessment in the thoracic spine are just the same as those applied to the cervical and lumbar spines; that is, single move ments are performed to examine range, then repeated movements are performed and the symptoms and mechanical responses noted. Move ments that centralise, abolish or decrease symptoms are indicated; movements that peripheralise or increase symptoms are temporarily avoided. As in other regions of the spine, clues to directional preference may be gained during the history-taking. Movements examined are flexion, extension and rotation in erect sitting. Extension can also be examined in prone or supine; pre-test symptoms are always noted prior to repeated movements.
THORACIC SPINE ASSESSMENT
86 87 88
The posture should be examined. The normal thoracic spine is kyphotic, but an increase should be noted. A protruded forward head posture is often associated with increased thoracic kyphosis, especially around the cervicothoracic junction area. Scoliosis may be present but not relevant to the symptoms (Dieck et al. 1985). The relevance or lack of relevance of any postures is best tested by changing the posture and noting symptom response. Thus, if the patient is Sitting with increased thoracic kyphosis and protruded head, symptoms are noted, posture correction is performed and any symptom change is recorded (Procedure 2).
Movements are examined in the following order:
Flexion
The patient is instructed to 'bend their trunk forward, bringing their head and shoulders towards their knees and then return to the starting position'. Any loss of range of movement is gauged as major, moderate or minor and any pain with the movement is noted.
Extension
Sitting upright on the treatment table the patient is instructed to 'stretch the head, neck and trunk backwards as far as possible and then return to the starting position'. Any loss of range of movement is gauged as major, moderate or minor and any pain with the move ment is noted.
Rotation
The patient sits upright on the treatment table with hands clasped across the sternum and the elbows and hands at chest height. The patient is instructed to 'turn to the right (left), keeping the hands clasped together, pointing the elbow as far behind as possible, and
CHAPTER TWENTY-EIGHT
1457
Photos 86, 87, 88: From
slumped position (86), genlle
pressure on the spine and sternum restores the lordosis
(87). Gentle pressure at the chin and thoracic spine cormcts the head posture
(88). Symptom response is monitored before and after.
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CHAPTER TWENTY-EIGHT THE CERVICAL & THORACIC SPINE: MECHANI AL DIAGNOSIS & THERAPY then return to the starting position' . Ensure that true rotation is performed by ensuring the hands remain on the sternum, rather than the patient simply sliding their arms around the trunk. Any loss of range of movement is gauged as major, moderate or minor and any pain with the movement is noted.Repeated movements
The repeated movement part of the physical examination provides the most useful information on symptom response and is the ultimate guide in identifying the management strategy to be applied (McKenzie 1981, 1990). A decrease, abolition or centralisation of pain is a reliable indicator of which movement should be chosen to reduce mechanical deformation. An increase or peripheralisation of pain is just as reli able to indicate which movements should be avoided. This, the cu mulative effect of the movement, provides the most important detail concerning the patient's symptomatic response - that is, whether they are worse, no worse, better, no better or the pain has centralised or peripheralised. These responses provide the clearest indication for the appropriate management strategy. The role of repeated movements is discussed more fully in Chapter 11, and the terminology to record symptom responses is described in Chapter 12.
Erect sitting flexion
The intensity and location of existing symptoms are noted, in par ticular the location of the most distal symptoms. The patient sits upright on the treatment table with hands over the shoulders to apply overpressure. The patient is instructed to slump so that the spine, from the neck to the sacrum, is in a fully flexed position. On reaching maximal flexion the patient returns to upright erect sitting. The effects of performing the movement once are recorded. The test movement should be repeated ten to fifteen times, or enough times to influence the symptoms, with overpressure being applied if the initial active movements have no effect. Symptom response is noted during the repeated movements, and most importantly a minute or so after a cycle of repeated movements.
THORACIC SPINE ASSESSMENT
89 90
Photos 89, 90: Flexion - overpressure can be applied through tbe upper thoradc transverse processes.
Erect sitting extension I Photo 91: Extension.
The intensity and location of existing symptoms are noted, in particular the location of the most distal symptoms. The patient sits upright on the treatment table with hands clasped behind the neck. The patient is instructed
to arch backwards to extend the 91
trunk as far as possible and point the elbows towards the ceiling. On reaching maximal extension, the patient returns to upright erect sitting. The effects of performing the movement once are recorded. The test movement should be repeated ten to fifteen times, or enough times to influence the symptoms. Symptom response is noted during the repeated movements, and most importantly a minute or so after a cycle of repeated movements. Sometimes overpressure applied by the clinician is necessary to generate
the symptom response.
Erect sitting rotation
The intensity and location of existing symptoms are noted, in particular the location of the most distal symptoms. The patient sits upright on the treatment table wi.th hands clasped across the sternum and the elbows and hands at chest height. The patient is instructed to turn to the right (left), keeping the hands clasped over the sternum, and point the elbow as far behind them as possible. Ensure that true rotation is performed by ensuring the hands remain on the sternum, rather than the patient simply sliding their arms around the trunk. On reaching maximal rotation the patient returns to upright erect sitting. The effects of performing the movement once are recorded.
460
I
Ci-IAPTE� TWENTY-EIGHTPhotos 92, 93, 94: Rotation overpressure is applied by increasing the speed of the mcmoeuvre,for instance by getting the patient to strike the clinician's hand with the elbow.
THE CE�VICAL & THORACIC SPINE: MECHANICAL DIAGNOSIS & THERAPY
92
93
94
Prone
The test movement should be repeated ten to fifteen times, or enough times to influence the symptoms. As repetitions are per formed the patient is instructed to move further into rotation; this is best done by rotating swiftly and vigorously as if striking an object behind with the elbow. Symptom response is noted during the repeated movements, and most importantly a minute or so after a cycle of repeated movements.
Extension in lying
Further testing can be performec;! in an unloaded posture if information from the previous test movements has been insufficient. Extension should be performed in prone as for the lumbar spine and in supinelas for the cervical spine. The formerlaffects predominantly lower thoracic segments, whilst the latter affects upper thoracic segments.
The intensity and location of existing symptoms are noted, in particular the location of the most distal symptoms. The patient lies prone on the treatment table with hands under the shoulders as for the traditional extension in lying exercise. The patient is instructed to straighten the arms and lift their upper body whilst the lower half, pelvis down, remains on the table. Upon fully extending the elbows, the patient returns to prone lying. The effects of performing the move ment once are recorded. The test movement should be repeated ten to fifteen times, or enough times to influence the symptoms. With repetition the patient must fully extend the elbows and let the trunk sag from scapulae region to pelvis, and push the chesL forward. These additions should ensure maximum thoracic extension is achieved. Symptom response is noted during the repeated movements, and most importantly a minute or so after a cycle of repeated movements.
THORACIC SPINE ASSESSMENT
Supine
The intensity and location of existing symptoms are noted, in par ticular the location of the most distal symptoms. The patient lies supine on the treatment table with the head and neck unsupported to the level of the fourth thoracic vertebra. They lower the head and neck until the cervicothoracic region is fully extended. Upon gaining maximum extension, the patient returns to a neutral position using their hands for support. The effects of performing the movement once are recorded. The test movement should be repeated ten to fifteen times, or enough times to influence the symptoms, with the repetitions ensuring that maximum range is gained. Symptom response is noted during the repeated movements, and most importantly a minute or so after a cycle of repeated movements.
Static mechanical evaluation
On occasions repeated movements and overpressures are not the appropriate mechanical forces to provoke or influence symptoms, especially in postural syndrome. In such patients sustained postural loading is necessary to provoke symptoms. Most commonly this is due to sustained thoracic flexion, as in the slumped Sitting posture; symptoms may also be present in the cervical and lumbar regions. In such cases postural correction and the resumption of an erect sitting pcfsture will abolish symptoms. This is best tested by having the patient maintain a relaxed, unsupported sitting posture during the history-taking. Usually such patients adopt a slumped posture, and it will be sustained for fifteen to twenty minutes whilst the patient is being interviewed. At the end of the interview, the procedure of posture correction is performed and symptoms present before and after correction are recorded (Procedure 2).
For testing sustained positions the same procedure is adopted for different postures. Intensity and location of pain is noted prior to the adoption of the position; the posture is sustained for at least three minutes. Sometimes a longer period will be reqUired; symptom response is noted during the sustained posture and on return to erect sitting posture. It is important to note that responses to sustained postures are different for different mechanical syndromes. In derange ment syndrome flexion may sometimes give temporary relief despite the directional preference being for extension, but more typically there is an increase or peripheralisation of symptoms. In patients
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CHAPTER TWENTY-EIGHT THE CERVICAL & THORACIC SPINE: MECHANICAL DIAGNOSIS & THERAPYwith thoracic extension dysfunction, sustained flexion will have no effect, with symptoms only being reported on end-range extension. Sustained loading in flexion, given the appropriate time period, will generate symptoms in patients with postural syndrome.
Sustained postures are as described in the chapter on procedures, and may include the following. The sleeping position may have to be examined if this is one of the aggravating factors.
•
•
•
•
sitting sustained flexion extension in lying prone extension in lying supine
rotation in sitting.
Role of palpation
The ability of clinicians to agree on findings obtained from palpation of motion abnormalities or segmental levels has not been substantdted in the lumbar spine (McKenzie and May 2003) nor in the cervical spine (see Table 9. 1). Inter-practitioner agreement on the presence of a finding actually constitutes a test of internal validity and is not
simply a measurement of reliability only (Nansel et al. 1989). If inter
rater reliability is poor the clinical phenomenon may not exist, and certainly not in any consistent way that gives it clinical value. Little similar work has been done that speCifically pertains to the thoracic spine, but extrapolation from the other areas and the little work