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Current Concepts of Orthopaedic Physical Therapy, 3rd Edition APTA American Physical Therapy Association CONTINUING Independent Study Course 21.2.7 The Thoracic Spine and Rib Cage: Physical Therapy Patient Management Utilizing Current Evidence William Egan, PT, DPT, OCS, FAAOMPT Temple University Philadelphia, Pennsylvania Scott Burns, PT, DPT, OCS, FAAOMPT Temple University Philadelphia, Pennsylvania Timothy W. Flynn, PT, PhD, OCS, FAAOMPT Regis University Denver, Colorado Heidi Ojha, PT, DPT, OCS, FAAOMPT Temple University Philadelphia, Pennsylvania An Independent Study Course Designed for Individual Continuing Education PHYSICAL THERAPY EDUCATION Current Concepts of Orthopaedic Physical Therapy, 3rd Edition Christopher Hughes, PT, PhD, OCS—Editor Michael Timko, PT, MS, FAAOMPT—Subject Matter Expert Beth Jones, PT, DPT, MS, OCS—Anatomy Reviewer Gordon Riddle, PT, OCS, ATC, CSCS—Test Item Reviewer Dear Colleague, I am pleased to welcome you to The Thoracic Spine and Rib Cage: Physical Therapy Patient Management Utilizing Current Evidence by William Egan, PT, DPT, OCS, FAAOMPT; Scott Burns, PT, DPT, OCS, FAAOMPT; Timothy W. Flynn, PT, PhD, OCS, FAAOMPT; and Heidi Ojha, PT, DPT,' OCS, FAAOMPT. This work is part of the Orthopaedic Section Independent Study Course series 21.2, Current Concepts for Orthopaedic Physical Therapy, 3'd edition. Dr Egan received his bachelor of arts in psychology from Rutgers College, New Brunswick, New Jersey in 1997. His master of physical therapy degree was granted by US Army-Baylor University Graduate Program in Physical Therapy, Fort Sam Houston, Texas in 1999. He received his OCS in 2002 and his DPT and manual therapy fellowship from Regis University, Denver, Colorado in 2006. He currently serves as Assistant Professor and Director of Orthopaedic Physical Therapy Residency, Department of Physical Therapy College of Health Professions, Temple University, Philadelphia, Pennsylvania. He also is an affiliate faculty member for the tDPT program at Regis University. Dr Egan has published in the Journal of Manual and Manipulative Therapy and Physical Therapy. He has also coauthored two chapters on the thoracic spine in the text, Diagnosis and Management of Tension Type and Cervicogenic Headache (Jones and Bartlett, 2009). His current teaching responsibilities at Temple University are in the areas of management of musculoskeletal disorders, evidence-based practice, and imaging. Dr Burns received his bachelor of arts degree in kinesiology from the University of Colorado, Boulder, Colorado in 2001. He also received his master of science in physical therapy and his transitional DPT degree from the University of Colorado-Denver in 2005 and 2006, respectively. Dr Burns then was granted a fellowship in manual therapy in 2009 from Regis University, Denver, Colorado. That same year he was awarded board certification as an orthopaedic clinical specialist. Dr Burns is currently an assistant professor in the Department of Physical Therapy, College of Health Professions and Social Work, Temple University, Philadelphia, Pennsylvania. His peer-reviewed articles have appeared in the Journal of Manual and Manipulative Therapy, Journal of Physiotherapy Theory and Practice, and Journal of Orthopaedic and Sports Physical Therapy. At Temple University, Dr Burns teaches primarily in the musculoskeletal tract and orthopaedic residency Dr Flynn received his bachelor of science degree in physical therapy from Marquette University, Milwaukee, Wisconsin in 1983. His master of science in biomechanics that included an advanced individual manual medicine tutorial with Philip E. Greenman, DO, FAAO, was awarded from Michigan State University, College of Osteopathic Medicine, East Lansing, Michigan in 1990. He received his PhD in kinesiology in 1997 from The Penn State University, Center for Locomotion Studies, University Park, Pennsylvania. Dr Flynn's military education included studies at Fort Sam Houston in Texas and Fort Leavenworth, Kansas. Dr Flynn is presently Distinguished Professor, Rocky Mountain University of Health Professions and also Associate Professor and Coordinator, Manual Therapy Fellowship, Department of Physical Therapy, Regis University, Denver, Colorado. Since 2006 he has been owner of Colorado Physical Therapy Specialists in Fort Collins, Colorado and also is principal owner of Evidence in Motion, LLC. He has been a frequent contributor to the Journal of Orthopaedic and Sports Physical Therapy and has also published noted works in Physical Therapy, Spine, and Journal of Manual and Manipulative Therapy as well as other peer-reviewed journals. He also serves as manuscript reviewer for many of these publications. Dr Ojha received her bachelor of science in health studies and a minor in psychology in 2001 from Boston University, Sargent College, Boston, Massachusetts. Her MSPT degree was also granted by Boston University in 2002. She then completed a clinical residency program and earned her certificate in orthopaedic physical therapy from the University of Southern California (USC), Los Angeles, California in 2006. She also received her postprofessional doctor of physical therapy in 2007 from USC as well as her OSC from the American Board of Physical Therapy Specialties. In 2010 she obtained fellowship status in Orthopaedic Manual Physical Therapy from Regis University, Denver, Colorado. Dr Ojha is currently appointed as course instructor for several courses at Temple University. She also serves as the Director of Temple Faculty PT Clinic. In their monograph, the authors first provide a discussion on the relevant clinical anatomy of the thoracic spine and rib cage to allow for an accurate clinical examination of the thoracic spine. This section includes a review of neurovascular structures that account for thoracic pain referral patterns. A nice overview of clinical biomechanics and pathomechanics of the thoracic spine and rib cage grounds the reader in understanding the basis of developing a sound impairmentbased diagnosis and treatment program. Screening for possible sources of thoracic spine pain that require medical referral is covered in the next section of the monograph. This information provides for an evidence-based examination of the thoracic spine with an emphasis on tests that guide the selection of treatment procedures. Intervention techniques with specific emphasis on joint manipulation treatments are described in detail and supported by clear figures showing patient-therapist positioning. Therapeutic exercises are also highlighted by the authors with the goal of increasing joint mobility and muscle re-education. Common outcome measures are then reviewed. The interpretation of these appropriate outcome measures and scales should be of value to clinicians in documenting patient improvements. Finally, 5 case studies offer a variety of patient scenarios to help the reader apply the knowledge and support the authors' rationale for choice of intervention and treatment planning. I believe the authors have done an excellent job writing on a topic and body region that many therapists admittedly are not as clinically competent with compared to other orthopaedic areas. My sincere thanks to the authors for sharing their expertise on a topic that is often a misunderstood area of physical rehabilitation. Sincerely, 004".9 Y#17/4 Christopher Hughes, PT, PhD, OCS, CSCS Editor 2920 East Avenue South, Suite 200 I La Crosse, WI 54601 I Office 608-788-3982 I Toll Free 800-444-3982 I Fax 608-788-3965 TABLE IcLsE OF CONTENTS LEARNING OBJECTIVES 1 INTRODUCTION 1 CLINICAL ANATOMY 1 Surface Anatomy 1 Osseous and Ligamentous Anatomy 1 Key Muscles 2 Neurovascular Structures 2 Thoracic Pain Referral Patterns 3 • CLINICAL BIOMECHANICS AND PATHOMECHA 4 Thoracic and Rib Cage Motion 4 Flexion and extension 4 Side bending 4 Rotation 5 Inspiration and expiration 5 Neural Dynamics 5 Pathomechanics 6 Rib joint pathomechanics PATHOLOGIC CONDITIONS Nonmusculoskeletal Thoracic Pain 6 7 7 Visceral causes of thoracic spine pain 7 Serious causes of thoracic spine pain 8 Thoracic Vertebral Fractures 8 EXAMINATION PROCEDURES 9 Diagnostic Imaging 9 Physical Examination 9 Inspection 9 Active range of motion 9 Measuring thoracic range of motion 9 Assessing for centralization 10 Cervical spine screening 10 Segmental examination of the thoracic spine 10 Segmental examination of the chest wall 11 Mechanical Movement Impairments Diagnosis 12 INTERVENTION TECHNIQUES 12 Joint Manipulation Techniques 12 Thoracic spine 13 Rib cage 17 Selected soft tissue techniques 20 Selected therapeutic exercises 21 REGIONAL INTERDEPENDENCE 22 Cervical Spine 22 Shoulder 23 REVIEW OF OUTCOME MEASURES AND SCALES 24 CASE SCENARIOS 24 Case Scenario 1 24 Case Scenario 2 25 Case Scenario 3 26 Case Scenario 4 27 Case Scenario 5 28 REFERENCES 29 • Opinions expressed by the authors are their own and do not necessarily reflect the views of the Orthopaedic Section. The publishers have made every effort to trace the copyright holders for borrowed material. If we have inadvertently overlooked any, we would be willing to correct the situation at the first opportunity. © 2011, Orthopaedic Section, APTA, Inc. Course content is not intended for use by participants outside the scope of their license or regulations. Subsequent use of management is physical therapy only when performed by a PT or a PTA in accordance with Association policies, positions, guidelines, standards, and ethical principals and standards. The Thoracic Spine and Rib Cage: Physical Therapy Patient Management Utilizing Current Evidence Therefore, clinicians should consider the thoracic spine as a potential cause of or contributing factor to, patients with upper quarter region musculoskeletal disorders. This monograph will review evidence-based examination, diagnosis, and intervention strategies to assist with management of individuals with both primary and secondary thoracic spine and rib cage disorders. William Egan, PT, DPT, OCS, FAAOMPT Temple University Philadelphia, PA CLINICAL ANATOMY Surface Anatomy The primary or key landmarks used in examination of the thoracic spine and rib cage are the spinous processes, the transverse processes, and the rib angles. In manual therapy and the medical literature, the rule of 3's has often been referred to when describing the location of bony landmarks. 6 In the thoracic spine, the length of the spinous processes vary by region. According to the rule of 3's, the spinous processes of T1 through T3 are at the same level as the transverse processes, the spinous processes of T4 through T6 are one half vertebral level below the transverse processes, the spinous processes of T7 through T9 are one full vertebral level below the transverse processes, the spinous processes of T10 through T12 are at the same vertebral level to which they are attached. 6' 7 A cadaver study investigated the rule of 3's. Geelhoed and colleagues, 8 in a study of 5 cadavers, found that the spinous processes of T7 through T12 were, in general, at the same level as the transverse processes of the next caudal vertebrae. Above T7, the results were similar but more variable. There are some limitations to this study, most notable that it was carried out on cadavers in a prone position. In summary, the thoracic transverse processes are frequently found above the spinous process and could also be located at the level of the spinous process. Based on this research, the transverse processes are not found below the spinous process. The rib angles, a prominent area where the posterior rib orients laterally and anteriorly, are key landmarks that are helpful for identifying rib cage dysfunction. These serve as the site for the attachment of the iliocostalis muscle and are located on the posterolateral aspect of the rib cage. In the authors' clinical experience, in patients with mechanical rib dysfunction, the rib angle will frequently be tender to palpation with accompanying soft tissue hypertonicity. Scott Burns, PT, DPT, OCS, FAAOMPT Temple University Philadelphia, PA Timothy W. Flynn, PT, PhD, OCS, FAAOMPT Regis University Denver, CO Heidi Ojha, PT, DPT, OCS, FAAOMPT Temple University Philadelphia, PA LEARNING OBJECTIVES Upon completion of this monograph, the course participant will be able to: 1. Describe the relevant clinical anatomy of the thoracic spine and rib cage to allow for accurate clinical examination. 2. Understand the clinical biomechanics of the thoracic spine and rib cage and its relation to forming an impairment-based diagnosis and treatment program. 3. Screen for possible sources of thoracic spine pain that require medical referral. 4. Perform an evidence-based examination of the thoracic spine with an emphasis on tests that guide the selection of treatment procedures. 5. Understand and be able to carry out manual therapy and exercise interventions guided by available evidence and the clinical examination. 6. Understand and apply the concept of regional interdependence and how examination and treatment of the thoracic spine can assist with treatment of other related areas. 7. Use and interpret appropriate outcome measures and scales associated with thoracic spine pathology. INTRODUCTION Compared to the cervical spine and lumbopelvic regions, the thoracic spine receives little attention in the medical and orthopaedic literature. Linton and colleagues' estimated that the prevalence of spinal pain in the general population is 66%, but only 15% reported thoracic pain compared to 44% reporting neck pain and 56% reporting low back pain. However, primary thoracic and chest wall dysfunction can be equally as painful and disabling. 2'3 Thoracic spine and rib cage dysfunction influence pain, motion, and posture of the entire spine. Furthermore, there is evidence that treatment of the thoracic spine and rib cage can affect pain and motion restriction in related spinal and peripheral joint regions. 45 Osseous and Ligamentous Anatomy The thoracic vertebrae vary by region, with the superior segments sharing commonalities with the cervical spine, and the inferior segments becoming more like the lumbar spine. Hence, the vertebral bodies become larger and denser from superior to inferior to support increasing loads superimposed by body mass.' The anterior to posterior and transverse dimensions of the vertebral bodies are uniform. 9 Their height is slightly higher posteriorly, and this contributes to the dorsal kyphosis of the thoracic spine.' The thoracic facet joints are synovial joints that are planar in structure. They are primarily oriented in the frontal plane, with the superior articulations oriented 1 60° from the horizontal plane and 20° from the frontal plane.' The inferior articulations match the superior articulations and face anteriorly, inferiorly, and slightly medially. The superior facet articulation originates from the superior vertebrae of the thoracic spine motion segment while the inferior facet articulation originates from the inferior vertebrae. The thoracic disks are thinner in relation to the cervical and lumbar spines. The ratio of disk height to vertebral body height is 1 to 5, compared to 2 to 5 in the cervical spine and 1 to 3 in the lumbar spine.' This, among other factors, is thought to contribute to the relatively lower mobility of the thoracic spine compared to the cervical and lumbar regions. The ribs are long, elastic, curved bones made of highly vascular spongy bone encased in a thin layer of compact bone.' The ribs are classified into true and false and typical and atypical.' Ribs 1 through 7 are true ribs because they directly attach to the sternum. Ribs 8 through 12 are false ribs because they attach distally to the costochondral cartilage of the superior rib or in the case of ribs 11 and 12, have no anterior attachment at all. The heads of ribs 3 through 9, the typical ribs, have 2 facets for attachment to the corresponding demifacets on the vertebral bodies. The superior rib facets attach to the superior vertebral body, and the inferior facet attaches to the numerically corresponding vertebral body forming the costovertebral joint. Between the 2 facets on the rib head is a crest that attaches to the intervertebral disk. The atypical 1st, 10th, 11th, and 12th ribs attach to only 1 facet on the corresponding vertebral body. The second rib attaches to T1 and T2, and it is considered atypical because of its attachment to the junction of the manubrium and sternum. Ribs 1 through 10 attach to the corresponding thoracic transverse process forming the costotransverse joint. Ribs 11 and 12 do not attach to the transverse processes and do not have a costotransverse joint. In the upper thoracic spine down to T5 or T6, the rib portion of the joint is concave and the transverse process portion is convex. In the lower thoracic spine, the costotransverse joints are planar. This shape appears to allow for more rotation or torsional movement above rib 7 and more planar gliding movement below that level. Thus, during inspiration the upper rib cage rises (flexes) in the sagittal plane while the lower ribs widen (abduct) in the frontal plane. cends to the angles of ribs 1 through 6 and the transverse process of C7. The iliocostalis lumborum originates on the posterior aspect of sacrum and thoracolumbar fascia and ascends to the angles of ribs 6 through 12. Tissue texture changes of these muscles at the rib angle are thought to indicate rib cage dysfunction. 6,1 ° The serratus anterior arises from the outer surface and superior border of the upper 8th through 10th ribs and the fascia of the associated external intercostal muscles. It courses close to the chest wall to attach to the anterior surface of the vertebral border of the scapula. Its action is to protract the scapula and it also assists with the force coupling for normal scapular upward rotation and posterior tipping. When the scapula is fixed, it is thought that the serratus anterior will pull the ribs posteriorly.' The pectoral is major is a thick muscle with 3 proximal attachments, from the clavicle, the sternum, and the costal cartilages of ribs 1-6. The distal attachment is into the lateral lip of the bicipital groove. The general action of the muscle is to adduct and internally rotate the humerus. The clavicular portion of the pectoralis can also assist the coracobrachialis and anterior deltoid with glenohumeral flexion. When the distal attachment is fixed with the humerus flexed, the pectoralis muscle will tend to pull the rib cage anteriorly, superiorly, and laterally. The pectoralis minor arises from the anterior and superior surfaces of ribs 3 through 5 and attaches to the medial superior coracoid process of the scapula. Shortening or hypertonicity of this muscle can lead to protraction and anterior tipping of the scapula and this can potentially affect the normal scapular motion during elevation of the arm." The anterior scalene arises from the anterior tubercle of the transverse processes of C3 through C6 and attaches to the scalene tubercle on the inner border of the first rib. The middle scalene arises from the transverse processes of C2 through C7 and attaches on the first rib medial to the anterior scalene. The anterior and middle scalenes are potentially relevant contributing factors to dysfunction of the first rib because they both can elevate the first rib when the cervical spine is fixed.' The posterior scalene arises from the posterior tubercle of the transverse processes of C4 through C6 and attaches to the outer surface of the second rib. Given its origin and insertion, the posterior scalene can potentially elevate the second rib when the cervical spine is fixed. The diaphragm is the primary muscle of inspiration and has broad musculoskeletal attachments to the ribs and spine. The muscles of the diaphragm are grouped into 3 parts: sternal, costal, and lumbar. The sternal portion arises from the back of the xiphoid process, the costal from the internal surfaces of the costal cartilages and adjacent parts of the lower 6 ribs, and the lumbar from the first two or 3 lumbar vertebrae.' Key Muscles The thoracic spine and rib cage serve as the attachment site for numerous muscles. The authors will discuss the muscles relevant to the examination, intervention, and diagnosis of thoracic spine and rib cage dysfunction. The trapezius muscle originates from all the thoracic spinous processes, the external occipital protuberance, the ligamentum nuchae, and the spinous process of C7. It has an important role in assisting with the force coupling to allow for normal scapular upward rotation and posterior tipping during elevation of the humerus. The iliocostal thoracis starts at the angle of ribs 7 through 12 and as- N eu rovascu I ar Structures The 12 thoracic spinal nerves are divided into anterior and posterior primary rami. Each thoracic spinal nerve exits below its respective intervertebral disk.' The cutaneous branches of the anterior and posterior thoracic rami 2 spinal nerve form each thoracic dermatome. The thoracic dermatomes run in a circumferential pattern just inferior to the corresponding thoracic vertebrae from posterior midline to anterior midline. The posterior rami are divided into medial and lateral branches. The medial branch of the upper 6 segments supplies the semispinalis and multifidus muscles and the skin of the upper back. The medial branch of the lower 6 thoracic segments supplies the transversospinalis and longissimus muscles. Each medial branch has ascending and descending branches to the zygapophyseal joints above and below." The lateral branch of the posterior rami supply the longissimus and iliocostalis muscles, and the costotransverse joints. The lower 6 segments eventually emerge from the iliocostalis lumborum muscles to become cutaneous. 12 The anterior rami travel anteriorly in the intercostal space and are known as the intercostal nerves. The 12th anterior rami forms the subcostal nerve as it travels below the 12th rib. Each thoracic spinal nerve contributes preganglionic sympathetic fibers to the sympathetic chain. The sympathetic chain is just anterior to the rib head and is lateral to the costovertebral joint. 12 The muscular branches of the typical intercostal nerves supply the innermost intercostal, internal intercostal, external intercostal, subcostal, and serratus posterior muscles. The cutaneous branches supply the skin on the lateral and anterior aspect of the thorax and abdomen. The muscular branches of the 7th through 11th intercostals and the subcostal innervate the abdominal muscles. The subcostal nerve supplies the skin of the abdominal wall, the lateral hip region, and over the iliac crest." This is one avenue through which dysfunction of the thoracolumbar junction can produce pain in the hip region." The superior part of the first intercostal nerve (T1) forms part of the brachial plexus. The lateral cutaneous branch of the second intercostal nerve is known as the intercostobrachial nerve." The intercostobrachial nerve supplies the floor of the axilla and joins the medial brachial cutaneous nerve to supply the medial side of the arm as far distal as the elbow region. This connection allows for dysfunction of the upper thoracic spine to contribute to symptoms in the arm." The sinuvertebral nerve is a recurrent branch of the spinal nerve and the anterior rami. The sinuvertebral nerve consists of both somatic and autonomic fibers and supplies the dura, the outer fibers of the intervertebral disk, medial aspect of the zygapophyseal joint, and the posterior longitudinal ligament. 12 The spinal canal within the thoracic spine is notably narrower than in other regions. The region from T4 through T9 is known as the critical zone due to the small diameter of the spinal canal and reduced blood supply in comparison to other regions of the spine.' The clinical significance of this is that significant pathology such as a large herniated disk has the potential to cause central spinal cord compression. Anecdotally, less serious pathology such as segmental stiffness in this region can have widespread effects on the neurodynamics in the spine and periphery. Often, treatment aimed at improving the segmental motion restrictions in this area results in clini- cally meaningful pain reduction and functional improv6t ments in distal regions including symptoms associated with adverse neural dynamics. Thoracic Pain Referral Patterns Regional examination of the thoracic spine and rib cage is indicated for patients whose symptoms originate from this anatomical region or are referred to areas segmentally innervated by these levels. Identification of appropriate patients is based on the location and nature of their symptoms or symptoms provoked during the upper or lower quarter screening examination. The pain referral pattern of the thoracic spine and rib cage articulations, and also what other somatic structures can refer pain to the thoracic spine, has implications for conducting and interpreting the physical examination. The pain referral patterns of the thoracic zygapophyseal or facet joints have been investigated in two studies. Dreyfuss et ale have provided preliminary evidence in the asymptomatic population that the thoracic zygapophyseal joints can cause both local and referred pain. The zygapophyseal joints from T3-4 through T10-11 were studied. The authors reported that in all subjects the most intense area of evoked pain occurred one segment inferior and slightly lateral to the joint injected. Furthermore, no joints referred pain more superior than one half of the vertical height of that vertebral segment; however, distal referral was up to 2.5 segments below the injected level. In addition, two subjects had anterior chest wall and sternal pain when the T3-T4 and the T4-T5 segments were injected. To complete the pain-referral map of the thoracic facet joints, Fukui et aP injected the C7-T1 through T2-T3 and T11-T12 segments in a group of 15 patients complaining of thoracic spine pain. Pain referral from the C7-T1 to T2T3 segments overlapped extensively, with pain reported over the paravertebral region, inferior toward the superior angle of the scapula, and the interscapular region toward the inferior angle of the scapula. The T11-T12 segment produced pain localized to the paravertebral region of the segment, and in one patient over the ipsilateral iliac crest. Across all subjects, only unilateral pain was reproduced and no radiating pain, including anterior or lateral chest wall pain, was reported. In a prospective case series of 46 patients with chronic thoracic spine pain, 48% responded to a medial branch block performed on 2 separate occasions.'s Manch i kanti et al's state that this indicates a 48% prevalence rate of zygapophyseal joint pain in patients with chronic thoracic pain. This is in comparison to the reported 15% to 45% prevalence of facet joint pain in patients with chronic lumbar pain and 54% to 60% in patients with chronic cervical pain. This study took place in one private pain management practice and there was no placebo intervention, so the applicability of the results to the general patient population is speculative. Due to their innervation, the costovertebral and costotransverse joints both have the potential to generate pain. Young et a1 16 performed a pain mapping study of the costovertebral joints with 8 asymptomatic volunteers. Using video fluoroscopic guidance, the T2-T7 costovertebral joints were injected. Subjects reported symptoms ipsilateral to and directly over the joint injected. Only with injection to the T2 costotransverse joint did subjects report pain 2 vertebral levels above the region injected. In a clinical case series, Benhamou et al 17 reported on 28 patients who had pseudovisceral pain that was relieved by injection into the costovertebral joint. In a cadaver dissection study, Nathan" noted a 60% incidence of osteophytes at the costovertebral articulation that appeared to encroach on the thoracic sympathetic chain. This could potentially explain the findings of pseudovisceral pain being relieved by injection of the costovertebral joint. Similar to the cervical and lumbar regions, the thoracic disk is capable of producing pain. Thoracic disk pathology is often seen on imaging studies such as x-ray film or magnetic resonance innaging.' 9 The presence of disk pathology on imaging studies, however, does not automatically implicate the disk as a source of pain. Wood and colleagues" have demonstrated that the incidence of asymptomatic thoracic disk protrusions is approximately 37%. Furthermore, a two-year follow-up by Wood et a1 2° reported that there was little change in the size of the protrusions, suggesting that these disk abnormalities exist in a state of relative flux. Therefore, the authors advised that clinicians should interpret thoracic magnetic resonance imaging with caution. Although descriptive in nature, the literature suggests a link between thoracic disk herniations and thoracic and chest wall pain. However, there are no studies reporting the pain referral pattern for the thoracic disk. A thoracic disk protrusion could potentially create thoracic nerve root compression and a radiculopathy. In this instance the clinician may find decreased sensation in the corresponding thoracic dermatome and the patient may report lancinating pain in a similar region. A recent case in the literature highlighted the potential for a lower thoracic disk herniation could be the source of referred abdominal pain. The patient in this case reported vague abdominal pain. Diagnostic work up for visceral causes including gastrointestinal was negative. The patient was subsequently diagnosed with a T12-L1 disk herniation and underwent decompression surgery that relieved her symptoms. 2 ' The lower cervical spine has the potential to refer pain into the upper to middle thoracic spine. In particular, the facet joints and intervertebral disks of the C5-C6 and C6C7 segments can refer pain into the upper thoracic spine and interscapular region. 22,23 For patients with upper thoracic and interscapular region pain, clinical examination is required to differentiate the thoracic spine versus the cervical spine or other structures as the source of the patient's symptoms. addition of the rib cage and rib articulations. The thoracic spine can be thought of as 3 units. The upper thoracic spine and cervicothoracic junction function more similar to the cervical spine. The middle thoracic spine functions independently and has significant influence from the rib cage. The lower thoracic spine and thoracolumbar junction more closely resemble the lumbar spine. Although the addition of the rib cage does certainly limit the range of motion and increases the stability of the thoracic spine, the thoracic segments are capable of moving independently of the rib cage. 24 Flexion and extension Due to the morphology of the facet joints, motion in the sagittal plane gradually increases from T1 2 to T1 1 1 2 as the facets become more oriented in the sagittal plane. With forward flexion, the superior vertebra translates forward in the transverse plane and rotates forward in the sagittal plane. 25 The articular facets of the superior vertebrae glide upward and forward on the superior facets of the inferior vertebrae. In a clinical model proposed by Lee, 25 flexion of the thoracic spine results in concomitant forward rotation of the rib head at the costovertebral joint. The hypothesis is that the anterior translation of the superior vertebrae of the motion segment pushes the superior demifacet of the rib head. The concave tubercle of the rib glides superiorly on the convex facet on the thoracic transverse process at the costotransverse joint. Recall that this motion is more rotational in the upper 6 ribs and more planar below rib 6 due to the costotransverse joint configuration. Extension results in posterior translation of the superior vertebrae and backward rotation in the sagittal plane. 25 The inferior facets of the superior thoracic vertebrae glide down and back on the superior facets of the inferior vertebrae at the zygapophyseal joint. In the clinical model proposed by Lee, 25 thoracic extension produces a concomitant posterior rotation of the rib head at the costovertebral joint and inferior glide at the costotransverse joint. - - Side bending Side bending of the thoracic vertebrae in the frontal plane is accompanied by a small ipsilateral lateral translatory movement of the superior vertebrae in the horizontal plane. 25 Side bending in the thoracic spine gradually increases from T1 -2 to Ti 1-12. In right side bending, the right inferior facet of the superior vertebrae glides inferolaterally and the left inferior facet glides superomedially. 25 Controversy exists as to whether thoracic rotation couples contralaterally or ipsilaterally during side bending. The thoracic spine coupling pattern was the subject of a systematic review involving 8 different studies. 26 The reviewed studies included both in vitro and in-vivo designs. Across the 8 studies there was no consistent coupling pattern reported. The authors concluded that methodological study design differences could account for the reported variability and that more research is needed. In an in vivo study by Willems et a1 27 using FAS- CLINICAL BIOMECHANICS AND PATHOMECHANICS Thoracic and Rib Cage Motion Motion in the thoracic spine is affected by the unique morphology of the thoracic functional spinal unit and the 4 • • TRAK motion analysis, rotation was found to couple to the ipsilateral side with primary side bending. There was some variability within and between subjects, and the ipsilateral coupling pattern was not as consistent in the upper thoracic spine. A study analyzing the T2 through T7 segments in asymptomatic individuals found that the thoracic spine extended, rotated, and side bent to the ipsilateral side during elevation of the arm." In the clinical model developed by Lee, 25 side bending of the thoracic spine leads to approximation of the ribs on the ipsilateral side and separation of the ribs on the contralateral side. Rotation Thoracic spine rotation is greatest in the upper segments and significantly reduced in the lower segments." Thoracic spine rotation is accompanied by slight translation of the superior motion segment to the contralateral side. 25 In the in vivo study by Willems et a1, 27 ipsilateral coupling of side flexion with primary rotation predominated, but there was variability within and between subjects. In the clinical model proposed by Lee, 25 right thoracic rotation results in posterior rotation of the right rib and anterior rotation of the left rib. In the osteopathic biomechanical model, the posterior rotation of the rib is referred to as external torsion and the anterior rotation of the rib is called internal torsion. 6,1 ° Inspiration and expiration Clinical models of rib cage motion during respiration postulate that the ribs follow a pump-handle and buckethandle motion." During inspiration, as the anterior-posterior diameter of the thorax expands and the intercostal muscles contract, the ribs move through the axes of their necks at the costovertebral and costotransverse joints and the anterior ends of the rib rise with the sternum. This anterior superior motion is referred to as the pump handle motion. Concurrently during inspiration, as the transverse diameter of the thorax expands and intercostal muscles contract, the ribs move laterally and superiorly. This movement is referred to as a bucket handle motion because it is similar to a bucket handle moving away from its attachments when the handle is raised. During expiration, the rib moves inferiorly in both the anterior and lateral aspects. Due to the axis of motion through the costovertebral and costotransverse joints, the pumphandle motion is thought to predominate in the upper ribs, whereas the bucket-handle motion predominates in the lower ribs. An in vivo study, however, determined that rib cage motion was similar at all levels in terms of the relative anterior and lateral expansion of each rib during inspiration. 30 The 11th and 12th ribs, due to the lack of anterior attachments and costotransverse joints, are thought to move in a caliper-type motion. In the caliper motion, the ribs move posterior and lateral during inspiration and anterior and medial during expiration. Of note is that during inspiration the thoracic segments extend, and during expiration the segments return to their neutral position. 3 ' Neural Dynamics The concept of neural tissue dynamics has been reported in clinical orthopaedic physical therapy literature. 32,33 Evaluation and treatment of neural tissue is supported by basic science research and clinical case reports. 34-36 In the thoracic spine, two areas deserve mentioning in relation to neural dynamics. The sympathetic chain lies anteriorly along the rib heads and costovertebral joints." Theoretically, the thoracic sympathetic chain is tensioned during flexion, contralateral rotation, and contralateral side bending of the thoracic spine. 32 Further stretching could be accomplished by performing thoracic flexion and contralateral side bending in a slump long-sitting position. As stated previously, the area from T4 through T9 is known as the critical zone due to the small diameter of the vertebral canal. In addition, the T6 spinal cord segment is reported to be a tension point. 32 This is an area where the motion of the spinal cord relative to the spinal canal converges in different directions. Butler 32 postulates that during flexion of the cervical and thoracic spine, similar to the slump position, the cord, in relation to the spinal canal, moves cranially toward the cervical spine and caudally toward the lumbar spine. Segmental stiffness of this middle thoracic region could contribute to signs and symptoms associated with adverse neural tissue dynamics. Anecdotally symptoms and range of motion associated with a positive slump test can be altered after spinal manipulative treatment of the middle thoracic region. Manipulation of the thoracic spine could produce an increase in thoracic spine segmental mobility allowing for increased thoracic flexion range of motion and improved neural dynamics of the spinal cord. A clinical syndrome referred to as the T4 syndrome, has been described as a constellation of signs and symptoms associated with stiffness of the upper to middle thoracic region." Typical signs and symptoms include headaches, neck pain, upper extremity pain, and bilateral "stocking glove" paresthesias. It is thought that these signs and symptoms could be resulting in part from the dysfunction of the thoracic spine and its resulting influence on the sympathetic nervous system. A published case report described a decrease in symptoms in a patient with upper extremity complex regional pain syndrome after a thrust manipulation directed to the upper thoracic spine. 38 An experimental study found that grade 3 posterior to anterior nonthrust mobilization applied to the T4 segment produced sympathoexcitatory effects in both hands of asymptomatic subjects." Sympathetic nervous system activity was measured via skin conductance that the authors report as a valid and reliable measure of sympathetic nervous system activity in the hand. The authors reported that manipulation of the T4 thoracic region produced an increase in skin conductance in the hands. However this study does not provide direct evidence into the mechanism of how manipulation of the thoracic region can provide a reduction in symptoms in patients with T4 syndrome. Further research is required to elucidate the etiology of T4 syndrome and the mechanisms behind how manipulation of the thoracic spine produces beneficial effects. plane, unilateral rib joint dysfunction, and unilateral adverse neural tissue, including the sympathetic chain mobility. A unilateral thoracic spine flexion impairment could be evident during combined motion testing of flexion, contralateral rotation, and contralateral sidebending. Extension impairments are the opposite of flexion impairments and reflect the inability of the thoracic motion segment to rotate backward in the sagittal plane. Extension impairments are thought to more commonly occur in the upper thoracic spine and cervicothoracic junction (C7 through T2), where an increased posterior thoracic kyphosis is often present.'° The lower thoracic spine is also thought to be more commonly restricted in extension, as observed by an increased middle to lower thoracic kyphosis. Age-related structural changes of the thoracic spine including disk height degeneration and anterior wedging of the vertebral body can also contribute to extension impairments." A unilateral extension impairment of a thoracic spine could theoretically occur when the ipsilateral facet joint is restricted in its inferior glide, ipsilateral rib joint dysfunction, or a space-occupying lesion (eg, a disk protrusion or osteophytes) creating painful closing down of the neurovascular structures in the intervertebral foramina. A unilateral extension impairment can be observed by a lack of combined motion into extension, ipsilateral rotation, and ipsilateral side bending. Pathomechanics To the authors' knowledge, there are no studies analyzing the motion of the thoracic spine and costal cage in subjects with primary or secondary thoracic spine disorders. As a result, the pathomechanics of the thoracic spine are based largely on applied anatomy and biomechanics, expert opinion, and clinical models. In the absence of evidence, a clinical model enables clinicians to categorize movement impairments and can be useful to direct treatment and interventions. In most clinical texts, pathomechanical models of motion restriction usually make reference to motion impairments of specific joint articulations. 6,10,40,41 In the thoracic spinal segments, motion impairments are usually made in reference to the motion of the facet joints. Recall that during flexion, the inferior facet of the superior vertebrae glides superiorly on the superior facet of its caudal neighbor. Restriction of a thoracic functional spinal unit can involve the facet joints, the intervertebral disk articulation; the costovertebral joints; the costotransverse joints; and associated muscular, neural, fascia!, and ligamentous structures. Because of the varied clinical terms used to describe these motion impairments, a common language to describe these various impairments does not exist. As a result, universal clinical and scholarly communication among spine practitioners is lacking. A proposed common language for movement impairments in the thoracic spine is presented below. Flexion movement impairments reflect the inability of the thoracic spinal unit to rotate forward in the sagittal plane. This could be due to impaired superior gliding of the facet joints, reduced anterior translation of the superior vertebral body on the inferior vertebral body, restricted anterior rotation of the rib joints, and segmental or multisegmental soft tissue restrictions. The cause of these perceived movement impairments is unknown at this time. In isolation, their relevance and contribution to a patient's complaints of pain and functional limitation is uncertain. In the thoracic spine, flexion impairments appear to most commonly occur in the upper to middle thoracic spine regions, approximately T3-4 through T67.6,10,40 This may be observed by a relative straightening or a reduction of the normal posterior thoracic kyphosis. A flexion movement impairment of the upper thoracic spine is thought to occur after a whiplash-type injury as a result of a rear-impact collision. It is thought that the upper thoracic segments become jammed into extension when the upper trunk is thrust forward and upward during the initial impact. 42,43 A unilateral flexion impairment may exist, whereby a thoracic spinal motion segment has decreased flexion, contralateral (to the side of the restriction) rotation, and side bending. This could be due to the inability of the facet on the ipsilateral side to glide forward, soft tissue restriction reduced ipsilateral lateral translation of the superior vertebrae in the horizontal Rib joint pathomechanics Upper ribs The upper rib joints could theoretically become dysfunctional at either the costovertebral or costotransverse joint articulations. Several authors describe a condition where the first rib becomes subluxed cranially at the costotransverse joint with a limited caudal glide. 6,10,45 This is thought to commonly occur with traumatic injuries such as during whiplash and with repetitive overuse of the extremity. The first rib joint is thought to be vulnerable to subluxation due to the lack of a superior reinforcing ligament at the costotransverse joint. 45 Impaired mobility of the first rib during inspiration and expiration has been demonstrated cineradiographically in patients suffering from thoracic outlet syndrome. 46 Middle and lower ribs Middle and lower rib movement impairments can occur either in isolation or concurrently with thoracic spine impairments. Reduced motion at costovertebral joint, costotransverse joint, or costosternal joint can contribute to rib joint impairments. Two other common rib joint dysfunctions have been observed clinically. 6,10 During a traumatic injury with a blow to the posterior chest wall, a rib can become subluxed anteriorly. This is usually indicated by a prominence of the rib anteriorly, a concavity of the rib posteriorly, and reduced motion during inspiration and expiration. Similarly, a posterior rib subluxation can occur after blunt trauma to the anterior chest wall. It is unknown 6 where the actual subluxation occurs anteriorly at the costochondral or sternocostal joint or posteriorly at the costotransverse or costovertebral joint. Furthermore these dysfunctions are purely anecdotal, are based on a biomechanical mode1, 6,1 ° and may not actually represent true joint subluxations. However, the authors have found that manual therapy interventions directed toward reducing these theoretical joint and related soft tissue dysfunctions can lead to decreased pain and functional limitations in patients with chest wall pain. tion requiring emergent care due to the high likelihood of mortality if this condition proceeds untreated. Pain from myocardial ischemia is accompanied by anterior chest pain or heaviness, occasional nausea, and sometimes pain radiating to the back." Patients presenting acutely with this condition obviously require immediate medical attention. Thoracic or chest pain may also be from exertional or variant myocardial ischemia, also known as stable or unstable angina. In stable angina, pain is related to exertion and relieved with rest." Unstable angina occurs in random or unpredictable fashion, and is not related to activity. Unstable angina is usually a progression of stable angina and is a risk factor for pending myocardial infarction. A clinical prediction rule was developed and validated to rule out coronary artery disease in primary care. 5° Subjects were included in the study if the patient was greater than 35 years old and reported anterior chest pain. The predictor variables in the rule are: age/sex (female 65, male 55), known clinical vascular disease (includes coronary artery, occlusive vascular, and cerebrovascular diseases), pain worse during exercise, pain not reproducible by palpation, and patient assumes pain is of cardiac origin. Sensitivity was 0.98 if two predictor variables were met, which would be a reasonable cut off for ruling out cardiac disease. The best overall discrimination, balancing sensitivity and specificity, was presence of 3 predictor variables with a sensitivity of 0.87 and specificity of 0.80, with a positive likelihood ratio of 4.52. A peptic ulcer of the posterior wall of the stomach or duodenum can cause boring pain from the epigastric area to the middle thoracic spine. Thoracic pain either triggered or relieved by eating is a sign of peptic ulcer disease." Peptic ulcer disease can result from prolonged use of nonsteroidal anti-inflammatory drugs (NSAIDs). A history of extensive NSAID use should raise suspicion for a peptic ulcer. 49 Pain from an inflamed gall bladder (cholecystitis) is usually experienced in the right upper quadrant and right infrascapular region." The pain is often accompanied by a moderate fever, nausea, and vomiting. Symptoms often occur one to two hours after the ingestion of a heavy meal. The Murphy sign is performed by palpating the right subcostal region and asking the patient to take a deep breath. The sign is positive if the patient reports pain with inhalation. 5 ' Patients with acute inflammation of the pancreas (pancreatitis) can experience pain around the thoracolumbar junction. Kidney or renal pain caused by pyelonephritis (kidney infection) and renal stones is usually referred to the costovertebral angle or flank area. 49 The flank refers to the lateral region of the trunk between the rib cage and iliac crest. Pain originating from the kidneys is typically accompanied by fever, nausea, vomiting, and renal colic. Renal colic is flank pain accompanied by lower abdominal pain that spreads into the labia in women and into the testicles in men. Those at risk for kidney infection either have a history of urinary tract infections or currently have an ongoing urinary tract infection. PATHOLOGIC CONDITIONS Nonmusculoskeletal Thoracic Pain The first concern in managing a patient with thoracic spine pain, especially in an era of the physical therapist becoming a direct access care provider, is to rule out a serious pathological or visceral cause that requires a medical referral. Because the presence of primary thoracic pain is relatively uncommon (only an estimated 15% of all spinal pain), clinicians should be suspicious of nonmechanical causes in patients presenting with a primary complaint of thoracic spine and chest wall pain. 47 A medical screening form, which the patient completes prior to the clinician conducting an examination, is a useful first step in the medical screening process. Positive responses to questions on the medical screening form will then cue the therapist to probe further in order to ascertain the possibility of serious pathology or disease. Potentially, conditions that would require a medical referral can be divided into visceral conditions that refer pain to the thoracic spine and serious conditions of the thoracic spine." Visceral causes of thoracic spine pain Visceral causes of thoracic spine pain should be considered when there are no clear mechanical features to a patient's pain. Visceral conditions that can refer pain to the thoracic spine include myocardial ischemia, dissecting thoracic aortic aneurysm, peptic ulcer, acute cholecystitis, renal colic, and acute pyelonephritis. Referred pain is pain perceived in a region separate from the location of the primary source of the pain. 12 The mechanism of referred pain is not completely clear. The most accepted theory is that referred pain is due to the convergence of primary afferent neurons to the same second-order neuron in the spinal cord. Pain elicited by a visceral structure can be misperceived as arising from a somatic structure that has a primary afferent neuron converging onto the same second-order neuron. 12 The majority of the visceral organs are innervated by the thoracic spinal nerves. Therefore, there is a potential for a host of visceral diseases to refer pain to the thoracic spine and rib cage. Pain from a dissecting thoracic aneurysm is usually felt in the chest and can radiate to the back if the descending aorta is involved." Pain is usually of sudden onset, often is unrelenting, and is not relieved by position change. A dissecting aortic aneurysm is a condi- 7 osteomyelitis, diskitis, and epidural infections. Fever is usually a hallmark sign in cases of spinal infection. Serious causes of thoracic spine pain Pain from serious conditions emanating from the thoracic spine includes infection, fractures and neoplasms, and inflammatory disorders. Spinal metastases, usually secondary to a primary breast, lung, or colon cancer, are the most common forms of cancer in the thoracic spine. 52 Primary thoracic spine tumors are less common. Ozaki et a1 52 reported on 22 cases of spinal osteoid osteoma or osteoblastoma of which 6 were in the thoracic spine. Among the common findings in these 6 cases were a painful scoliosis, long-tract neurological signs, and leg pain. Deyo and Diehl" reported on 1975 patients in an outpatient primary care setting with spinal pain of which 316 (16%) had thoracic spine pain. Two (0.63%) of these patients had cancer as the cause of the thoracic pain. This was similar to the 0.66% of cancer-related pain for patients with low back pain. Historical findings that carried the most accurate diagnostic information for predicting cancer were as follows: age over 50 (sensitivity 0.77, specificity 0.71, positive likelihood ratio 2.7, negative likelihood ratio 0.32), history of cancer (sensitivity 0.31, specificity 0.98, positive likelihood ratio 15.5), unexplained weight loss (sensitivity 0.15, specificity 0.94, positive likelihood ratio 2.5), and failure of conservative therapy (sensitivity 0.31, specificity 0.90, positive likelihood ratio 2.6). Therefore, the greatest shift in probability of cancer (positive likelihood ratio 15.5) occurs when the patient reports a history of cancer. Ankylosing spondylitis is an inflammatory disease that can affect the thoracic spine and rib joints. Information from the patient history can assist in guiding diagnosis. An initial diagnostic criteria set was proposed with the following predictor variables: stiffness of > 30 minutes duration, improvement in back pain with exercise but not with rest, awakening because of back pain during the second half of the night only, and alternating buttock pain. 54 This set has reasonable diagnostic accuracy. If two of the 4 parameters were fulfilled, the sensitivity was 0.70 and specificity is 0.81. If 3 parameters were fulfilled, the sensitivity was 0.33 and the specificity was 0.94. The key physical examination finding implicating ankylosing spondylitis is limited chest expansion." The normal expansion of the rib cage measured at the nipple line is 5 centimeters. Chest expansion of less than 2.5 centimeters is considered pathologic. Other signs alerting the clinician to the possibility of ankylosing spondylitis include sacroiliitis, morning pain and stiffness, and peripheral joint involvement. The ratio of those affected by the disease is 3 to 1 for men to women, and age of onset is between 15 and 40 years." Ninety percent of patients with ankylosing spondylitis are HLA-B27 positive. However, only 10% to 20% of individuals who are HLA-B27 positive develop ankylosing spondylitis; therefore, the false positive rate for this test is high. Infection is an uncommon cause of thoracic spine pain. The pretest probability of infection as the cause of back pain in general in the primary care setting is less than 0.01%." Causes of thoracic spine infection include Thoracic Vertebral Fractures Fractures as a serious cause of thoracic spine pain can be divided into traumatic fractures and osteoporotic fractures. Traumatic fractures are usually a result of blunt trauma or injury. Osteoporotic fractures represent an increasingly common serious cause of thoracic spine pain in our aging patient population. Osteoporosis is an agerelated disorder characterized by decreased bone mass and increased susceptibility to fracture. Osteopenia is a generalized decrease in bone mineral density appearing as excessive radiolucency on radiographs. Risk factors for osteoporosis include Caucasian race, history of smoking, early menopause, thin body build, sedentary lifestyle, steroid treatment, and excessive consumption of caffeine or alcohol." In a large study in the Finnish population, the prevalence of thoracic vertebral fracture was 6.2 per 1000 in men and 3.9 per 1000 in women." The prevalence in men gradually increased with age, and in women it greatly increased over the age of 65. The majority of those with fractures in this study were asymptomatic. A hospital-based study found that the majority of thoracolumbar compression fractures occurred spontaneously or as a result of a trivial strain. 57 The clinical implication is that in men or women age 60 or older presenting with acute thoracic spine pain, osteoporotic fracture must be considered. Vertebroplasty and kyphoplasty are minimally invasive and commonly used surgeries to manage vertebral compression fractures. Previously, it was thought that vertebroplasty had at least short-term effectiveness in reducing pain and improving function but recent double blind placebo controlled trials concluded that there was no significant difference between vertebroplasty compared with a sham procedure in pain, function, disability, quality of life, and perceived improvement at one- to 6-month followup 58,59 These results indicate that there is no benefit of vertebroplasty over passage of time. Two editorials have criticized these randomized trials stating that the population in both studies was chronic (> 12 months post-fracture) whereas vertebroplasty may be effective for a more acute population. 6°,61 There are no randomized controlled trials to date comparing kyphoplasty to sham or conservative care. Although no studies have directly compared surgery with physical therapy, it is likely that physical therapy can serve as a low-cost alternative to more invasive management, with little to no risk of serious complications. A pilot randomized trial compared the effects of a multimodal physical therapy program to a control group in 20 patients with an osteoporotic vertebral compression fracture. 62 All patients were older than 50 and had sustained at least one vertebral compression fracture between the past 3 months and two years. The physical therapy program took place once a week for 10 weeks. The program consisted of education, postural taping, manual therapy, range of motion exercises, and back extensor strengthening. Manual ther- 8 apy included soft tissue massage and nonthrust posterior to anterior manipulation directed to the thoracic spine. At the completion of the study the physical therapy group reported decreased pain, improved physical functioning, and displayed improvement in physical impairments compared to the control group. No serious adverse events were reported in the physical therapy group. EXAMINATION PROCEDURES Diagnostic Imaging Although the ordering of imaging studies is not currently a standard part of most physical therapists' practice, physical therapists should be knowledgeable of when an imaging study is indicated. In the absence of trauma, imaging of the thoracic spine is indicated when investigating a serious cause of thoracic spine pain. Individuals with acute thoracic pain who are at risk for an osteoporotic fracture should have plain radiographs to assess for the presence of a fracture. 47 In cases where cancer or infection are suspected, magnetic resonance imaging and bone scans are typically the preferred initial imaging modalities due to their high sensitivity in detecting these conditions. In the presence of trauma, one guideline recommends plain radiographs for patients with positive or equivocal clinical findings, such as spinal tenderness and neurologic signs, and for those with altered consciousness. 47 For those patients who are awake and alert, and have no clinical findings, radiographs are not indicated. In the absence of trauma or indications of serious causes of thoracic spine pain, imaging studies, including magnetic resonance imaging and radiographs, are not useful in determining the source of a patient's pain. Physical Examination Inspection At the stage of inspection in the examination, the therapist is interested in the global visual presentation of the patient including the posture of the thoracic spine. The reliability of postural assessment in the cervicothoracic spine has been studied by Griegel-Morris and colleagues. 63 They visually assessed for the presence of a forward head posture, the rounding of the right and left shoulders, and degree of thoracic kyphosis against a plumb line. Using this method, the intrarater reliability across 3 therapists was = 0.825, and the interrater reliability across the 3 therapists was x = 0.611. The primary purpose of the study was to assess the association of postural abnormality and a history of pain. In 88 asymptomatic subjects aged 20 to 50, a relationship between pain frequency and severity and the severity of postural abnormalities was not found. However, chi-square analysis did reveal a significant increase in the incidence of pain, including interscapular pain, in individuals with the most severe postural abnormalities. The majority of subjects displayed posture that is traditionally considered abnormal, including forward head = 66%, kyphosis = 38%, right rounded shoulder = 73%, and left rounded shoulder = 66%. In a smaller study, Refshauge et al 64 did not find an association between cervicothoracic posture and pain. In isolation, postural abnormalities have uncertain relevance to the patient's symptoms. However, their presence can alert the clinician to areas of potential movement impairment. For instance, areas of increased kyphosis suggest an extension restriction, whereas areas of decreased kyphosis or flatness suggest a flexion restriction. Active range of motion Patterns of active range of motion impairments and pain provocation at end range are helpful in determining treatment classifications. Active range of motion of the thoracic spine is performed with the patient seated with the arms crossed in front over the chest. In performing these procedures, the clinician will attempt to determine the range of motion present in each direction and the behavior of the patient's symptoms during and immediately following the evaluated movement. The patient forward bends, backward bends, side bends to the right and to the left, and rotates to the left and right. The patient may require verbal or manual cueing in order to emphasize motion in the thoracic spine versus the lumbar spine and pelvis. If the patient reports no pain with the active range of motion, the clinician can provide passive overpressure at end range to assess for both symptom response and end feel. In addition to cardinal plane range of motion, the clinician can also use quadrant positions or combined range of motion. Combined motions are used when the clinician is unable to reproduce the patient's symptoms with cardinal plane ranges of motion. Combined motion quadrants include flexion or extension with combined right or left rotation and side bending. The patient actively performs these motions with guidance from the clinician and the clinician may provide overpressure at end range as needed. The clinician should also consider using a combined motion if the position is similar to a functional position during which the patient reports pain. For example, if the patient is a right-handed tennis player and reports middle thoracic pain while reaching for an overhead shot, the clinician could assess combined thoracic extension with right rotation and right side bending. Measuring thoracic range of motion Moderate reliability for the quantification of forward bending and right and left side bending with inclinometry has been reported. 65 Thoracic rotation is difficult to quantify with inclinometry but it is important to assess given the requirements of trunk rotation for various functional activities. Thoracic rotation range of motion is commonly estimated with visual inspection. When using inclinometry, the examiner locates and marks the T1 spinous process and places the inclinometer at the mark and zeros it. The T1 spinous process is located inferior to the vertebral prominens C7. To distinguish T1 from C7, the C7 spinous process will move away from the palpating finger during active cervical extension while Ti will remain relatively prominent. The examiner can also attempt to locate T1 by palpating the posterior aspect of the shaft of the first rib and following it medially to the T1 spinous process. The of motion testing and accessory mobility testing such as posterior to anterior spring testing over the cervical spinous processes and articular pillars. If the patient's upper thoracic or scapular symptoms are reproduced with cervical range of motion and accessory mobility testing, the symptoms are likely originating from the cervical spine. The reader is referred to the cervical spine monograph for further information on evaluation of the cervical spine. Patients with upper thoracic and interscapular pain can also have a cervical radiculopathy. Wainner et a1 69 developed a test-item cluster that can assist the clinician in determining the presence of a cervical radiculopathy. The 4 items in the test-item cluster include cervical rotation range of motion to the painful side of less than 60°, positive Spurling A test, positive upper limb tension test-A (median nerve bias), and positive cervical distraction test. Positive findings on all 4 tests produce a positive likelihood ratio of 30.3 for the presence of a cervical radiculopathy as determined by positive electrodiagnostic testing. Three of 4 positive tests produce a positive likelihood ratio of 6.1. Furthermore, the upper limb tension test-A was the single most sensitive test (0.97), with a resultant negative likelihood ratio of 0.12. Therefore, a negative upper limb tension test-A effectively rules out the disorder. examiner stabilizes the inclinometer against the patient's trunk with the thumb and index finger while his remaining fingers rest on the upper trunk. The range of motion is measured for forward bending, backward bending, and right and left side bending. The therapist can determine the range of motion and note any change in the patient's symptoms as a result of the movement. The sequence is repeated with the inclinometer at the T12 segment. To locate the T12 spinous process, the clinician can find the 12th rib on the posterior lateral aspect and palpate superiorly until he feels the spinous process of T12. Normative values for thoracic spine motion using inclinometry do not exist. Measuring thoracic range of motion at baseline and then after intervention can alert the clinician to objective changes in range of motion and the potential success of the intervention. Although not studied for the thoracic spine, clinical research has shown that increases in cervical range of motion within a treatment session predict an increase in cervical range of motion between treatment sessions. 66 Assessing for centralization In addition to recording the range of motion, it is important to ascertain the effect of each movement on the patient's status. The patient's status change with movement is assessed using the following terms: peripheralizes, a neurological sign or paresthesia is produced or the patient's paresthesia or pain moves distal to the thoracic spine, and the pain can radiate into the upper or lower extremity, or wrap around the rib cage to the anterior aspect; centralizes, a neurological sign is improved, or paresthesia or pain is abolished or moves from the periphery toward the thoracic spine; status quo, symptoms may increase or decrease in intensity but do not centralize or peripheralize and remain unchanged from the baseline assessment. The judgment of a status change with movement testing may be an important component for classifying patients. The presence of centralization is a positive prognostic indicator in low back pain and is used in the cervical spine region as we ll .67,68 This phenomenon is less common in the thoracic spine but can be useful in certain situations. More often, in the thoracic spine, symptoms fall in the category of status quo. However, the therapist should carefully evaluate the provocation of symptoms with movement even if they rapidly return to baseline. After an intervention, the same motions that previously produced symptoms can then be reassessed. A useful, quick screening of the thoracic spine for symptom provocation is seated rotation. During this test, the patient is seated with arms crossed over the chest. The patient then rotates the trunk to the right and left, and the therapist assesses for symptoms and range of motion. Segmental examination of the thoracic spine The physical therapist has a number of proposed examination systems and models to consider when assessing restricted segmental motion or segmental dysfunction in the thoracic spine. It should be noted that in general, spinal segmental motion palpation procedures have poor to fair reliability. Christensen et a1 7° assessed the reliability of a manual examination of the upper thoracic spine by two experienced chiropractors. Subjects included 29 patients with stable angina pectoris and 27 control subjects. Palpatory assessment, including seated and prone accessory motion restriction and palpation for segmental paraspinal tenderness, was carried out from T1 through T8. Intrarater reliability was superior to interrater reliability, and reliability for assessment of tenderness was superior to motion palpation. For tenderness, kappa scores for intrarater reliability were 0.63 to 0.77 and for interrater reliability were 0.67 to 0.70. Kappa scores for motion palpation were 0.24 and 0.22 for the seated and prone examination interrater reliability, and ranged from 0.59 to 0.68 for intrarater reliability. Cleland et al 71 reported that segmental mobility testing of the thoracic spine, using posterior to anterior spring testing with the patient prone, has poor to fair interrater reliability for both pain and mobility assessment in patients with neck pain. Because this study involved patients with primary neck pain, the results may not be generalizable to patients with primary thoracic spine pain. Previous research has shown that clinicians can be fairly reliable in detecting painful motion segments in the cervical spine in patients with neck pain. Further research is required to determine the reliability of detecting painful motion segments in patients with a primary complaint of thoracic spine pain. In a study involving subjects with- Cervical spine screening Symptoms in the upper to middle thoracic spine may be caused by cervical irritation. It can be difficult to differentiate between the lower cervical and upper thoracic spine as the source of the patient's symptoms. The clinician should screen the cervical spine with active range 10 out symptoms, reliability of segmental mobility testing of the thoracic spine and ribs improved when an expanded definition of agreement was used." The authors of this study reported that most of the errors in measurement came from accurately identifying the same thoracic vertebral segment. In the expanded definition of agreement, the authors allowed for agreement within and between raters to within ±1 thoracic vertebral level. More research is required; however, one could conclude that reliability within and between raters for thoracic segmental mobility testing is improved when assessment is based on a region of the thoracic spine rather than a specific segment. In other words, clinicians could consider mobility testing of various thoracic regions (upper, middle, lower) divided into 4 segments when assessing thoracic spine mobility. The poor to fair reliability of the segmental examination does not necessarily make these procedures obsolete or not useful. Models or systems of segmental examination allow the therapist to assess individual segmental levels or spinal regions and, when coupled with the history, form the basis of a movement—impairment-based diagnosis. The authors caution the reader that the diagnosis of movement impairments is based on a model. The model allows physical therapists to think about restriction of motion in the thoracic spine and chest wall. The joints, in fact, may have all or nothing to do with the loss of perceived motion. The therapist must be cautious of what Blomberg73 terms systematic palpatory illusions. In other words, the therapist should understand that when identifying a hypomobile segment, the actual structural position of the segment is unlikely to be significantly altered. However, these serve as markers of dysfunction, guiding the therapist toward both a particular targeted spinal region and treatment technique. The therapist should assess the effectiveness of the intervention by reassessing the markers of dysfunction, the aggravating factors, and the outcomes instruments. During the first step in the thoracic spine segmental examination, the therapist assesses for tenderness and tissue reactivity by running the fingers down the patient's spine in the medial gutter between the spinous process and the transverse process. Segmental mobility testing of the thoracic spine is then performed with posterior to anterior spring testing, conducted with the patient prone. The clinician screens the thoracic spine for mobility and pain by applying his hypothenar eminence to the thoracic spinous process and producing a graded posterior to anterior force. The examiner records the presence or absence of pain and notes whether the mobility is normal, hypomobile, or hypermobile for each thoracic segment/ 1,72 The clinician can spring unilaterally over the region of the thoracic transverse processes in a similar fashion. Segmental examination of the chest wall Chest wall range of motion Thoracic spine range of motion as described above also involves rib cage motion. In addition to those tests, the clinician can also assess rib cage range of motion visually and manually as the patient is breathing. Assess the first rib by sitting at the head of the table with the patient lying supine. The therapist's palpating fingers should be just inferior to the sternoclavicular joint. Instruct the patient to take a deep breath and then exhale completely. Monitor the motion for right to left symmetry and also for the presence of pain. Perform a similar assessment on the remaining rib segments by standing at the side of the patient and testing the remaining ribs in groups: upper (ribs 2-5), middle (ribs 6-10), and lower (ribs 11-12). For the upper and middle ribs, the examiner can assess both the bucket handle and pump handle motions. This is accomplished by placing his finger tips on the lateral aspect of the ribs for the former and the anterior aspects for the latter, while the patient fully inspires and then expires. Recall that ribs 11 and 12 move in a caliper fashion. To assess range of motion of these ribs, the examiner palpates the lateral aspects while the patient fully inspires and expires. Rib cage static positioning and segmental mobility Loss of rib cage mobility results from a variety of factors including poor postural habits, myofascial shortening, and joint dysfunction. 1 ° Following the general assessment of overall rib cage range of motion, the ribs are palpated for tenderness and symmetry. The ribs are palpated for symmetry and tenderness anteriorly at the costochondral junction and posteriorly at the rib angle and the intercostal spaces. Rib cage dysfunction frequently presents with tenderness at the rib angle, and therefore this is a key palpatory landmark. The ribs are for segmental mobility and pain using posterior to anterior spring testing with the patient prone. Using a crossed handed technique, the clinician stabilizes the opposite side of the thoracic spine with his hypothenar eminence lateral to the spinous process and springs over each rib, just lateral to the transverse process, using the hypothenar eminence of his opposite hand. The clinician can also perform passive accessory mobility of the anterior ribs by springing in an anterior to posterior direction over the costosternal joints using his thumbs.'" The clinician records the presence or absence of pain and notes whether the mobility is normal, hypomobile, or hypermobile for each rib." First rib testing using the cervical rotation lateral flexion test First rib dysfunction can be present in a number of upper quarter clinical syndromes. The cervical rotation lateral flexion test is an additional method that has been reported to assess for the presence of an elevated first rib in patients with brachialgia. The test is performed with the patient in a sitting position. The cervical spine is rotated passively and maximally away from the side being tested (eg, rotation to the right to test the left side) (Figure 1). In this position, the cervical spine is gently side bent as far as possible, moving the ear toward the chest. A test is positive when the side bending movement is limited or blocked. A reduction in sidebending mobility is suggestive of an elevated first rib on the side opposite from which the cervi- endurance, and motor control particularly of the scapular stabilizing muscles. Figure 1. The Cervical Rotation Lateral Flexion Test Assessing the Left First Rib INTERVENTION TECHNIQUES Joint Manipulation Techniques The manual joint manipulation techniques discussed in this section will include both thrust and nonthrust procedures. The nonthrust procedures demonstrated will be contract-relax techniques and graded joint movement at varying speeds and amplitudes also known as joint mobilization. Thrust manipulation techniques are by definition high-velocity and low-amplitude procedures. The reader should be aware that the majority of the thrust manipulation procedures described in this section could be performed in a graded mobilization fashion. 75 In the authors' experience, thrust manipulation is used more frequently than other manual therapy techniques when treating the thoracic spine. However, nonthrust techniques are still employed but frequently in a preparatory manner or after thrust manipulation to assist with muscle re-education. Based on the evidence for superior effects of manipulation when combined with exercise for patients with neck disorders, manipulation is rarely performed in isolation. 76 The therapist provides specific exercise and postural corrective instructions immediately following the manual therapy procedures. The risks of manipulation in the thoracic spine are extremely low, provided trained therapists properly select and assess patients and perform the technique. The estimated rate of occurrence of cauda equine syndrome as a complication of lumbar spinal manipulation is estimated to be less than one case per 100 million manipulations!' Overall, serious or severe complications of lumbar spinal manipulation are extremely rare. 78 However, to the authors' knowledge, similar data regarding the thoracic spine are not present in the literature. Senstac 79 reported on symptoms following manipulation in more than 100 patients. Manipulation was included for the cervical, thoracic, and lumbar spine. The authors reported that muscle and joint soreness following manipulation was common but rarely led to even short-term impairment in functional status. Therapists should always do everything within their power to limit risk of patient harm. However, it is helpful to put the risk of harm from manipulation into context with competing therapies. Tannenbaum et a1, 8° reporting on the major side effects from NSAIDs, noted that 1% to 3% of users are thought to develop gastrointestinal bleeding. Furthermore, each year in the United States, 7600 deaths and 76,000 hospitalizations may be attributed to NSAIDs. 81 One contraindication to manipulation in the thoracic spine is the presence of osteoporosis. Supporting clinical data is lacking, but manipulation and mobilization have the potential to cause vertebral or rib fracture in an individual with osteoporosis." A survey of therapists in one Canadian city found that about half used manual therapy in patients with osteoporosis, although over 90% had some concerns about using it." Bone mineral density is most accurately measured with dual-energy x-ray cal spine was rotated. Lindgren and colleagues 74 reported excellent interrater reliability (lc = 1.0) and good agreement with cineradiographic findings (lc = 0.84). Lindgren 74 reports that the cervical side bending movement during this test is limited due to the transverse process of T1, on the contralateral side, contacting and being blocked by the superiorly subluxed rib. However, additional research is required to substantiate this claim. Mechanical Movement Impairments Diagnosis After excluding red flags or serious causes of thoracic spine pain, there is no reliable or valid clinical examination scheme for diagnosis of specific pathoanatomical causes of a patient's thoracic spine pain. Therefore, a pathoanatomical diagnosis is not appropriate for most patients with thoracic spine and rib cage pain. They are often considered a homogeneous group and labeled as nonspecific mechanical thoracic pain, thoracic pain of unknown origin, or somatic thoracic spinal pain. 47 Such terms, however, are not useful in guiding the therapist's selection of treatments appropriate for specific patients. Instead of focusing on a pathoanatomical diagnosis, the therapist can focus on clusters of signs, symptoms, and impairments identified during the examination that will assist in determination of the most appropriate treatment approach. Interventions are then used that address the specific impairments found during the examination. Common impairments in patients with thoracic spine or rib cage pain include limited joint mobility of the thoracic vertebral joints and ribs; impaired posture; soft tissue mobility restrictions involving shortened and hypertonic muscles; and impairments in muscle strength, 12 • absorptiometry, or a DXA test." Patients who have a tscore 2.5 or more standard deviations below the reference standard are considered to have osteoporosis and are at risk for vertebral and other fractures. Individuals with t-scores between 1 to 2.5 standard deviations below the reference are considered to have osteopenia. Individuals with osteopenia are at risk for developing osteoporosis. Further research is warranted, but it seems prudent to limit manual therapy procedures in individuals with moderate to severe osteoporosis (eg, a patient with a prior history of compression fracture) to nonthrust procedures. In the authors' opinion, for patients with osteopenia, the potential for a vertebral fracture from spinal manipulation is less of a concern given the low risk of fractures in these individuals. However, it is important to note that the great majority of research using thoracic spine manipulation has been performed on patients 60 years old and younger. The reader is cautioned to use judgment and sound clinical reasoning when selecting patients appropriate for thoracic spine manipulation. There is currently a lack of evidence, in terms of highquality clinical trials, concerning the effectiveness of interventions for patients with primary thoracic spine pain. One small pilot study assessed the effects of manipulation compared to placebo ultrasound." There were 15 patients in each group who had responded to a newspaper article for individuals with middle back pain. The authors found a significant reduction in pain on the numeric pain rating scale (NPRS) at the completion of 6 treatments and at 1 month follow-up for the manipulation group compared to the placebo group. In a case report, Kelley and Whitney 86 described the immediate relief of right lower chest wall pain following a nonthrust manipulation of the middle thoracic spine in an adolescent athlete. Fruth 87 reported a case of a patient with right upper thoracic pain that was resolved after 7 physical therapy visits including nonthrust manipulation of the ribs, ischemic compression of trigger points, and therapeutic exercise. In a retrospective review of 73 patients reporting to a rheumatology clinic with a primary complaint of thoracic spine pain, Bruckner and colleagues" reported that the majority of the patients were either pain-free (77%) or noted some improvement (15%) after postural advice and manipulative treatment of the thoracic spine. The majority of patients (75%) in this retrospective review reported middle thoracic pain and about half also complained of anterior chest wall pain. Larger high-quality trials are needed to determine the optimal treatment interventions for patients with primary thoracic spine pain. What follows are interventions to improve motion impairments based on a model of mechanical spinal segmental restriction. It is useful to follow a model in order to have a basis from which to make clinical decisions about the selection of particular techniques. There is currently no evidence showing that following a particular model of mechanical spinal segmental restriction is necessary to achieve the desired outcome. While the authors have focused on identifying mechanical segmental restrictions, there is evidence that shows that manual therapy procedures produce a regional neuromodulatory effect. For example, non manipulation of the cervical spine has been shown to:1 to a decrease in the pain-pressure threshold over the area: application and also at sites distal to the application such: the ipsilateral lateral elbow. 89 This effect has been coined') manipulation-induced analgesia. There is indirect evidence' that this effect comes from stimulating endogenous nono- . pioid central descending pain-inhibiting systems located in the periaqueductal gray region of the midbrain. 89 Due to the nonspecific neuromodulatory effect of manipulation, targeting motion impairments with specific manipulation techniques may not be necessary to achieve a positive outcome in a patient with thoracic spine pain. Haas and colleagues, 9° using cervical manipulation in patients with neck pain, showed an equal short-term reduction in neck pain after manipulating a segment, based on segmental testing versus a randomly selected segment. In two recent and similar studies involving nonthrust manipulation of the cervical spine at targeted versus random segments, the authors reported similar findings. 91,92 Furthermore, evidence also suggests that clinicians are unable to precisely limit manipulative forces to a targeted segment. Using microphones to record cavitation sounds during prone thoracic thrust manipulation, Ross and colleagues 93 reported that cavitations occurred up to 4 levels above and below the targeted joint. The conclusion was that manipulation likely produces forces to a region of the spine as opposed to only at the specific targeted segment. Merging this recent evidence with a model of mechanical motion restriction, the authors continue to use and recommend using palpatory examination and mobility testing to direct manual therapy interventions. However, less emphasis is placed on correcting perceived motion restriction and more on patient centered outcomes such as decreasing pain, improving function, and increasing the patient's health-related quality of life. Furthermore if a technique, selected based on a perceived loss of motion to a targeted region, creates increased pain during the setup, it is not uncommon for the authors to target regions above or below or on the opposite side of the painful or irritable segment. Using a test-retest model, previously painful functional movements are improved and less painful even if the specific segment was not addressed. It is also common for a patient to report pain with manual techniques that takes the patient into the perceived direction of motion loss. In these cases, a manipulation in the opposite or pain-free direction quite often leads to a decrease in pain and restoration of motion. Thoracic spine Supine upper thoracic thrust manipulation (a high-velocity, end-range, anterior to posterior force through the elbows to the upper thoracic spine in a bridged position) For this technique, the therapist stands at the side of the patient. The patient crosses the arms with the opposite arm on top. A rolled towel can be placed underneath the patient's arms to increase patient comfort and to help establish a firm lever arm. In this example, the therapist is targeting 13 Supine cervical thoracic junction thrust manipulation (A high-velocity, end-range, caudal to cranial force through the cervical spine in the supine position) Prior to initiating the technique, it is useful to relax any hypertonic soft tissue structures that directly affect this area. The posterior scalenes are commonly involved. The manipulative technique begins with the therapist attempting to take up the soft tissue of the upper thoracic spine with a wide-based handgrip (Figure 3A). This is an attempt to securely and comfortably contact the C7 or T1 segment. With the other hand, the clinician then stabilizes the head and neck with a chin hold. Slack is taken up, final minor adjustments are made, and a quick thrust of short amplitude is delivered in a straight, cranial direction (Figure 3B). If needed, this technique can then be followed by a more direct technique to gain upper thoracic spine extension. the T1-T2 segment. The therapist rolls the patient toward himself and places his thenar eminence and palmar region of his hand proximal to the second MCP joint on the inferior vertebrae: T2 (Figure 2A). To establish a firm contact, the therapist applies a skin lock by ulnarly deviating his hand and pulling caudally. The therapist rolls the patient back to the supine position. In this technique, the aim is to restore extension at the T1 -T2 segment. The therapist lifts the patient to directly place the T1 -T2 segment over his hand to assist with directing the manipulative forces to the targeted segment. While applying pressure through the patient's crossed arms, the therapist makes final minor adjustments until a crisp end feel is established. The patient is asked to inhale and then exhale, and the therapist performs a quick thrust down toward his underneath hand and the table. It is often useful to have the patient perform a supine bridge in order to bring the upper thoracic spine onto the therapist's hand. Once the patient bridges and the targeted thoracic region is firmly on the therapist's hand, the thrust is delivered (Figure 2B). Figure 3. Supine Cervicothoracic Junction Thrust Manipulation Figure 2. Supine Upper Thoracic Thrust Manipulation A, hand placement for supine upper thoracic thrust manipulation. B, position for thrust. A high-velocity, end-range, anterior to posterior force through the elbows to the upper thoracic spine in a bridged position. A, hand position. B, final thrust position. A high-velocity, endrange, caudal to cranial force through the cervical spine in the supine position. 14 Seated upper thoracic/cervical thoracic junction thrust manipulation (a high-velocity, end-range, anterior to posterior force through the elbows to the upper thoracic spine in a seated position) The patient sits on a treatment table with his hands clasped behind the neck as low down on the cervical spine as possible The therapist stands behind the patient and loops his hands through the patient's arms and places the hands clasped over the patient's hands. The patient's elbows should be allowed to drop forward so as to not place the shoulders into the vulnerable abducted, externally rotated position. Care should be taken to not force the patient's neck into flexion by forward pressure from the therapist's hands (Figure 4). The clinician leans backwards by extending his hips and avoiding hyperextension of his own back, to take up slack in a superior direction. A thrust is delivered by the therapist thrusting upwards towards the ceiling in an attempt to create a distraction force in the patient's upper thoracic region. The thrust should be generated by the clinician's legs. Care is taken with this procedure to not cause strain to the patient's shoulder girdle. If the patient experiences shoulder discomfort, is unable to attain the position with his arms, or has a history of anterior shoulder instability, an alternate technique should be selected. Figure 5. Seated Middle Thoracic Thrust Manipulation TM A high-velocity, end-range, anterior to posterior force through the elbows to the middle thoracic spine in a seated position. suggests that the most comfortable position is with the elbows in parallel and this also allows for the therapist to attempt the technique on a larger patient. The therapist applies his sternum to the patient's middle thoracic spine. Alternately a rolled towel can be placed horizontally on the caudal vertebra of the segment of interest between the patient and the clinician in an attempt to be segment specific. The therapist reaches around the patient and grasps around the patient's elbows. If possible, the clinician interlocks his hands. The therapist takes up slack by adducting his arms, retracting his shoulder girdle, and pushing his chest towards the patient's thoracic spine. A high velocity thrust is performed by the therapist thrusting through the patient's arms in an anterior to posterior direction while at the same time keeping the chest pushed forward. Some therapists attempt to produce a distractive force by lifting the patient during this procedure. This could potentially injure the clinician with a larger patient and this practice should be discouraged. The clinician should also make sure to direct the manipulative thrust through the patient's elbows and towards the therapist's sternum and not through the patient's diaphragm. If the therapist cannot reasonably reach his arms around the patient, another technique should be selected. Figure 4. Seated Upper Thoracic Thrust Manipulation A high-velocity, end-range, anterior to posterior force through the elbows to the upper thoracic spine in a seated position. Prone middle and lower thoracic spine thrust and nonthrust manipulation (a high or low-velocity, mid- to end-range, posterior to anterior force to the middle thoracic spine on the lower thoracic spine in a prone position) An extension movement impairment with an increased kyphosis can occur commonly in the lower or middle thoracic spine. In the authors' experience and based on evidence from two trials, extension movement Seated middle thoracic spine thrust manipulation (a highvelocity, end-range, anterior to posterior force through the elbows to the middle thoracic spine in a seated position) The patient sits on the treatment table with his arms across the body with the hands grasping the opposite posterior shoulder region (Figure 5). Clinical experience 15 impairments of the middle to lower thoracic spine are associated with lower trapezius inhibition. 94,95 This is detected with the patient prone and the arms fully flexed and resting on the table. The therapist then observes the lower trapezius while the patient attempts to lift the arm off the table. In order to improve extension in the middle-lower thoracic spine, prone techniques are commonly used. In this example, the T8-T9 segment is targeted. The patient lies prone with the therapist standing on either side of the patient. The therapist's hypothenar eminences will contact the transverse processes of the T8 segment (Figure 6). It is useful to improve contact with the segment with direct skin contact using a skin lock. In this example, the therapist would establish skin contact and twist the right hand in a clockwise fashion while introducing the ventral force, and twist the left hand in a clockwise fashion while introducing the caudal force. Ask the patient to take a deep breath in and exhale. At the end of the exhalation effort, the therapist applies either graded nonthrust mobilizations (I through IV) or a high-velocity, low-amplitude thrust. The therapist's movement is similar to the compressions used during cardiopulmonary re- suscitation. This movement introduces extension of the middle/lower thoracic region. As with other techniques, excessive force is unnecessary. It is more comfortable, and achieves a similar goal, if the thrust is not initiated from the end range position of extension. Allow for some slack to remain prior to the thrust in order to have a range in which to thrust through. Supine middle to lower thoracic spine thrust manipulation (a high-velocity, end-range, anterior to posterior force through the elbows to the middle thoracic spine on the lower thoracic spine in a supine position) Supine techniques are typically used to improve mobility of the middle and lower thoracic spine into flexion. Flexion movement impairments are commonly seen at the T3 through T7 region of the thoracic spine. In this example, a manipulation or high-velocity thrust technique will be described to target the T4-T5 segment. The therapist stands at the side of the patient and crosses the patient's arms with the opposite arm on top. The key element of this technique is establishing a firm fulcrum at the segment below the dysfunctional segment, therefore stabilizing T5, and subsequently moving T4 on the stabilized T5 segment. Next, the therapist rolls the patient's opposite shoulder toward himself and reaches his arm around the patient's trunk. Using the thenar eminence and palmar region of his hand proximal to the second MCP joint, the therapist creates a skin lock of the T5 segment by firmly contacting the tissue overlying the T5 vertebrae and applying an ulnar deviation twisting movement of the wrist (Figure 7A). A common mistake with novice therapists is to have the stabilization contact too far laterally. The therapist then rolls the patient's trunk completely back over onto his stabilizing hand and places firm pressure through the patient's elbows in the direction of his stabilizing hand. At this point, flex the patient's head and neck down to the targeted segment. It is often easier to not lift the patient's head and create the flexion by placing the patient's head on pillows or, if available, raising the head piece of the treatment table. The therapist must not remove any pressure from the patient's trunk. The therapist then instructs the patient to take a deep breath in and then exhale. As soon as the therapist senses the movement nearing the fulcrum, a high-velocity thrust is given with the therapist's chest wall through the patient's elbows in a vector toward T5 (Figure 7B). In both the supine upper and middle thoracic spine thrust techniques the height of the table should be positioned low enough for the therapist to place his body over the patient's elbows. Instructing the patient to move to the side of the table closest to the therapist is also beneficial for this reason. Figure 6. Prone Middle Thoracic Manipulation, Thrust and Nonthrust Seated thoracolumbar thrust manipulation (a high velocity, end-range, rotational force to the lower thoracic spine on the upper lumbar spine in the seated position) The thoracolumbar junction may be a source of dysfunction in patients with lumbar pain, hip pain, and A high-velocity, end-range, posterior to anterior force to the middle thoracic spine on the lower thoracic spine in a prone position. 16 the treatment table. The patient folds the arms and the therapist places his left shoulder, with a pillow placed on top, underneath the patient's left axilla. The therapist reaches under the patient's folded arms with the left arm and grasps the posterior aspect of the patient's right shoulder or rib cage (Figure 8A). The therapist introduces a moderate amount of right trunk side bending using the left shoulder and by translating the patient's trunk from right to left. With his right hypothenar eminence, the therapist contacts the right transverse process of T12 and secures the contact with a skin lock. The therapist then walks around behind the patient, rotating the patient's trunk to the left with both hands and applying a traction force with the right hand. Once directly behind the patient, a thrust with the right hand is initiated in mostly an anterior and superior direction creating a distractive and rotary force (Figure 8B). To optimize the speed of the thrust and for safe therapist body mechanics, it is important that therapists use their trunk and legs to set up the technique and complete the thrust. Figure 7. Supine Middle Thoracic Thrust Manipulation Rib cage Seated upper rib thrust and nonthrust manipulation (a high or low-velocity, mid- or end-range, infero-medial force to the first thoracic rib on the lower cervical spine in a seated position with the head in a laterally flexed and ipsilaterally rotated position) Movement restrictions of the first and second ribs can contribute to loss of thoracic spine motion. If difficulty is experienced in restoring motion of the upper thorax, the therapist should consider mobilization of the first and second ribs. An example of treating the right first rib is provided. The therapist stands behind the patient and supports the patient's left trunk (Figure 9). The web space of the therapist's right hand contacts the posterior border of the right first rib. The therapist's hand is rolled slightly backward to position the trapezius muscle out of the way. While the therapist's left arm supports the patient's head and neck, move T1 through an arc of flexion and extension to locate the midrange or neutral position. The therapist's right arm guides a right to left translatory movement at T1 while the hand maintains contact with the first rib. This will result in right side bending the patient's neck placing the cervical soft tissue, including the scalene muscles, on slack. Ask the patient to take a deep breath and exhale. During exhalation, the therapist translates further into the barrier, and at the end range, the therapist provides a high-velocity, short-amplitude thrust on the posterior aspect of the first rib (downward and to the left). Immediately re-examine the motion segment. A modification of this technique is applicable for a second rib restriction. In this instance, the thrust is in an anterior direction and the thumb of the therapist's right hand is placed on the shaft of the second rib. The therapist allows slightly greater left rotation of the patient's head to occur in order to introduce neutral mechanics down to the T2 segment. A, hand placement for supine middle thoracic manipulation. B, position for thrust. A high-velocity, end-range, anterior to posterior force through the elbows to the middle thoracic spine on the lower thoracic spine in a supine position. lower thoracic pain. A useful technique to improve the quality and range of motion in this area is a seated rotational technique. In this example, the T12-L1 segment will be moved into left rotation. The patient is seated, straddling the end of the treatment table with the therapist standing on the left side. Straddling the table assists with stabilization of the pelvis during the technique. If the patient is unable to straddle the table due to restricted hip range of motion, it is possible to perform this manipulation with the patient sitting on the side of 17 Figure 8. Seated Thoracolumbar Thrust Manipulation Figure 9. Seated First Rib Manipulation Thrust and Nonthrust Directed Towards the Right First Rib A high- or low-velocity, mid- or end-range, infero-medial force to the first thoracic rib on the lower cervical spine in a seated position with the head in a laterally flexed and ipsilaterally rotated position. Supine rib thrust manipulation (A high-velocity, endrange, anterior to posterior force through the elbows to the rib the thoracic spine in a supine position) To manipulate the ribs, a technique similar to the thoracic spine supine techniques can be used. In this example, the supine thrust technique is directed to the left fifth rib. The patient is supine with the therapist standing on the right side of the patient. The patient's arms are crossed with the left arm over the right arm. The therapist rolls the patient toward himself and places a stabilizing hand on the patient's trunk. It is important that the hand contact in this technique is slightly more lateral than previously described. The therapist places his thenar eminence on the fifth rib medial to the rib angle and uses a twisting motion of the wrist to establish a skin lock. The therapist rolls the patient back onto his hand and places his abdomen on the patient's elbows and applies a downward pressure to engage the stabilizing fulcrum. The therapist then cradles the patient's head and neck and slightly flexes inferiorly to the region of T4-5 while maintaining firm contact against the therapist's thenar eminence. The therapist asks the patient to take a deep breath in and exhale. A A, hand position for seated thoracolumbar rotational manipulation. B, position for thrust into left rotation. A high velocity, endrange, rotational force to the lower thoracic spine on the upper lumbar spine in the seated position. 18 manipulative thrust through the therapist's chest wall in a vector toward the fifth rib is introduced. translation of the rib. In this example, the right sixth rib is treated. The patient is seated with the right arm across the chest. A rolled up towel is placed over the costochondral region of the right sixth rib and the patient's left fisted hand is placed directly over the towel. The patient's right arm is crossed over the chest while the therapist's left arm firmly pulls the patient's arms into the chest wall (Figure 11). This movement helps with the posterior translation of the right sixth rib. The patient is then guided into a diagonal slump position (flexion, left side bending, and left rotation at T6). This encourages a lateral and posterior glide of the sixth rib. The therapist's hand can also be placed on the medial border of the rib angle and palpated to ensure that the lateral motion is occurring. The technique is performed by asking the patient to gently lift the right elbow up and out. This movement facilitates the right serratus anterior muscle. With the arm fixed, the right serratus anterior will produce a posterior translatory motion to the right sixth rib. After 3 to 5 seconds, the patient is told to relax, and the therapist engages the new barrier by increasing the slump of the patient and the compression of the patient's right elbow. This procedure is repeated 3 to 5 times followed by a re-examination of the segment. Prone rib thrust and nonthrust manipulation (A highor low-velocity, mid- or end-range, postero-medial to antero-lateral force to the rib on the vertebrae in a prone position) The therapist stands at the head of the table with the patient prone and the arms positioned comfortably at the sides. Using a cross-handed technique, the therapist stabilizes the opposite side of the thoracic spine using his hypothenar eminence (Figure 10). With the other hand, the therapist contacts the shaft of the rib just lateral to the transverse process with the hypothenar eminence. Using a slight skin lock, the therapist can apply graded nonthrust or thrust manipulation to the ribs. Figure 10. Prone Rib Manipulation Thrust and Nonthrust Directed Towards the Right Fourth Rib Figure 11. Seated Nonthrust Rib Manipulation Directed Posteriorly A high- or low-velocity, mid- or end-range, postero-medial to antero-lateral force to the rib on the vertebrae in a prone position. Seated rib nonthrust manipulation directed posteriorly Reprinted from Orthopaedic Manual Physical Therapy Management of the Thoracic Spine and Ribcage. Copyright 2000, with Trauma can produce a subluxation at the costovertebral, costotransverse, or costochondral joints. An anterior subluxed rib can occur following a blow to the posterior thorax. Treatment of an anterior subluxation employs a contract relax technique to facilitate a posterior permission of the publisher Evidence in Motion, LLC (www.evi denceinmotion.com ). 19 Seated rib nonthrust manipulation directed anteriorly A posterior subluxed rib can occur with a blow to the anterior chest wall. Treatment of the posterior subluxed rib uses a contract relax technique to facilitate an anterior translation of the rib. In this example, treatment will be directed at the right sixth rib. The patient is seated and the therapist stands behind the patient. The patient's right arm is brought across the chest with the patient's hand resting on the left shoulder. The therapist reaches around and grabs the patient's right elbow. The patient is told to gently stick out the stomach to introduce thoracic extension and to drop the right shoulder to introduce right side bending. This facilitates an anterior glide of the right sixth rib. The patient is then translated into an extension and right side bending left rotation position of the T6 segment (Figure 12). During this maneuver, the therapist should sense the right sixth rib translating forward. The patient is then asked to gently pull the right elbow down to the left. This should facilitate the right pectorals to provide an anterior translatory force on the right sixth rib. After 3 to 5 seconds, the patient is told to relax, and the therapist engages the new barrier by increasing the patient's tho- racic extension and right side bending at that segment. Additionally, the therapist's right thumb can introduce an anteromedial glide of the rib. The entire procedure is repeated for 3 to 5 times followed by re-examination of the motion segment. Selected soft tissue techniques Active assisted pectoral stretching The purpose of the active assisted pectoral stretch is to improve scapular retraction and thoracic extension. The patient is positioned in side lying with the therapist standing behind the patient. The therapist, using a broad hand contact, compresses the pectoral major and/or minor muscle and then glides the tissue towards the midline. The patient's arm is then slowly horizontally abducted with slight flexion (Figure 13). The patient is asked to continue the motion to the point of tension, hold for 2 to 3 seconds, relax, and then repeat this motion. The therapist can then reposition the hand contact in an attempt to segmentally lengthen different portions of the muscle. Figure 13. Active Assisted Pectoralis Stretch Figure 12. Seated Nonthrust Rib Manipulation Directed Anteriorly Scapulo-thoracic manipulation The purpose of the scapulo-thoracic manipulation is to improve scapular mobility particularly retraction and posterior scapular tipping. The patient is positioned in side lying with the therapist standing behind the patient. The therapist, using broad hand contacts, grasps the scapula posteriorly and with the other hand grasps the clavicle and acromioclavicular (AC) joint (Figure 14). The therapist then begins a slow oscillatory circular motion predominately in the sagittal plane. When increased tension is felt, the therapist can Reprinted from Orthopaedic Manual Physical Therapy Management of the Thoracic Spine and Ribcage. Copyright 2000, with permission of the publisher Evidence in Motion, LLC (www.evi denceinmotion.com ). 20 Figure 14. Scapular Manipulation Figure 15. Increasing Middle Thoracic Flexion (BarrelHug Stretch) Demonstrating Stretching of the Left Side patient's thoracic spine. The patient supports his head with the hands and produces graded mobilization of the targeted thoracic region by extending and flexing the thoracic spine over the roll (Figure 16). The mobilization can be enhanced by having the patient inhale while extending over the roll. provide a manipulative thrust with both hands in a direction that increases the posterior scapular tipping. Selected therapeutic exercise It is recommended that the clinician instructs the patient in exercises immediately following manual therapy intervention. The goal of these exercises should be to encourage movement in the restricted or painful range of motions and also to re-educate the local musculature involved in stabilization of the segment. Emerging evidence supports that manual therapy techniques may provide a short window of opportunity during which an active movement re-education program is more efficiently accomplished secondary to pain reduction and reduced muscle guarding. 96 Figure16. Increasing Thoracic Extension Using Foam Roller Increasing middle thoracic flexion The purpose of the barrel-hug stretch is to improve or maintain flexion in the T3 through T7 region. The patient is asked to imagine that there is a 55-gallon drum on his lap and that he is trying to get his arms around it. When stretching the left side of the upper back, the patient is asked to turn slightly to the right and to put more weight on the left hip (Figure 15). The patient should be bent forward slightly, and the apex of the curve should be at the area where the greatest flexion or opening is desired. This exercise is typically given to the patient immediately after the supine manipulation technique to the T3 through T7 region. Increasing thoracic spine extension Using either a towel roll or foam roll, the patient lies supine over the roll that is placed horizontally under the Lower trapezius muscle re-education The purpose of the lower trapezius muscle re-education exercise is to improve or maintain extension in the 21 middle to lower thoracic region and to facilitate normal scapular-thoracic motion. The patient assumes a prone position with one arm off the side of the table. The therapist directs the patient to flex the arm in the plane of the scapula with the shoulder in external rotation (thumb towards the ceiling). The therapist can facilitate the activation of the lower trapezius tapping on the muscle and directing the patient to bring the shoulder blade into retraction and depression (Figure 1 7). If the patient has difficulty firing the lower trapezius, a manipulation targeting the middle to lower region can facilitate the muscle firing. Figure 18. Serratus Anterior Muscle Re-education Figure 17. Lower Trapezius Muscle Re-education on the patient reaches forward and maintains contact with the floor with the palm of the hand (Figure 19A). The patient is encouraged to let the trunk rotate and stretch while reaching in a large circle around the body (Figures 19B, C). Deep breathing and self-mobilization into the restricted ranges is encouraged. In addition, the therapist can provide a mobilization on the anterior or posterior rib cage to facilitate motion into the restricted range. REGIONAL INTERDEPENDENCE Regional interdependence refers to how impairments and treatment of a particular body region can affect related regions. There is evidence that manipulative treatment of the thoracic spine can improve neck and shoulder conditions. 97 Cervical Spine Several authors have reported positive results using thoracic spine manipulation in patients with mechanical neck pain, cervical radiculopathy, cervical myelopathy, and post-whiplash injury. In a systematic review, Walser and colleagues 97 determined there was sufficient evidence to recommend thoracic spine manipulation procedures for individuals with neck pain. In that review, 4 high-quality studies demonstrated significant reductions in pain for individuals with neck pain who received manipulation to the thoracic spine. In a randomized trial, Cleland et al' found a 15-mm reduction in the visual analogue pain scale in patients with mechanical neck pain immediately following thoracic spine manipulation when compared to a placebo manipulation. In a high quality randomized controlled trial, Lau and colleagues 98 found .that thoracic spine manipulation was superior to electrothermal modalities in reducing pain and disability Serratus anterior muscle re-education The patient assumes a quadruped position. From this position, he is instructed to protract the scapulas and flex the upper to middle thoracic spine to activate the serratus anterior muscle and facilitate thoracic flexion (Figure 18). Shoulder circle or sweep The purpose of the shoulder circle or sweep exercise is to mobilize the chest wall and integrate upper extremity function with thoracic spine and rib cage motion. The patient lies on the floor with the hips and knees bent to 90°. A small pillow can be placed under the head. The 22 cal neck pain. Gonzdlez-Iglesias et a1 10° reported that the addition of thoracic spine manipulation to an electrotherapy/thermal modality regimen resulted in significant reductions in pain and disability, and increases in active cervical range of motion compared to modalities alone. In a prospective case series, Flynn and colleagues 101 noted immediate improvement in flexion, extension, total rotation, and total side bending in patients with mechanical neck pain or cervical radiculopathy following thoracic spine manipulation. In a case series of 7 patients with cervical myelopathy, Browder et ar 02 used a combination of thoracic spine manipulation and intermittent cervical traction. They reported reduced pain, improved cervical range of motion, and a reduction in long tract signs in all patients. In a randomized trial, Fernandez-de-lasPenas et a1 43 reported a significant reduction in a NPRS in patients with whiplash injury when using a combination of thoracic spine manipulation and standard physiotherapy including modalities, exercise, and massage when compared to patients receiving standard therapy alone. Savolainen et al 103 reported superior 12-month reduction in the worst pain on a NPRS in Finnish broadcast workers complaining of neck and shoulder pain who received thoracic manipulation compared to those who received only home exercise instruction. Numerous theories abound as to why thoracic manipulation would improve cervical range of motion and decrease pain. At this time, they all remain purely speculative. The clinical bottom line is that there is sufficient evidence to warrant examining the thoracic spine in patients with cervical dysfunction and to consider using thoracic spine manipulation. In patients with acute or irritable cervical conditions such as a radiculopathy or postwhiplash injury, thoracic spine manipulation is well tolerated and leads to improvement in cervical complaints. Once the level of irritability has decreased, the cervical spine can then be directly addressed. A case report by Pho and Godges 104 provides an example of this treatment approach in a patient after whiplash injury. Figure 19. Shoulder Circle or Sweeping Exercise on the Left Side Shoulder There is emerging evidence demonstrating the effectiveness of manual therapy directed toward the thoracic spine and ribs for patients with shoulder pain. In a large randomized trial, Bergman et al 4 reported decreased pain and disability in patients with shoulder pain who received 6 treatments of manual therapy to the cervicothoracic spine and upper ribs as compared to patients receiving the usual medical care. These patients were prestratified, having been identified as patients with shoulder pain and concomitant cervicothoracic dysfunction including reduced cervical or thoracic range of motion, spinal tenderness, and reduced segmental mobility. In a study by Winters et a1, 105 symptoms resolved more quickly in patients with shoulder impingement who received manipulative therapy of the cervicothoracic spine and upper ribs compared to those receiving physiotherapy consisting of exercise, massage, and modalities. This A, starting position. B, middle position. C, ending position. Reprinted from Orthopaedic Manual Physical Therapy Management of the Thoracic Spine and Ribcage. Copyright 2000, with permission of the publisher Evidence in Motion, LLC (www.evi denceinmotion.com ). for patients with chronic neck pain at 3- and 6-month follow-up. Cleland and colleagues," in a randomized trial, incorporated thoracic spine manipulation into a standardized exercise program and found a significant reduction in disability at 1 week, 4 weeks, and 6 months compared to exercise alone for patients with mechani- 23 was a prestratified group, identified with pain arising from the structures of the shoulder girdle compared to of the glenohumeral joint. In the same study, those identified as having a synovial disorder, or pain arising from the glenohumeral joint, responded most quickly to a subacromial injection as compared to manipulation or standard physiotherapy. With longer term follow-up, the differences in manipulative therapy versus standard physiotherapy were not nnaintained. 106 Boyles and colleagues 107 performed thrust manipulation procedures directed to the thoracic spine in individuals with subacromial impingement syndrome. Significant reductions in disability and pain with provocative testing were observed at 48 hours postmanipulation. Tate and colleagues'° 8 used a combination of strengthening, manual stretching, thrust and nonthrust techniques directed to the thoracic spine and glenohumeral joints in 10 patients with subacromial impingement syndrome. At 12 weeks, 80% of patients reported at least 50% reduction in disability or a perceived recovery of at least "moderately better." Strunce and colleagues 109 investigated the immediate effects of thoracic spine and rib manipulation in patients with a primary complaint of shoulder pain. A significant reduction in pain and improvements in active shoulder range of motion were seen immediately following the intervention. Additionally, 51% of patients reported feeling "quite a bit better" to "a very great deal better" following the intervention. Mintken and colleagues"° identified potential predictor variables for patients, with a primary complaint of shoulder pain, whom are likely to respond to manual therapy (thrust and nonthrust techniques) and exercise to the cervicothoracic region. The potential predictor variables included pain-free shoulder flexion < 127°, glenohumeral internal rotation < 53° (at 90° abduction), symptoms < 90 days, not taking medications for shoulder pain, and a negative Neer test. Caution should be used when applying these potential predictor variables to patients as they have not been validated. In a prospective case series of 15 patients with shoulder pain, Jensen"' found an immediate improvement in shoulder flexion range of motion in patients receiving a seated traction manipulation to the upper thoracic spine. Boyle 112 reported on 2 cases of shoulder impingement that completely resolved after mobilization of the second rib. In a randomized trial, Bang and Deylem found superior short-term outcomes for patients with shoulder impingement who received 6 sessions of manual therapy and exercise compared to exercise alone. Manual therapy techniques were selected based on the patients' individual impairments, but the majority received mobilization of the glenohumeral joint, cervical spine, thoracic spine, and upper rib joints. Similar to the cervical spine, multiple theories exist to explain the potential mechanisms by which manipulative therapy of the cervicothoracic spine can lead to decreased shoulder pain. Based on the above-mentioned studies, there is preliminary evidence to suggest that patients with a primary complaint of shoulder pain may benefit from manual therapy directed towards the thoracic spine. REVIEW OF OUTCOME MEASURES AND SCALES In relation to outcomes, patient self-reported functional scales are recommended use for both clinical and research purposes. Clinicians have historically relied most heavily on physical impairments, such as range of motion and strength, to track patient outcomes. In many cases, physical impairment measures account for only a small portion of a patient's disability. 114,115 No specific measures for functional loss and disability have been reported for use in patients with thoracic spine and rib cage pain. One option is to use a cervical spine-specific scale such as the Neck Disability Index for patients reporting upper thoracic spine pain above the level of T4, and to use a lumbar-specific form such as the Oswestry Disability Index for patients complaining of pain below T4. The Patient-Specific Functional Scale (PSFS) is another tool that can be used for patients with thoracic spine pain. 115117 Patients list up to 5 important functional activities and rate their ability to complete them on a numeric rating scale. The average score (from 0 to 10) of these activities is then used. The PSFS has been shown to be reliable, responsive, and valid in patients with knee pain, neck pain, and low back pain. 115- " 7 The PSFS is a generic functional measure that can assist the clinician and the patient in tracking the progress of the patient's individual functional limitations. Due to the individualized nature of the items on the scale, the PSFS is not designed for use in comparing outcomes across patients. The PSFS has not been validated for use in patients with thoracic spine pain. Pain is assessed at baseline using a NPRS, which is a reliable, responsive, and appropriate measure of pain for patients with musculoskeletal conditions. 118-12 ° CASE SCENARIOS Case Scenario 1 A 35-year-old male presents with a chief complaint of middle thoracic spine pain for the past 3 weeks. The patient is employed as an information technology specialist and spends 8 to 9 hours per day on his laptop computer. He reports the symptoms began after a particularly stressful work period during which he was working up to 12 hours per day. He reports that the pain is located in the center of the middle thoracic region and does not radiate from this area. The patient reports that his symptoms increase with sitting or working on his computer for > 1 hour. His symptoms are relieved with stretching, exercise, and lying down. The patient reports that his general health is good with a family history of diabetes. Besides intermittent neck stiffness associated with prolonged sitting, this is his first episode of thoracic spine pain. The patient is active recreationally and enjoys golf, tennis, and running. Current average pain on the NPRS is 6/10, his Oswestry Disability Index is 24%. 24 . If the patient reports increased pain after the ingestion of a fatty meal, what diagnosis would be most likely? a. cholecystitis. b. peptic ulcer. c. unstable angina. d. vertebral metastases. nipulation of the middle to lower thoracic region ratus anterior weakness could exist but is more comrn with a flexion restriction of the upper thoracic regid Transversus abdominis muscle inhibition is commonly reported with low back pain. Pectoral is minor shortening could be present but is more commonly associated with a protracted shoulder girdle. The correct answer is a. cholecystis. Gall bladder disease typical refers to pain the right periscapular region and is often exacerbated after eating a fatty meal. Unstable angina would present more commonly with chest pain and a history of heart disease. A peptic ulcer could cause thoracic pain but the symptoms are often relieved after eating. Vertebral metastases is possible but the patient does not have the key red flags for cancer including age > 50, night pain, weight loss, and a previous history of cancer. 4. You decide to perform a seated, followed by a prone thrust manipulation to the middle thoracic region. Afterwards the patient displays increased thoracic spine extension and bilateral rotation with less pain. Which of the following exercises would be the best to immediately follow? a. barrel hug. b. self extension mobilization. c. serratus anterior re-education. d. shoulder sweep. 2. Given the patient's current area of symptoms, aggravating factors, and chief complaints what is the most likely diagnosis? a. mechanical rib cage dysfunction. b. mechanical thoracic spine pain. c. thoracic facet joint inflammation. d. thoracic spine disk herniation. The correct answer is b. self extension mobilization. This most closely matches the patient's presenting impairments in addition to the manipulation techniques. Furthermore the patient could potentially perform this in his chair during working hours by extending his spine over the back of his chair. The barrel hug is more directly related to treating flexion restrictions. The shoulder sweep could be potentially taught; however, the extension exercise is more specific to the patient's impairments. Serratus anterior re-education could be taught; however, a lower trapezius dysfunction is more commonly associated with middle to lower thoracic spine dysfunction. The correct answer is b. mechanical thoracic spine pain. While the source of the patient's pain could be either the thoracic disk or facet joint, it is difficult from the history and physical examination to determine the pathoanatomical cause of the pain. Furthermore even with diagnostic imaging, perhaps displaying a herniated thoracic disk, it would be difficult to determine that the imaging findings are the source of the patient's symptoms. This is due to the frequent finding of thoracic disk herniation in an asymptomatic population. Rib cage dysfunction is unlikely due to the location of the patient's symptoms in the middle thoracic region. Patients with rib dysfunction often report pain located further laterally in the region of the costovertebral or costotransverse joints. Patients with rib dysfunction also often report pain with deep inspiration or expiration. The patient exhibits an increased middle thoracic kyphosis, hypomobility, and pain in the T6-T9 region with posterior to anterior spring testing, and restricted and painful active thoracic extension and bilateral rotation. Case Scenario 2 The patient is a 42-year-old female with a chief complaint of thoracic spine pain, headaches, and bilateral upper extremity paraesthesias. She reports an insidious onset of these symptoms beginning 2 months ago. Her symptoms are aggravated by sustained postures such as sitting and driving for longer than 15 minutes and are relieved with exercise such as walking and stretching. She denies night pain, chest pain, shortness of breath, or a history of cancer. During the physical examination, she displays a reduced thoracic kyphosis in the T3-T6 region and bilateral scapular winging. During posterior to anterior spring testing applied to the T4-5 region there is local pain, hypomobility, and her bilateral upper extremity paraesthesias are reproduced. The slump test is positive for a reproduction of her thoracic spine pain and headache that eases with cervical extension. Her upper quarter sensory motor screening is normal. Her Neck Disability Index is 34% and her average pain on the Numerical Pain Rating Scale is 6/10. 3. What muscle dysfunction often accompanies middle to lower thoracic spine extension restriction and hypomobi I ity? a. lower trapezius weakness. b. pectoralis minor shortening. c. serratus anterior weakness. d. transversus abdominis inhibition. 1. Given the above presentation, which of the following diagnoses is most likely? a. cervical myelopathy. b. thoracic disk herniation. c. thoracic outlet syndrome. d. T4 syndrome. The correct answer is a. lower trapezius weakness. This is a common finding in patients with a variety of upper quarter musculoskeletal disorders, and two studies have found improved lower trapezius strength after ma- 25 The correct answer is d. T4 syndrome. The patient presents with the constellation of signs and symptoms consistent with this disorder including thoracic spine pain and stiffness, headaches, and bilateral upper extremity paraesthesias with a normal neurological examination. Cervical myelopathy is a possibility but less likely due to the normal neurological examination and that cervical extension eases her symptoms during the slump test. With cervical myelopathy, symptoms are often worsened during cervical extension due to the narrowing of the cervical canal in this position. Thoracic outlet syndrome is another possibility however the distribution of symptoms with this syndrome is usually unilateral and located towards the ulnar region of the distal upper extremity. In addition, involvement of the thoracic spine is more likely to occur in the upper thoracic spine (T1-T2) and first rib region as opposed to the T3-T7 region. A thoracic disk herniation could potentially cause these symptoms but it is difficult to make this diagnosis based on physical examination alone. The correct answer is b. serratus anterior re-education. The patient presents with a restriction in thoracic spine flexion and bilateral scapular winging. Serratus anterior weakness or inhibition often presents with these findings. Furthermore during serratus anterior re-education, there is the added benefit of producing a flexion mobilization to the thoracic spine. Answer "a," lower trapezius re-education, could also be indicated as part of a comprehensive scapular stabilization program but is not specific to the patient's presenting impairments. Answer "d," thoracic extension mobilization, would be indicated if the patient had a restriction in thoracic spine extension. Similarly answer "c," the shoulder sweep exercise, is not specific to the patient's presenting impairments. 4. Which of the following is theorized to cause the constellation of signs and symptoms associated with T4 syndrome? a. compression of the thoracic spine cord. b. peripheral neuropathy of thoracic nerve roots. c. referred mechanical thoracic pain. d. sympathetic nervous system dysfunction. 2. Given the above presentation which manual therapy intervention is indicated? a. prone middle thoracic nonthrust manipulation b. prone middle thoracic thrust manipulation. c. seated middle thoracic thrust manipulation. d. supine middle thoracic thrust manipulation The correct answer is d. sympathetic nervous system dysfunction. Due to the proximity of the sympathetic chain to the thoracic spine, it is thought that mechanical movement impairment of the thoracic spine could lead to altered sympathetic nervous system function. Answer "b" is incorrect because thoracic spine peripheral neuropathy would present with pain or paraesthesias along the sensory distribution of the thoracic nerve roots in the chest wall region. Answer "a" is incorrect because compression of the thoracic spine cord would lead to symptoms below the level of the compression and the patient would be more likely to present with neurological signs and symptoms in the lower quarter region. Answer "c" is incorrect because pain mapping studies have shown that the thoracic spine refers pain locally or within one segment above or below and does not typically create widespread symptoms in the upper extremities or headaches. Following a purely mechanical model, the correct answer is d. supine middle thoracic thrust manipulation. The patient presents with a reduced thoracic kyphosis indicating a region of the thoracic spine that is in relative extension or lacking flexion range of motion. The supine manipulation with the patient's thoracic spine in flexion most closely targets her presenting impairment. Answers "a" and "b" are incorrect because the prone technique would theoretically be used to improve extension range of motion. Answer "c" is incorrect because the seated technique is not direction specific. However based on recent evidence, it is also likely that the type of technique used would not make a difference in the patient's outcome. A major consideration for technique selection should be selected based on the patient's comfort level with the technique. It is recommended that key comparable signs be retested immediately following a technique to determine if there has been an improvement. If no improvement has occurred, then an alternate technique could be selected. Recent studies involving thoracic spine manipulation for patients with neck or shoulder pain have used multiple techniques to target the same region of the thoracic spine. At this time, there is no research to guide what the optimal technique or dosage is for manual therapy procedures in the thoracic spine. Case Scenario 3 A 72-year-old female presents to physical therapy with a chief complaint of middle thoracic spine pain. The symptoms began after she bent down to pick up a laundry basket 2 days ago. She was referred by her primary physician who diagnosed her with a thoracic spine strain. She reports constant pain in the middle thoracic region that worsens with sitting, standing, and walking. Her pain eases with lying down. The pain does not radiate and she does not report any neurological complaints. She has a history of smoking, having smoked 1 pack per day until 10 years ago. Her health history indicates she has chronic shortness of breath, hypertension, and she is postmenopausal. The patient denies a history of cancer or surgery. Her Oswestry Disability Index is 52% and she rates her pain on the analog pain scale as an 8/10. 3. Which of the following exercise interventions should be used immediately following the manipulation? a. lower trapezius re-education. b. serratus anterior re-education. c. shoulder sweep exercise. d. thoracic extension mobilization. 26 1. Based on the above presentation which of the following is the most likely diagnosis? a. cardiac ischemia. b. mechanical thoracic spine pain. c. thoracic compression fracture. d. thoracic spine bone metastases. tebroplasty versus conservative management. 5859 Due to the decreased costs and risks associated with more conservative care including physical therapy, this should be the first treatment option for this patient; therefore, answers "c," kyphoplasty, and "d," vertebroplasty, are incorrect. If initial conservative care fails to reduce the patient's symptoms and they remain severe and disabling, then percutaneous procedures such as vertebroplasty are a viable treatment option. Answer "a" is incorrect as bed rest would lead to deterioration in overall health from the effects of inactivity and immobilization. The correct answer is c. thoracic compression fracture. Given the patient's age, gender, history of smoking, and sudden onset of symptoms after a trivial strain, a thoracic compression fracture is a high probability. Answer "d," boney metastasis, is a possibility due to her history of smoking but usually there are no additional red flags, the primary being a history of cancer. 47 Answer "a," cardiac ischemia, is possible due to her history of shortness of breath and hypertension; however, this usually presents with chest pain upon exertion also known as angina. Mechanical thoracic spine pain or a thoracic spine strain is possible but given the patient presentation a fracture should be ruled out before making this diagnosis. 4. What type of physical therapy intervention is indicated for this patient once the fracture has healed and is less acute? a. aerobic conditioning. b. aquatic therapy. c. progressive spinal extensor muscle strengthening. d. stretching and range of motion exercises. The correct answer is c. progressive spinal extensor muscle strengthening. Several clinical trials have shown that extensor strengthening improves health-related quality of life and decreases the incidence of future fractures in women with osteoporotic compression fractures." Answer "b," aquatic therapy, is incorrect as weight bearing exercise has been shown to be most beneficial for bone mineral density. Answer "d," stretching and range of motion, is incorrect, while this may be beneficial, it does not address deficits in bone mineral density. Aerobic conditioning, answer "a," is incorrect because although aerobic conditioning is important for overall health it will not directly address the bone mineral density. 2. Which of the following is the best plan of treatment given this patient's presentation? a. continue physical therapy respecting her pain tolerance. b. refer her to an orthopaedic surgeon for a surgical consultation. c. refer her to the primary physician with a recommendation for magnetic resonance imaging. d. refer her to the primary physician with a recommendation for radiographs. The correct answer is d. refer her to the primary physician with a recommendation for radiographs. This patient should be referred for a radiograph due to the high likelihood of a thoracic spine compression fracture. Response "c" is incorrect because a magnetic resonance imaging is more expensive and is not usually required to make the diagnosis of a compression fracture. She could be referred to an orthopaedic surgeon (answer "b") but only after she's had the radiograph; invasive surgery is always not required for this injury. While physical therapy could still be indicated, imaging is required in order to effectively and safely implement a plan of care for this patient. Case Scenario 4 The patient is a 23-year-old female who presents to physical therapy with a chief complaint of right anterior chest wall pain. The symptoms began about 6 weeks ago and have progressively increased. The patient is a collegiate rower and believes that the pain is related to her rowing activities. The patient reports pain located on the right anterior chest wall in the region of the costosternal junction. Symptoms increased with deep inspiration, rowing, pushups, and with direct pressure to the region of pain. Symptoms ease with rest, ice, and ibuprofen. Treatment by the team trainer has consisted of electrothermal modalities and stretching exercises. This has not changed the patient's symptoms. Past medical history is unremarkable. Average pain on the numerical rating of pain scale is 6/10. And the composite score on the Patient Specific Functional Scale is 5/10. 3. Assuming the patient had a thoracic spine compression fracture what is the best initial treatment option for this patient? a. bed rest until the fracture heals. b. conservative care including physical therapy. c. kyphoplasty procedure. d. vertebroplasty procedure. 1. Give the current patient presentation which of the following serious conditions is most likely? a. cardiac ischemia. b. gall bladder disease. c. penetrating ulcer. d. rib stress fracture. The correct answer is b. conservative care including physical therapy. Randomized trials have shown that medium to long-term outcomes are identical with ver- 27 3. Which of the following exercises is best to now teach the patient? a. pectoralis major stretching. b. serratus anterior strengthening. c. thoracic extension over a foam roller. d. thoracic flexion, barrel hug. The correct answer is d. rib stress fracture. The patient engages in heavy, repetitive activity involving use of the musculature attached to the rib cage. Rib stress injuries are common in rowers. Answer "c," penetrating ulcer, is a possibility but the patient's symptoms are mechanical in nature and there are no other indications in the history that would suggest an ulcer. Answer "a," cardiac ischemia, is a possibility but the patient's younger age and symptom presentation do not match with this diagnosis. Answer "b," gall bladder disease, usually presents with right-sided periscapular pain that is associated with ingestion of a fatty meal. The correct answer is c. thoracic extension over a foam roller. The patient presents with an increased thoracic kyphosis and is also involved in an activity, rowing, involving repetitive thoracic flexion. Teaching the patient a thoracic extension mobilization would address the postural deficits and the hypomobility found on the examination. Answer "d," flexion barrel hug stretch, would be more appropriate for the patient who lacks thoracic flexion. Answers "a" and "b" could be appropriate but these impairments were not reported as part of the physical examination. You decide to refer the patient back for a rib radiograph that was read as negative. The patient returns to physical therapy and your key examination findings are as follows: • Increased thoracic kyphosis. • Active right thoracic rotation restricted x 25% with reproduction of the anterior pain. • Reduced excursion of the right middle ribs during inspiration. • Thoracic hypomobility with spring testing centrally from T4 6. • Rib hypomobility with spring posterior to anterior testing over the right fifth rib. • Severe pain and hypomobility with spring testing over the right fifth rib at the costosternal junction. Case Scenario 5 A 32-year-old female presents to physical therapy with a chief compliant of cervical and upper thoracic pain. The symptoms began one week after she sustained a whiplashtype injury. The patient reports she was in her car stopped at a light when she was struck from behind by another vehicle that was traveling approximately 35 miles per hour. The patient had cervical radiographs taken the day of her injury that were read as normal. She has been wearing a soft cervical collar prescribed by the emergency department physician. She reports that her cervical pain is severe, constant, and worsens with active range of motion of the neck, driving, and sitting. She is taking naproxen 500 mg twice per day that helps to decrease her pain. Her goal is to decrease her pain and improve her neck range of motion. Average pain score is 8/10 and her Neck Disability Index is 42%. During the physical examination, the patient has a normal upper quarter neurological examination, negative signs of cervical instability including alar and transverse ligament stress testing, painful and restricted active cervical range of motion in all planes by 50%, and segmental hypomobility of the upper thoracic spine. - 2. Which of the following is the best manual therapy intervention for this patient? a. nonthrust manipulation to the anterior aspect of rib 5. b. nonthrust manipulation to the posterior aspect of rib 5. c. thrust manipulation to the posterior aspect of rib 5. d. thrust manipulation to the T4 T6 region. - The best answer is d. thrust manipulation to the T4T6 region. Despite no evidence to support this notion, manipulation of the thoracic spine in the presence of a rib dysfunction is recommended first.' Often this can relieve the pain from the rib dysfunction likely because the thoracic techniques have a regional effect and the rib will get mobilized during the techniques. Answer "a" is incorrect because there is significant pain with spring testing in an anterior to posterior direction over the costosternal junction and direct mobilization of this area has the potential to exacerbate the patient's symptoms. Mobilization of the anterior aspect of the rib could be used later in the course of treatment if there is less pain when mobilizing this area. Answers "c" and "d" are considerations and could be used after first addressing the thoracic spine hypomobility. You performed a supine manipulation to the T4-T6 region followed by a prone thrust to the right fifth rib. The patient now has full, pain-free thoracic rotation and inspiration. 1. Given the above findings, which of the following interventions is indicated? a. cervical nonthrust manipulation and active cervical range of motion exercises. b. cervical thrust manipulation and active cervical range of motion exercises. c. electrothermal modalities and advice to rest as much as possible. d. thoracic thrust manipulation and active cervical range of motion exercises. The correct answer is d. thoracic thrust manipulation and active cervical range of motion exercises. Research has shown that patients with whiplash disorders often have thoracic spine hypomobility, and one clinical trial has shown that thoracic manipulation is an effective treatment for patients with neck pain from whiplash. 43 There 28 is significant evidence that patients with neck pain benefit in terms of reduced pain and disability from thoracic spine thrust manipulation. Answers "a" and "b" are incorrect because it is likely that direct cervical spine manipulation could lead to an increase in the patient's symptoms due to the recent traumatic injury involving the neck and the patient's presentation of high irritability. As the patient's symptoms resolve and become less irritable, the patient may benefit from cervical manipulation to restore full range of motion. Answer "c" is incorrect as there is currently no evidence for modalities in the treatment of whiplash and the best current evidence supports advice to remain as active as tolerated after a whiplash injury. volve direct hand pressure to the targeted vertebrae. The prone techniques (answers "a" and "b") are not indicated at this time because the patient reports increased pain with lying prone. As there currently is no evidence to guide the clinician on the optimal manual therapy technique to use for the thoracic spine, patient comfort and irritability are important treatment considerations. 3. According to research, what type of thoracic spine restriction is found in patients with whiplash-related neck pain? a. extension restriction. b. flexion restriction. c. first rib subluxation. d. rotation restriction. During the examination, the patient has significant tenderness with direct pressure to the upper thoracic spine and reports pain with lying prone. The correct answer is b. flexion restriction. Answers "a," "c," and "d" are incorrect as Fernandez-de-las-Penas and colleagues43 reported the highest incidence of flexion restrictions of the upper thoracic spine found on physical examination in patients with whiplash disorders. The authors theorized that this occurs when the patients cervical and upper thoracic spine is driven into a hyperextended posture during a typical rear-end collision. 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