Physical Therapy Protocols for conditions of Thorax

Red Flags for Potential Serious Conditions in Patients with Thoracic Spine/Rib Problems

Condition Myocardial Infarction1-3

Stable Angina Pectoris4

Unstable Angina Pectoris4 Pericarditis5 Spinal Fracture6

Pneumothorax7

Pneumonia5 Pleurisy5

Pulmonary Embolus5

Chest Pain without cardiac disease8

Red Flags for the Thoracic Spine and Ribcage Region Red Flag Red Flag Data obtained during Data obtained during Interview/History Physical Exam Chest Pain Pallor, sweating, dyspnea, nausea, palpitations Presence of risk factors: Previous history of: Symptoms lasting greater than 30 minutes and not coronary artery disease, hypertension, relieved with sublingual nitroglycerin smoking, diabetes, elevated blood serum cholesterol (>240 mg/dl) Men over age 40, women over age 50 Chest pain/pressure that occurs with predictable levels of exertion Symptoms are also predictably alleviated with rest or sublingual nitroglycerine Chest pain that occurs outside of a predictable Not responsive to nitroglycerine pattern Sharp/stabbing chest pain that may be referred to Increased pain with left side lying the lateral neck or either shoulder Relieved with forward lean while sitting (supporting arms on knees or a table) History of fall or motor vehicle crashHistory of Midline tenderness at level of fracture osteoporosisProlonged steroid useAge over Brusing 70Loss of function or mobility Lower extremity neurological deficitsEvidence of increased thoracic kyphosis Recent bout of coughing or strenuous exercise or Chest pain - intensified with inspiration trauma Difficult to ventilate/expand ribcage Hyperresonance upon percussion Decreased breath sounds Pleuritic pain - may be referred to shoulder Fever, chills, headaches, malaise, nausea Productive cough Severe, sharp “knife-like” pain with inspiration Dyspnea - deceased chest wall excursion History of a recent/co-existing respiratory disorder (e.g., infection, pneumonia, tumor, tuberculosis) Chest, shoulder, or upper abdominal pain Dyspnea Dyspnea Tachynea History of, or risk factors for developing a deep Tachycardia vein thrombosis Age under 40 Type “A” male or “neurotic” female High perceived level of vital exhaustion Recent uncontrollable and undesirable life events

References: 1. Berger JP, Buclin T, Haller E, et al. Right arm involvement and pain extension can help to differentiate coronary diseases from chest pain of other origin: a prospective emergency ward study of 278 consecutive patients admitted for chest pain. J Int Med. 1990;227:165-72.

2. Canto JG, Shlipak MG, Rogers WJ, Malmgren JA, et al. Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain. JAMA. 2000;283:3223-3229.

3. Culic V, Eterovic D, Miric D, Silic N. Symptom presentation of acute myocardial infarction: influence of sex, age, and risk factors. Am Heart J. 2002;144:1012-7.

4. Henderson JM. Ruling out danger: differential diagnosis of thoracic spine. Physician and Sportsmedicine. 1992;20:124-31.

5. Wiener SL. Differential Diagnosis of Acute Pain by Body Region. New York, McGraw-Hill, 1993 6. Hsu JM, Joseph T, Ellis AM. Thoracolumbar fracture in blunt trauma patients: guidelines for diagnosis and imaging. Injury.

2003;34:426-33.

7. Misthos P, Kakaris S, Sepsas E, et al.A prospective analysis of occult pneumothorax, delayed pneumothorax and delayed hemothorax after minor blunt thoracic trauma. Eur J of Cardio-thoracic Surg. 2004;25:859-864.

8. Roll M, Theorell T. Acute chest pain without obvious organic cause before age 40: personality and recent life events.

Journal of Psychosomatic Research. 1987;31:215-221.

Joe Godges DPT, MA, OCS

KP So Cal Ortho PT Residency

THORAX AND RIBCAGE SCREENING QUESTIONNAIRE NAME: __________________________________________ Medical Record #: _________________________

DATE: _____________

Yes

No

1. Do you have a history of heart problems?

2. Have you recently taken a nitroglycerine tablet?

3. Do you have diabetes?

4. Do you take medication for hypertension?

5. Have you been or are you now a smoker?

6. Does your pain ease when you rest in a comfortable position?

7. Have you recently had a major trauma, such as a vehicle accident or a fall from a height?

9. Have you had a recent surgery?

10. Have you recently been bedridden?

11. Have you recently noticed that it is difficult for you to breathe, laugh, sneeze or cough?

12. Have you recently had a fever, infection or other illness?

13. In the past few weeks, have you notice that when you cough, you easily cough up sputum.

8. Have you ever had a medical practitioner tell you that you have osteoporosis?

Joe Godges DPT, MA, OCS

KP So Cal Ortho PT Residency

Thoracic Spine Mobility Deficits ICD-9-CM: ICF codes:

847.1

thoracic sprain

Activities and Participation Domain code: d4105 Bending (Tilting the back downward or to the side, at the torso, such as in bowling or reaching down for an object) Body Structure code: s76001 Thoracic vertebral column Body Functions code: b7101 Mobility of several joints

Common Historical Findings: Symptoms precipitated by a trauma, strain, awkward movement, or prolonged static posture (bottom line - an identifiable mechanical stress) Pain is usually perceived inferior and lateral to the symptomatic segment Common Impairment Findings - Related to the Reported Activity Limitation or Participation Restrictions: Pain increases at end range of the one particular motion Palpable asymmetry of adjacent transverse processes in either thoracic spine flexion or extension Unilateral posterior-to-anterior (PA) pressures on the involved segment reproduce the reported symptoms Physical Examination Procedures:

TP Symmetry in Flexion: Upper Thoracic Spine

TP Symmetry in Flexion: Mid and Lower Thoracic Spine

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TP Symmetry in Extension: Upper Thoracic Spine

TP Symmetry in Extension: Mid and Lower Thoracic Spine Performance Cues: Use neck flexion and extension when assessing segments above T4 Use trunk flexion and prone on elbows position for assessing segments around T4 and below Determine involved segment(s) by assessing: (1) Observable ROM limitations (2) Symmetry of transverse processes (3) Resistance to unilateral posterior to anterior (PA) pressures over transverse processes (segmental ROM restrictions) (4) Symptom response to PA pressures (5) Tenderness and hypertonicity of multifidi and rotatori myofascia of the involved segment(s)

Unilateral PA – using thumbs

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Unilateral PA: using a “spacer” thumb and pisiform Performance Cues: Determine amount of mobility, resistance to motion, and symptom response to PA pressure in order to determine the involved spinal segment

Thoracic Spine Mobility Deficits: Description, Etiology, Stages, and Intervention Strategies The below description is consistent with descriptions of clinical patterns associated with the vernacular term “Thoracic Facet Syndrome”

Description: This dysfunction is due to the inability of a thoracic spinal segment to move on a neighboring spinal segment. This decreased mobility is usually the result of the superior segments inability to slide up or down on the inferior segment during flexion, extension, rotation, side bending or any combination of thoracic spinal movement. The symptoms of “thoracic facet syndrome” are similar to the widely researched cervical and lumbar facet syndromes.

Etiology: The suspected cause for the hypomobility of the involved thoracic zygapophyseal joint is due to molecular binding of the collagen fibers within the joint capsule. The cause of capsule disorders may be due to a displacement of fibro-fatty tissue within the outer borders of the facet capsule or from post-traumatic fibrosis of the facet capsule. The origin of this movement abnormality may be from a traumatic injury, awkward and/or unguarded movement such as a sudden twisting or bending motion, or from immobilization/prolonged static posture. The healing of the post-traumatic facet capsule may have an accompanying capsular contracture and shortening of the adjacent segmental myofascial. Thus, when the involved segment moves, it activates pain receptors resulting in perceived pain locally to or distal to the involved segment.

The referral pain is no more than 2.5 segments inferiorly. The origin of chronic spinal pain may be from compressed or destroyed nerves from malignant or degenerative disorders or by musculoskeletal structures including, but not limited to facet joints. Facet joint pain is usually related to degenerative processes, collapse of vertebrae and/or continuous straining.

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Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions code: b7101.3 SEVERE impairment of mobility of several joints • • • • • • •

Pain is unilateral more often than bilateral and increases at end of ranges of flexion, extension, side bending or rotation - one direction is usually more symptomatic than the others, usually extension or rotation The paravertebral pain is in a distinct thoracic area of the back, without objective neurological signs, nerve root tension Nondermatomal referred pain that is difficult to localize The patient experiences pain before resistance; pain-limited inclinometer measurements / reduced ROM Pain is not worsened or lessened with repeated flexion or extension movements Symptoms can be replicated using unilateral posterior to anterior pressures over the involved segment(s) Restricted accessory movement of the involved segmental spine segment – with tenderness and hypomobility of the adjacent segmental myofascial; paravertebral tenderness in the same area

Sub Acute Stage / Moderate Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions code: b7101.2 MODERATE impairment of mobility of several joints • • •

As Above with the following differences Pain replication at end of range of one particular movement with or without overpressure; pain at resistance A decrease in tenderness and motion restrictions of the involved segment commonly is associated with a reduction in symptoms

Settled Stage / Mild Condition Physical Examinations Findings (Key Impairments) ICF Body Functions code: b7101.1 MILD impairment of mobility of several joints As above with the following differences • The patient’s unilateral symptoms are reproduced only with end range overpressures in either a combined extension and sidebending motion or a combined flexion and sidebending motion

Intervention Approaches / Strategies Acute Stage / Severe Condition Goals: Decrease pain inflammation Restore normal segmental joint mobility Restore inclinometer measurements to within normal limits of spinal movements

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•

Physical Agents Electrical stimulation, ice (or heat) to provide pain relief and reduce muscle guarding

•

Manual Therapy Soft tissue mobilization primarily to multifidus and rotatores of the involved segment Joint mobilization/manipulation using isometric mobilization and contract/relax procedures to the involved segment to reduce associated rotatores or multifi muscle guarding Passive stretching procedures to restore normal thoracic segmental mobility to the involved segment

•

Therapeutic Exercise Instruct in exercise and functional movements to maintain the improvements in mobility gained with the soft tissue and joint manipulations

•

Re-injury Prevention Instruction Instruct the patient in efficient, painfree, motor performance of movements that are related by the patient to be the cause of the current episode of mid back pain

Sub Acute Stage / Moderate Condition Goal: Restore normal, painfree response to end of range motions or to overpressures at end ranges of rotation •

Approaches / Strategies listed above – focusing on soft tissue mobilization and joint mobilization/manipulation to normalize segmental mobility followed by mobility exercises to maintain the improvements gained from the manual procedures

Settled Stage / Mild Condition Goal: Restore normal, painfree responses to overpressures of combined extension and sidebending and/or combined flexion and sidebending •

Approaches / Strategies listed above

•

Therapeutic Exercises Instruct in stretching exercises to address the patient’s specific muscle flexibility deficits Instruct in strengthening exercises to address the patient’s specific muscle strength deficits

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If symptoms persists (>12 months), when conservative measures fail, then the patient may consider radiofrequency facet denervation.

Intervention for High Performance / High Demand Functioning in Workers or Athletes Goal: Return to desired occupational or leisure time activities •

Approaches / Strategies listed above

•

Therapeutic Exercises Encourage participation in regular low stress aerobic activities as a means to improve fitness, muscle strength and prevent recurrences

Selected References Defranca G, Levine L: The T4 syndrome. J Manipulative Physiological Therapeutics, 18:34-37 Donatelli R, Wooden MJ: Orthopedic Physical Therapy, 2nd ed. Churchill Livingston Inc, New York, 1994, pp 126 Dreyfuss P, Tibiletti C, Dreyer SJ: Thoracic zygapophyseal joint pain patterns: A study in normal volunteers. Spine 19:807-811, 1994 Flynn T. Thoracic Spine and Rib Cage Disorders. Orthopedic Physical Therapy Clinics of North America 8-1:1-20, 1999 Saunders HD, Saunders R: Evaluation, Treatment, and Prevention of Musculoskeletal Disorders: Volume I Spine, 3rd ed. The Saunders Group, Chaska, Minnesota, 1995, pp 103-105, 147-149.

Schiller L. Effectiveness of Spinal Manipulation Therapy in the Treatment of Mechanical Thoracic Spine Pain: A Pilot Randomized Clinical Trial. Jour of Manipulative and Physiological Therapeutics. July/Aug 2001; 24(6): 394-401 Stolker RJ, Vervest ACM, Groen GJ. Percutaneous Facet Denervation in Chronic Thoracic Spinal Pain. Acta Neurochir (Wien). 1993; 122: 82-90

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Thoracic Spine Manual Examination and Treatment Procedures Upper Thoracic Mobility Assessment:

Physiologic Forward Bending (sitting) Physiologic Rotation (sitting) Physiologic Sidebending (sitting) TP Positional Symmetry in Flexion (sitting) TP Positional Symmetry in Extension (sitting) Accessory Rotation (via transverse pressures on SPs) Accessory Rotation (via unilateral PA pressures on TPs) Palpation/Provocation of Segmental Myofascia

Mid Thoracic Mobility Assessment:

Physiologic Forward Bending (sitting) Physiologic Sidebending (sitting) TP Positional Symmetry in Flexion (sitting) TP Positional Symmetry in Extension (prone on elbows) Accessory Rotation (unilateral PA pressures in flexion) Accessory Rotation (unilateral PA pressures in extension) Accessory Rotation (unilateral PA pressures in neutral) Palpation/Provocation of Segmental Myofascia

Upper Thoracic Treatment Procedures:

Contract/Relax for restoring segmental Flexion/SB/ROT Contract/Relax for restoring segmental Extension/SB/ROT Soft Tissue Mobilization of involved segmental myofascia Joint Mobilization/Manipulation: Segmental Rotation (using pisaform/scaphoid on adjacent SPs) Rotation via TPs (using “spacer” thumb and pisaform) Rotation in Neutral (gaping – prone) Rotation/SB in Extension (closing – prone) Rotation/SB in Flexion (opening – supine or prone) Mid Thoracic Treatment Procedures: Contract/Relax for restoring segmental Flexion/SB/ROT Contract/Relax for restoring segmental Extension/SB/ROT Soft Tissue Mobilization of involved segmental myofascia Joint Mobilization/Manipulation: Flexion/SB/ROT (opening – supine) Extension/SB/ROT (closing – prone)

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Upper Thoracic Segmental Myofascia Soft Tissue Mobilization

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Impairment: Limited Upper Thoracic Segmental Flex, Right SBing and Right Rotation

Upper Thoracic Contract/Relax (of segmental extensors and left sidebenders) Cues: Forward bend the cervical and thoracic spine to the midrange of the involved segment, then, laterally translate the spine to the left so that the apex of the curve is localized to the involved segment Maintain the patient’s center of mass over his/her base of the support during the translation (i.e., counter-translate the head to the right during the lateral translation) Upper thoracic forward bending localization is not as specific as mid thoracic – unless the forward bend is also taken up from below the involved segment (i.e., a localized slump) which is difficult to do in the upper thoracic area and still maintain the patient’s comfort The following reference provides additional information regarding this procedure: Timothy Flynn MS, PT: The Thoracic Spine and Ribcage: Musculoskeletal Evaluation and Treatment, p. 176-177, 1996

Joe Godges DPT, MA, OCS

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Impairment: Limited Upper Thoracic Segmental Ext, Right SBing, and Right Rotation

Upper Thoracic Contract/Relax (of segmental flexors and left sidebenders) Cues: Note the following details in the photo: the patient’s position, the therapist’s position, the position of the therapist’s right fingers, palm, and thumb (thumb is on the right side of the interspace of the impaired segment), the therapist’s left forearm, elbow and little finger (cuing head flexion to maintain the upper cervical spine in neutral)

The following reference provides additional information regarding this procedure: Timothy Flynn MS, PT: The Thoracic Spine and Ribcage: Musculoskeletal Evaluation and Treatment, p. 181-182, 1996

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Impairment:

Limited Upper Thoracic Right Segmental Rotation

Upper Thoracic Segmental Rotation (using adjacent spinus processes) Cues: Turn patient’s head in direction of rotation if possible Using the pisiform of your left hand apply a left lateral translatory force to the spinous process of the superior vertebrae of the involved segment Using the scaphoid of your right hand apply a right lateral stabilizing translatory force to the spinous process of the inferior vertebrae of the involved segment

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Impairment: Limited Upper Thoracic Segmental Flexion, Right SBing and Right Rotation

Upper Thoracic Unilateral PA (Segmental Superior/Anterior Glide) Cues: Position patient with pillow under thorax to reduce excessive cervical lordosis, arms at side to abduct the scapulae, and, if possible, rotate the patient’s head into the direction of the desired rotation Caution: with all prone upper thoracic techniques – be tuned into the patient at all time assessing for signs of VBI Stand on side of pressure application Use your left thumb as the dummy thumb – catch the skin and myofascia about two segments above the involved segment’s transverse process Use your right pisaform to apply a unilateral posterior-to-anterior pressure through your dummy thumb to the left transverse process of the involved segment in a direction parallel to the plane of the facet

Joe Godges DPT, MA, OCS

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KP So Cal Ortho PT Residency

Impairment:

Limited Upper Thoracic Segmental Rotation

Upper Thoracic Right Rotation in Neutral (“neutral gap”)

Cues: Patient Prone, forehead on table - don’t delay here as this is uncomfortable Left sidebend down to the involved segment Firmly block the inferior vertebrae of the involved segment Maintain the sidebend - right rotate down to the involved level Stabilize either 1) the left side of the spinous process of the inferior vertebrae of the involved segment, or 2) the right transverse process of the inferior vertebrae of the involved segment The mobilization or manipulation force is delivered through this stabilizing contact on the inferior vertebrae of the involved segment with slight counter pressure through the occiput (this force is through the occiput is mainly a long axis distraction counter force) The following reference provides additional information regarding this procedure: Timothy Flynn MS, PT: The Thoracic Spine and Ribcage: Musculoskeletal Evaluation and Treatment, p. 188-189, 1996

Joe Godges DPT, MA, OCS

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KP So Cal Ortho PT Residency

Impairment:

Limited Upper Thoracic Segmental Extension, Right SBing, and Right Rotation

Upper Thoracic Rotation/Sidebending in Extension Cues: Here are the steps; 1. Position patient prone with head and neck in neutral - “forehead on table” 2. Sidebend head, neck, and upper thoracic spine down to the impaired level - stabilize the spinous process of the inferior vertebrae of this segment with your left thumb, guide the sidebending with your right hand under the patient’s forehead 3. Maintain the sidebending “barrier”, rotate the head, neck, and upper thoracic spine also to the impaired level - the “barrier” or end feel should now be even firmer 4. At the end of the patient’s exhalation, apply a posterior-to-anterior mobilization or manipulative force to the right transverse process of the inferior vertebrae of the impaired segment with your left hand – your right hand is on the back of the patient’s occiput maintaining the sidebending and rotation “barrier” The following reference provides additional information regarding this procedure: Timothy Flynn MS, PT: The Thoracic Spine and Ribcage: Musculoskeletal Evaluation and Treatment, p. 183-184, 1996

Joe Godges DPT, MA, OCS

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Impairments: Limited Mid Thoracic Segmental Flexion, Left SBing, and Left Rotation

Mid Thoracic Contract/Relax (of segmental extensors and right sidebenders) Cues: Mid thoracic techniques work most effectively in the T4 - T9 area. They can be used in the other thoracic regions but often require modifications in body positioning and manual contacts Position patient at end range of posterior translation and right lateral translation at the involved segment - elicit contraction of the lengthened myofascia - relax - take up the slack in both end ranges - repeat contraction The following reference provides additional information regarding this procedure: Timothy Flynn MS, PT: The Thoracic Spine and Ribcage: Musculoskeletal Evaluation and Treatment, p. 177-178, 1996

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Impairments: Limited Mid Thoracic Segmental Flexion, Left SBing, and Left Rotation

Mid Thoracic Segmental Rotation/Sidebending in Flexion Cues: Here are the steps: 1. Position elbows over involved segment - hand away from you underneath (in armpit); if patient has proportionally long humerii, a rolled-up towel may help spread the pressure.

2. Stand on side that you want to rotate toward - for left rotation stand on left side.

3. With your right hand, grasp the patient’s right shoulder and roll the patient toward you exposing the involved segment.

4. Reach around with your left arm and “twist” the skin to take out the skin slack so the pressure is firm over the right (thenar eminence - scaphoid) and left (“padded” DIP of the 2nd or 3rd finger) transverse processes of the inferior vertebrae of the involved segment.

5. Roll the patient back into your left scaphoid and DIP. 6. Support the patient’s head with your right forearm - right hand in upper t-spine area.

7. Flex, sidebend and rotate the thorax to the left - fine tune these combined movements to create a “crisp,” firm barrier at the involved segment with trunk flexion through the elbows, deliver the mobilizing or manipulating force by via trunk flexion from your body weight (upper rectus abdominus over the patient’s elbows) The following reference provides additional information regarding this procedure: Timothy Flynn MS, PT: The Thoracic Spine and Ribcage: Musculoskeletal Evaluation and Treatment, p. 179-181, 1996

Joe Godges DPT, MA, OCS

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Impairment:

Limited Mid Thoracic Segmental Right Rotation

Mid Thoracic Contract/Relax (of segmental sidebenders) Cues: Right rotation in neutral is coupled with left sidebending Create left sidebending with depression of the left scapula - using left hand Create the apex of the sidebending to the involved segment by guiding the movement with the right fingers (on the spine) and the left hand (on the superior part of the shoulder Use this procedure to “gap” a joint prior to “closing” (i.e., extending) the segment The following reference provides additional information regarding this procedure: Philip Greenman DO, FAAO: Principles of Manual Medicine, p. 217, 1996

Joe Godges DPT, MA, OCS

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Impairment:

Limited Mid Thoracic Segmental Ext, Right SBing and Right Rotation

Mid Thoracic Contract/Relax (of segmental flexors and left sidebenders) Cues: To create right sidebending have right hand on the superior aspect of the right shoulder Position the patient at end range of anterior translation (using manual and verbal cuing “move your chest forward right here”) and left lateral translation of the involved segment – elicit contraction of the lengthened myofascia - relax - take up the slack in both translatory barriers - repeat contraction - take up slack - repeat 3 to 5 times The following reference provides additional information regarding this procedure: Timothy Flynn MS, PT: The Thoracic Spine and Ribcage: Musculoskeletal Evaluation and Treatment, p. 184-185, 1996

Joe Godges DPT, MA, OCS

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KP So Cal Ortho PT Residency

Impairment:

Limited Mid Thoracic Segmental Extension, Right Sidebending and Right Rotation

Mid Thoracic Rotation/Sidebending in Extension Cues: Stand on right side of patient (who is prone) Position patient close to edge of table – arms at side At the involved segment (same vertebrae) contact the left transverse process with your left pisiform and contact the right transverse process with the right pisiform Use a “Texas Twist” to eliminate the skin and myofascial slack over the transverse process. (The right pisiform will need to catch the skin about two segments above the involved level and take up the slack with its inferior pressure) Posterior-to-anterior pressure to the left transverse process provides right rotation, superior-to-inferior pressure to the right transverse process provides right sidebending Preload the rotation and sidebending motions – then – anterior mobilization or manipulative pressure evenly applied on both transverse processes provides the anterior translation (i.e., extension) The following reference provides additional information regarding this procedure: Timothy Flynn MS, PT: The Thoracic Spine and Ribcage: Musculoskeletal Evaluation and Treatment, p. 185-186, 1996

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Thoracic Cage Respiratory Mobility Deficits ICD-9-CM: ICF codes:

733.6

costochondritis (Tietze's Disease)

Activities and Participation Domain code: d498 Mobility, other specified (Expansion of the ribcage during forceful respiratory movements such as deep breathing, coughing, sneezing or laughing) Body Structure code: s4302 Thoracic cage Body Functions code: b4402 Depth of respiration (Functions related to the volume of expansion of the lungs during breathing)

Common Historical Findings: Lateral or anterior chest wall pain Pain worsens with respiratory movements - especially a deep breath or cough Blunt trauma to thorax Common Impairment Findings - Related to the Reported Activity Limitation or Participation Restrictions: Asymmetrical position of rib - anterior/posterior or superior/inferior Limited and painful rib mobility with either anterior-to-posterior (AP) glides or posteriorto-anterior (PA) glides of the involved rib Tender iliocostalis insertion, and/or intercostal myofascia Physical Examination Procedures:

Rib Positional Assessment (Anterior Rib Asymmetry)

Rib Positional Assessment (Superior Rib Asymmetry)

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Performance Cues: For anterior-posterior symmetry assessment palpate near costochondral junction anteriorly and rib angle posteriorly For superior-inferior symmetry assessment palpate width of intercostal spaces Palpate for tenderness and symptom reproduction/provocation in conjunction with palpating for asymmetries

Rib AP Pressures

Rib PA Pressures Performance Cues: For AP pressures - stand at side of patient, use gentle pressure, keep fingers in area of xiphoid and clavicular areas For PA pressures - stand on opposite side of the rib to be assessed, use hypothenar eminence, thumb down - ok to use "dummy thumb" under hypothenar eminence in scapular area Assess mobility, restriction to movement, and symptom response to pressures

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Thoracic Cage Respiratory Mobility Deficits: Description, Etiology, Stages, and Intervention Strategies The below description is consistent with descriptions of clinical patterns associated with the vernacular term “Rib Dysfunction”

Description: Rib dysfunctions involve the ribs and their associated articulations to the vertebral bodies (costovertebral joints), cartilage (costochondral joints), transverse processes of the vertebra (costotransverse joints) or sternum (sternocostal joints). A change in the position or alignment of a rib can put pressure on the soft tissues around where the rib attaches or along edges of the rib where muscles of the thorax attach (sternum) in front or along the side of the spine in back.

With a Stage I disability, the patient may experience inability to perform functional activities, such as overhead work and computer keyboard activity/operation. Patient may be experiencing moderate headaches, changes in breathing patterns secondary to pain, upper limb pain or symptoms suggestive of thoracic outlet syndrome and vague, visceral complaints.

With a Stage II dysfunction, the patient reports less severe symptoms or primary postural-related symptoms. Deficits may be noted in body mechanics and work site positions.

With a Stage III dysfunction, the patient’s symptoms are reproduced with activity or work. The primary goal is to improve tolerance to perform occupational or recreational tasks.

Etiology: The cause of rib dysfunction is most commonly due to a significant trauma to the chest or sternum from a fall, surgery, or contact sport related injury. This may cause pain with abnormal mobility of the ribs and their joints, poor postural alignment, sprain, costochondral injury, costochondritis or inflammation, dislocation, subluxation, arthritis or infection. Tietze’s syndrome is characterized by benign, localized, and painful swelling of an upper costochondral area, without any evidence of overlying disease.

Slipping rib syndrome is an infrequent cause of thoracic and upper abdominal pain and is thought to arise from the inadequacy or rupture of the interchondral fibrous attachments of the anterior ribs. This disruption allows the costal cartilage tips to sublux, impinging on the intercostals nerves. In most cases it is attributed to luxation of the costal cartilage at the eight, ninth or tenth ribs.

After serious cardiac disease and gastrointestinal problems are ruled out, most non-traumatic chest pain is usually diagnosed as costochondritis or Tietze’s syndrome. Yet non-traumatic causes may be serious diagnoses such as Hodgkins lymphoma and viral/bacterial/yeast infection seen in drug abusers. More attention needs to be focused on the atraumatic diagnoses examination to rule out ones that need to be referred back to the physician.

Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions code: b4402.3 SEVERE impairment of respiratory mobility, (e.g., severely impaired depth of respiration) • • •

Pain with cough, sneeze, deep breathing, and/or trunk movements Pain with rectus abdominus contraction (slipping rib syndrome) Pain noted during respiration at the extremes of inhalation and exhalation

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• • • • • • •

Limited and painful rib mobility with either anterior-to-posterior or posterior-toanterior glides to the involved rib(s). Painful hypermobility of a rib may be present following some types of traumas or surgical procedures Muscle guarding, tenderness of the intercostal muscles associated with the involved ribs - palpation may reproduce the reported pain with its referral pattern along the costal border.

Tenderness at the costochondral junction of the involve rib Tender iliocostalis insertion and/or intercostals myofascia Palpable asymmetrical position of a rib – anterior/posterior or superior/inferior Localized tender spot that corresponds to the site of injury Pain limited mobility of the thorax and shoulder girdle may be present

Sub Acute Stage / Moderate Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions code: b4402.2 MODERATE impairment of respiratory mobility (e.g., moderately impaired depth of respiration) • • •

As above with the following differences Pain replication at end of range of one particular movement with or without overpressure; pain at resistance A decrease in tenderness and motion restrictions of the involved segment commonly is associated with a reduction in symptoms

Settled Stage / Mild Condition Physical Examinations Findings (Key Impairments) ICF Body Functions code: b4402.1 MILD impairment of respiratory mobility (e.g., mildly impaired depth of respiration) • •

As above with the following differences The patient’s unilateral symptoms are reproduced only with end range overpressures in either a combined extension and sidebending motion or a combined flexion and sidebending motion

Intervention Approaches / Strategies

Acute Stage / Severe Condition Goals: Decrease pain and inflammation Restore normal rib movement Restore rib alignment and symmetry •

Physical Agents Cold application, ice or ice pack Electrical stimulation, combined with ice Ultrasound

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External Devices (Taping/Splinting/Orthotics) Consider taping procedures for hypermobile rib (placing tape along the rib attachment to temporarly keep it from moving, helps to hold the rib still while giving the soft tissue around the rib a chance to heal) May use a direct pressure pad over costochondral joint. A rib belt or strapping may be used to hold the pad in place. Union of acute costochondral separation occurs slowly, typically ~ 6-8 weeks

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Manual Therapy Soft tissue mobilization to restricted intercostal myofascia Joint mobilization to restricted rib movement to restore normal symmetry and mobility – including isometric mobilizations Joint mobilization to thoracic spine segmental motions associated with rib dysfunction(s)

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Therapeutic Exercises Segmental breathing exercises maintain and enhance gain in mobility from soft tissue and joint mobility Thorax extension and flexion and rotation exercises Shoulder girdle and upper extremity mobility exercises Normal breathing pattern retraining with Pursed Lip Breathing, which takes less excursion and same amount of oxygen than closed mouth breathing.

•

Re-Injury Prevention Instruction Limit contact sports for 3-4 weeks

Sub Acute Stage / Moderate Condition Goal: Reduce deficits in posture, strength, flexibility, coordination, and body mechanics •

Approaches / Strategies listed above – focus on promoting/maintaining rib symmetry, normal respiration, and normal trunk mobility

•

Physical Agents Heat application alternating with cold

•

Manual Therapy Passive treatments should be used cautiously and only to rapidly facilitate a patient into an active rehabilitation program

•

External Devices (Taping/Splinting/Orthotics) If the symptoms have resolved, the athlete may return to sports participation in 710 days with lower chest strapping

Joe Godges DPT, MA, OCS

5

KP So Cal Ortho PT Residency

•

Therapeutic Exercises Add progressive resistive exercises, stabilization and postural exercise. These should be designed to improve the movement restriction and re-educate or stretch the appropriate muscle groups that assist in normal movement in postural alignment

Settled Stage / Mild Condition Goal: Improve tolerance to perform occupational or recreational tasks.

•

Approaches / Strategies listed above – focus on long-term strategies for good posture, ergonomics, prevention, and exercises

•

Therapeutic Exercises Maintain and increase general fitness through low-stress aerobic and general conditioning exercises

•

Ergonomic Instruction Perform work site evaluation and intervention if indicated

•

Re-injury Prevention Instruction Teach bracing techniques to athletes

Intervention for High Performance / High Demand Functioning in Workers or Athletes Goal: Return to desired occupation or leisure time activities •

Approaches / Strategies listed above – focus on long-term strategies for good posture, ergonomics, prevention, and exercises

•

Therapeutic Exercises Encourage participation in regular low stress aerobic activities as a means to improve fitness, muscle strength and prevent recurrences Incorporate a regulated program to allow the athlete to return to their sport without re-injury

Joe Godges DPT, MA, OCS

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KP So Cal Ortho PT Residency

Selected References Flynn T, PhD, PT OCS. Orthopaedic Physical Therapy Clinics of North America Upper Quadrant: Evidence-Based Description of Clinical Practice. March 1999: 1-20.

Benhamou C, Roux C, et al. Pseudovisceral pain referred from costovertebral arthropathies.

Spine. 1993;18: 790-795.

Mukamel M., Kornreich L., et al. Tietze’s syndrome in children and infants. Pediatrics. 1997; 131: 774-775.

An exploratory report of chest pain in primary care: a report from ASPN. J Am Board Fam Pract. 1990 Jul-Sep; 3(3): 143-50.

Saltzman DA, et al. The slipping rib syndrome in children. Paediatric Anasthesia. 2001; 11:740-743 Klinkman MS, Stevens D, Gorenflo DW. Episodes of care for chest pain: a preliminary report from MIRNET (Michigan Research Network). J Fam Pract. 1994;38:345-52.

Cocco R, Galieni P, Bellan C, Fioravanti A. Lymphomas presenting as Tietze’s syndrome: a report of 4 clinical cases. Ann Ital Med Int. 1999;14:118-23.

Jones GE, Evans PA. Treatment of Tietze’s syndrome pain through paced respiration.

Biofeedback Self Regul. 1980;5:295-303.

Zachazewski J, Magee D, Quillen W. Athletic Injuries and Rehabilitation. Pennsylvania: W.B. Saunders Co. 1996; 498-500. http://www.chehalempt.com/Spine/rib_rehab.htm A Patient’s Guide to Rehabilitation for Rib Dysfunction.

Joe Godges DPT, MA, OCS

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KP So Cal Ortho PT Residency

RIB PHYSICAL EXAMINATION Structure:

Symmetry of Rib Contours:

Active Movements:

Passive Movements:

Palpation:

Anterior/Posterior Superior/Inferior Intercostal Spaces

Inhalation, Exhalation: Lateral/Medial Motion Anterior/Posterior Motion Superior/Inferior Motion AP Glides (supine) PA Glides (prone) Lateral Glides (sidelying) Inferior Glide of 1st Rib Rib Angle/Iliocostalis Intercostal Myofascia Costocondral Articulation

RIB MANUAL TREATMENT Patient Problem: Limited 1st Rib Inferior Glide ST MOB:

Scalene Myofascia

JNT MOB:

Inferior Glide (sitting and supine) Inferior Glide combined with contralateral scalene contraction

RE-ED:

Ipsilateral scapular posterior depression

Patient Problem: Limited Rib Posterior Glide ST MOB:

Intercostal Myofascia

JNT MOB:

Posterior Glide (supine) Posterior Glide combined with ipsilateral serratus anterior contraction

RE-ED:

Lateral Expansion

Patient Problem: Limited Rib Anterior Glide ST MOB:

Intercostal Myofascia

JNT MOB:

Anterior Glide (prone) Anterior Glide combined with ipsilateral pectoralis major contraction

RE-ED:

Anterior-Posterior Expansion

Joe Godges DPT, MA, OCS

8

KP So Cal Ortho PT Residency

Impairments: Positional Rib Asymmetry Limited Rib Posterior Translation

Rib Posterior Glide with Isometric Mobilization

Cues: Passively glide the involved rib and its costal cartilage posteriorly Elicit serratus anterior contraction to provide additional posterior glide mobilization Be precise with your manual resistance to ensure that pectoralis major is not facilitated (i.e., contact only the posterior surface)

Joe Godges DPT, MA, OCS

9

KP So Cal Ortho PT Residency

Impairments: Positional Rib Asymmetry Limited Rib Anterior Translation

Rib Anterior Glide with Isometric Mobilization

Cues: Passively Glide the involved rib anteriorly Elicit pectoralis major contraction to provide additional anterior glide mobilization The anterior passive force is countered with the pectoralis major resistance force (This keeps the patient balanced on his/her ischial tuberosities).

Joe Godges DPT, MA, OCS

10

KP So Cal Ortho PT Residency

Impairment:

Positional Asymmetry of the lst Rib Limited Left lst Rib Inferior Glide

lst Rib Inferior Glide Cues: Sidebend head slightly to the left to lessen tension on the left upper trapezius and scalene myofascia Contacting the1st Rib with the index finger metacarpal head using a “flat palm” (slightly supinated and extended wrist) is usually the most comfortable for the patient Swinging your stool a bit to the right may help line up your forearm to allow a more “connected” weight shift Elicit a sustained contraction of the right scalenes to reciprocally inhibit the left scalenes during the mobilization Consider using a sitting 1st rib inferior glide if a stronger mobilizing force is indicated

lst Rib Inferior Glide (sitting) The following reference provides additional information regarding these procedures: Freddy Kaltenborn PT: The Spine: Basic Evaluation and Mobilization Techniques, p. 266, 1993

Joe Godges DPT, MA, OCS

11

KP So Cal Ortho PT Residency

Thoracic Region Pain ICD-9-CM: ICF codes:

724.4

Thoracic or Lumbosacral neuritis or radiculitis, unspecified

Activities and Participation Domain code: d4108 Changing basic body position, other specified (specified as diffuse back pain, often with related diffuse extremity pain, associated with sustaining a long sitting or flexed position, such as driving in a car or sitting in a bathtub) Body Structure code: s76000 Cervical vertebral column s76001 Thoracic vertebral column s76002 Lumbar vertebral column Body Functions code: b28013 Pain in back

Common Historical Findings: Pain or paresthesia associated with prolonged long sitting or flexed positions (e.g., driving in car, sitting in bath tub) Diffuse and multiple areas of symptoms (e.g., headaches, entire spine, extremities) May report autonomic nervous system symptomatology (e.g., intolerance to cold, nausea following prolonged neck flexion activities, excessive sweating while in a slump sitting position) Common Impairment Findings - Related to the Reported Activity Limitation or Participation Restrictions: Symptom reproduction with slump testing Less than normal range of motion with nerve tension tests Physical Examination Procedures:

Slump Test Neck Flexion and Ankle Dorsiflexion

Joe Godges DPT, MA, OCS

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KP So Cal Ortho PT Residency

Performance Cues: Establish baseline: Neutral sitting on edge of table, arms behind back Note changes in symptoms with each maneuver: Trunk Flexion Neck Flexion Knee Extension Ankle Dorsiflexion Bilateral Knee Extension Bilateral Ankle Dorsiflexion Determine symptom alteration with neck flexion and extension, knee flexion and extension, ankle dorsiflexion and plantar flexion With high level of symptoms - active movements will reproduce/alleviate symptoms With low level of symptoms - passive overpressures are required to reproduce/alleviate symptoms

Thoracic Region Pain: Description, Etiology, Stages, and Intervention Strategies The below description is consistent with descriptions of clinical patterns associated with the vernacular term “Dural Adhesion”

Description: The dura mater is innervated primarily by the sinuvertebral nerve also known as recurrent meningeal nerve, but is also innervated by the nerve plexus of the posterior longitudinal ligament and the nerve plexus of radicular branches of segmental arteries. The sinuvertebral nerve is primarily a sympathetic nerve and courses in a cephalic direction up to 4 segments and a caudal direction for up to 4 segments. This results in considerable overlap of innervations between adjacent segments and count for the multiple pain sites of the dural adhesion. The anterior region of the dura mater is densely innervated, while the posterior region of the dura is sparsely innervated, which gives evidence as to why diffuse pain is noted with dural adhesions. In addition, there is no innervation in the medial part of the posterior region, which explains the fact that no pain is elicited on piercing of this area in such procedures as lumbar puncture.

Dural pain is described as funicular pain; diffuse, poorly localized, burning sensation or abrupt stabbing pain. It is not radicular in distribution but rather involves unilateral or bilateral limbs, trunk, or entire body. Headaches may also occur. Patients with dural disorders may also report autonomic nervous system symptomatology (i.e. cold intolerance, nausea, diffuse sweating with prolonged slump sitting). If there is pressure on the nerve trunk, paresthesia or an abnormal sensation such as a “pins and needles” feeling or tingling may be present. Pain or paresthesia is associated with prolonged long sitting or flexed positions (i.e., driving in car, working at computer, sitting in bathtub). Dural symptoms can also be triggered by spinal cord compression from cervical spondylosis or neoplasm of the cervical, thoracic and/or lumbar spine. Decreased tolerance with prolonged long sitting or flexed positions at the spine and/or hip is the main characteristic of this disorder Etiology: The cause is of this disorder is largely unknown. Theories state that dural adhesions can be caused by disc degeneration, intradural arachnoid cysts, spinal stenosis, trauma and intramedullary mass lesions among others. These disorders can cause inflammation of the spine,

Joe Godges DPT, MA, OCS

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KP So Cal Ortho PT Residency

which in turn may cause irritation and fibrosic adhesion in the dura to form. Myofascial and soft tissue restrictions in the muscles of the back may inhibit the mobility of the posterior primary rami nerve through its normal pathway, which may limit normal mobility of the mixed spinal nerve and the adajacent dura producing decreased mobility and quality of range of motion (i.e., a positive slump test). Research studies also suggest possible etiologies of trauma at more distal sites, such as repetitive hamstring strain or ankle inversion sprain.

Acute Stage / Severe Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions code: b28013.3 SEVERE pain in back • • • • •

Symptoms are produced or aggravated with slump test positions Postural adaptation to pain-free position may be observed – such as diminished thoracic kyphosis Limb nerve tension tests (e.g., SLR test) commonly exhibit limited range of motion Soft tissue restrictions in the posterior segmental spinal myofascial Autonomic nervous system signs (such as excessive perspiration) may be present

Sub Acute Stage / Moderate Condition: Physical Examinations Findings (Key Impairments) ICF Body Functions code: b28013.2 MODERATE pain in back • • • •

As above – except less severe symptoms are exhibited Pain takes longer to present itself while in slumped position Pain perception during the slump test is strongly correlated with passive tissue resistance felt by the examiner A decrease in tenderness and a reduction mobility deficits of the involved segments during the slump test is commonly is associated with a reduction in symptoms

Settled Stage / Mild Condition Physical Examinations Findings (Key Impairments) ICF Body Functions code: b28013.2 MILD pain in back • •

As above with the following differences: Passive overpressure while in slump position may be required to reproduce symptoms Intervention Approaches / Strategies

Acute Stage / Severe Condition Goal: Reduce dural (i.e., slump) related symptoms Alleviate pain with normal (non end range) activities •

Manual Therapy Soft tissue mobilization to restricted segmental myofascial of the thoracic region or site of peripheral nerve entrapments related to the patient’s complaints Joint mobilization/manipulation is usually restricted spinal segments

Joe Godges DPT, MA, OCS

3

KP So Cal Ortho PT Residency

•

Therapeutic Exercises Slump and peripheral nerve mobility exercises in painfree ranges

Sub Acute Stage / Moderate Condition Goals: As above Increased flexibility of the dural elements (as measured by ability to assume the slump positions without symptoms) •

Approaches / Strategies listed above

•

Therapeutic Exercises Slump and peripheral nerve mobility exercises in creating mild stretch sensation at end ranges that do not worsen the symptoms with repeated exercises

Settled Stage / Mild Condition Goals: As above Increased flexibility of spinal flexion Increased flexibility of upper and lower extremities •

Approaches / Strategies listed above

•

Therapeutic Exercises Slump and peripheral nerve mobility exercises in creating a strong stretch sensation at end ranges that do not worsen the symptoms with repeated exercises

•

Re-injury Prevention Instruction: Promote cardiovascular and flexibility and strengthening programs in order to maintain neural mobility and decrease the probability of future dural adhesions

Intervention for High Performance / High Demand Functioning in Workers or Athletes Goals: Return to desired occupational or recreational activities •

Approaches / Strategies listed above

•

Therapeutic Exercises Provide specific stretches to enhance the ability to perform desired activity General stretching/conditioning programs, such as yoga or Pilates type programs may be helpful interventions to promote high performance/high demand functioning

Joe Godges DPT, MA, OCS

4

KP So Cal Ortho PT Residency

Selected References Briggs CA, Lew PC. Relationship between the cervical component of the slump test and change in hamstring muscle tension. Manual Therapy. 1997;2:98-105.

Butler DS: Mobilization of the Nervous System. Melbourne: Churchill Livingstone, 1991 Butler DS: The concept of adverse mechanical tension in the nervous system. Physiotherapy.

1989;75:622-636.

Byrne T: Spinal Cord Compression. F.A. Davis Co. Salem, 1990.

Chiarello CM, Johnson EK: The slump test: the effects of head and lower extremity position on knee extension. J Orthop Sports Phys Ther. 1997;26:310-317.

Cuillere P, Faure A, Hamel O, Le Borgne J, Raoul S, Robert R, Rogez JM. Role of the sinuvertebral nerve in low back pain and anatomical basis of therapeutic implications. Surg Radiol Anat. 2002;24:366-371.

Groen GJ, Baljet B, Drukker J. The innervation of the spinal dura mater: anatomy and clinical implications. Acta Neurochir 1988;92:39-46.

Kimmel D: Innervation of the spinal dura mater and dura mater of the posterior cranial fossa.

Neurology 1961;10:800-809.

Kornberg C, Lew P: The effect of stretching neural structure on grade one hamstring injuries. J Orthop Sports Phys Ther. 1998;13:418-487.

Maitland GD: The slump test: examination and treatment. Aust J Phys. 1985;31:215-219.

Pathor S, Toppenberg R. An investigation of neural tissue involvement in ankle inversion sprains. Manual Therapy 1996;1:192-197.

Simon DG, Travell JG: Myofascial origins of low back pain. Post Grad Med. 1983;73:66 –108.

Turl S, George P: Adverse neural tension: A factor in repetitive hamstring strain? J Orthop Sports Phys Ther. 1998;27:16-21.

Webright WG, Randolph BJ, Perrin, DH: Comparison of nonballistic active knee extension in neural slump position and static stretch techniques on hamstring flexibility. J Orthop Sports Phys Ther. 1997;26:7-13.

George SZ. Characteristics of patients with lower extremity symptoms treated with slump stretching: a case series. J Orthop Sports Phys Ther. 2002;32:391-398.

Joe Godges DPT, MA, OCS

5

KP So Cal Ortho PT Residency

Thoracic Spine and Rib Cage Algorithms

Pain with Respiration, Coughing, or Sneezing?

No

Mid/Lower Thoracic Single Plane Active Mobility Exam

Yes Transverse Plane Mobility Loss

Sagittal Plane Mobility Loss

Coronal Plane Mobility Loss Go To Rib Cage Clinical Pathways

Contralateral Pain End of Range

Ipsilateral Pain End of Range

Contralateral Pain End of Range

Contralateral Pain End of Range

Ipsilateral Pain End of Range

Ipsilateral Pain End of Range

Mid/Lower Thoracic Spine Segmental /Soft Tissue Mobility Exam

Mid/Lower Thoracic Spine Segmental/Soft Tissue Mobility Exam

Mid/Lower Thoracic Spine Segmental /Soft Tissue Mobility Exam Transverse Plane Flexion Dysfunction Pattern

Transverse Plane Extension Dysfunction Pattern

Skulpan Asavasopon MPT, OCS

Sagittal Plane Extension Dysfunction Pattern

Coronal Plane Flexion Dysfunction Pattern

Coronal Plane Extension Dysfunction Pattern

Sagittal Plane Flexion Dysfunction Pattern KP So Cal Ortho PT Residency

Thoracic Spine Examination Algorithm End of Range Pain Contralateral Side

Thoracic Spine Active Mobility Exam (with over pressure if indicated)

Pain Limited Positive Asymmetry in Flexion on Painful Side

End of Range Pain Ipsilateral side

Active Mobility

Transverse Process Symmetry Palpation

Positive Asymmetry in Extension on Painful Side

Structural Asymmetry Soft Tissue Mobility Restriction/Provocation on Painful Side

Soft Tissue Mobility/Provocation Exam

Soft Tissue Mobility Restriction/Provocation on Painful Side

Pain Limited Soft Tissue Mobility Resistance Limited Accessory Motions with Symptom Provocation

Mobility Examination of Thoracic Spine Accessory Motions

Resistance Limited Accessory Motions with Symptom Provocation

Pain Limited Accessory Motions

Flexion Mobilization Pattern

Skulpan Asavasopon MPT, OCS

Stabilization Or Modalities Pattern

Extension Mobilization Pattern

KP So Cal Ortho PT Residency

Rib Cage Algorithm

Palpation/Provocation of: • Costovertebral Joints • Costochondral Junction

Suspect Underlying Stress Fracture?

Consult With Referring Healthcare Practitioner Costovertebral Joint Pain

Costrochondral Junction Pain

Observe Rib Cage: • Excursion with Inhalation/Exhalation

Palpation for Symmetry

Costovertebral Joint Mobilization Pattern

Skulpan Asavasopon MPT, OCS

Anterior Rib Mobilization Pattern

Posterior Rib Mobilization Pattern

KP So Cal Ortho PT Residency

Rib Cage Clinical Pathways Inhalation Breathing Exercises Pain with Inhalation Respiratory Pattern Recognition

Pain with Exhalation

Anterior with Internal Rotation Anterior with External Rotation Rib Positional Testing

Exhalation Breathing Exercises

Posterior Rib Mobilization with STM to facilitate Internal or External Rib

Posterior with Internal Rotation Posterior with External Rotation

Anterior Rib Mobilization with STM to facilitate Internal or External Rib

Costovertebral Joint Provocation Testing

Sternocostal Joint

Intercostal Muscle

Skulpan Asavasopon MPT, OCS

Mobilization of Costovertebral, Sternocostal Joint, or STM Intercostal Muscles

KP So Cal Ortho PT Residency

SUMMARY OF THORACIC SPINE AND RIBS DIAGNOSTIC CRITERIA AND PT MANAGEMENT STRATEGIES DISORDER

“Thoracic Facet Syndrome” 847.1

onov = 4 or less mnov = 12

“Rib Dysfunction” 733.6

onov = 4 or less mnov = 12

“Dural Adhesion” 724.2

onov = 4 or less mnov = 12

Chest Wall Contusion 922.1

onov = 4 or less mnov = 12

HISTORY Mid back pain – usually perceived inferior and lateral to the involved segment Sx’s precipitated by an identifiable mechanical stress (e.g., trauma, strain, awkward movement, or prolonged static posture) Lateral or anterior chest wall pain Often precipitated by blunt trauma to the thorax – or – coughing/sneezing Pain worsens w/respiratory movements (e.g., deep breath or cough) Diffuse and multiple areas of symptoms Pain and paresthesias associated with pro-longed long sitting or flexed positions May report ANS symptomatology Chest wall/thorax pain Blunt trauma or fall onto chest wall

PHYSICAL EXAM Pain increases at end range of one particular movement Palpable asymmetry of adjacent TP’s in T-spine flexion or extension SR with unilateral PA pressures on the involved segment Palpable asymmetrical position of rib SR with AP or PA glides of the involved rib Palpation/provocation of the intercostal myofascia and/or iliocostalis insertion at rib angle SR with slump testing Nerve mobility deficits with LLTTs or ULTTs

PT MANAGEMENT Segmental STM and C/R Joint mob/manip Ther Ex’s

SR with contraction of involved myofascia End range stretch to the involved myofascia and joints Provocation of the involved myofascia and joints

If acute: P.R.I.C.E. instructions Ther Ex’s (including breathing ex’s) STM/Joint mob if needed to restore normal motion when subacute

Segmental STM and C/R Joint mob/manip Ther Ex’s

STM, Joint mob/manip, Ther Ex to areas of potential spinal and peripheral nerve entrapments Slump/nerve mobility ex’s

onov = optimal number of visits mnov = maximal number of visits SR = Symptom Reproduction

Joe Godges, DPT, MA, OCS

KP So Cal Ortho PT Residency

1

Spinal Compression Fracture Repair and Rehabilitation Surgical Indications and Considerations Anatomical Considerations: Compression fractures are characterized by anterior compression of the vertebral body. Posterior elements of the vertebral body my also be involved but the posterior body remains intact.

Pathogenesis: Spinal compression fractures are caused by axial loading on a flexed spine. The most common pathology behind these fractures is osteoporosis. Compression fractures are a major contributor to both the substantial morbidity and the cost associated with osteoporosis.

The spinal deformity caused by vertebral compression fractures (VCFs), whether painful or not, has significant impact on the longevity and quality of life of VCF patients. Compression of the abdominal viscera by the rib cage or loss of lumber spine height leads to decreased appetite, early satiety and weight loss. Similarly, thoracic hyperkyphosis compresses the lungs and results in a reduction of forced vital capacity (FVC) and forced expiratory volume (FEV1). Additionally these patients may suffer from chronic pain, sleep disorders, clinical depression, and anxiety.

Epidemiology: The number of osteoporotic vertebral compression fractures (700,000) per year easily outnumbers fractures of the hip and ankle combined. The five-year survival rate for a patient with a vertebral body compression fracture is lower than an individual with a hip fracture.

Patients with VCF have a 23% increased risk of mortality compared to aged matched controls without VCF. The increased mortality is primarily related to pulmonary complications.

Mortality increases with the number of fractures and the degree of kyphosis. After the first compression fracture, the risk of additional vertebral fractures increases 5 to 25 times above baseline. Osteoporotic vertebral compression fractures are associated with debilitating psychological effects, including impaired body image and self esteem. The percentage of women with clinical depression increases with number of spinal fracture deformities. Patients report a fear of falling, further fracture and a loss of independence. Additionally, patients with increasing numbers of VCF demonstrate decreased functional status as recorded in physical function tests.

Diagnosis: • • •

A spinal compression fracture can be readily diagnosed on plain radiographs and with computed tomography The pain associated with the fracture is typically localized at the apex of the fracture MRI may be used to assist in differentiation between acute and chronic fractures

Nonoperative Versus Operative Management: Open surgical intervention in this frail population, with osteoporotic spinal compression fractures, is fraught with morbidity and implant failure. Therefore, nonoperative management including narcotic pain medication, bed rest and bracing has been historically recommended for the vast majority of patients.

Traditionally surgery has been limited to those who have neurologic complications.

Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs

Joe Godges DPT, MA, OCS

2 Unfortunately, large numbers of patients report intractable pain and an inability to return to their prior level of function. The recommended and frequently self imposed bed rest leads to accelerated bone mineral loss and diminishing muscle mass, which exacerbates the disease process and increases the risk of additional fractures. Neurological deficits often develop months after the index fracture, as the spinal cord drapes over the apex of the deformity. When neurologic complications occur, open surgical intervention is usually an anterior decompression and fusion, coupled with posterior instrumentation and fusion. However, two new noninvasive techniques (first used in the United States in 1993) offer rapid pain relief and return to routine activities through percutaneous bone augmentation: vertebroplasty and balloon kyphoplasty.

Surgical Procedure: The noninvasive surgical techniques of percutaneous vertebroplasty and balloon kyphoplasty both internally stabilize the fractured vertebral body through injection of polymethylmethacrylate (PMMA) and are typically performed within three months of the fracture. Both procedures are performed with imaging guidance in the radiology suite or operating room and can be done under local anesthesia with conscious sedation, or with general anesthetic. Kyphoplasty is distinctly different from vertebroplasty by its ability to reduce the fracture using an inflatable balloon tamp to create a void within the vertebral body that allows for injection of PMMA in a thick, doughy state under low pressure, thereby reducing the risk of emboli and extrusion outside the vertebral body. Theoretically, kyphoplasty should have longterm benefits beyond those of pain relief provided by vertebroplasty by avoiding the pulmonary and gastrointestinal complications through improved spinal alignment.

Preoperative Rehabilitation • Pain management with narcotics • Bracing and instruction on body mechanics • Appropriate treatment for the underlying osteoporosis

POSTOPERATIVE REHABILITATION Treatment Goals: The goals of nonoperative and operative management of vertebral compression fractures are the same and include the restoration of a painless, balanced, stable spinal column with optimal neurologic function and minimal treatment morbidity.

Following a vertebroplasty or kyphoplasty the patient is instructed to remain supine for 1 hour to allow the cement to harden. Observation in the hospital for 1 to 2 hours post procedure is typical, at which time most patients will be able to stand and walk with minimal or no pain.

Some practitioners request a physical therapy consult for patients on the day of surgery to assist in early mobilization, as necessary, and for the instruction of body mechanics to avoid heavy lifting, bending and twisting. Early return to daily activities is encouraged.

Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs

Joe Godges DPT, MA, OCS

3

All osteoporotic patients with VCFs should have an appropriate evaluation and treatment of their underlying osteoporosis. Medical management can include medications to increase bone mineral density and physical therapy can assist in establishing an appropriate strengthening and weight bearing exercise program to stimulate an increase in bone density. If the compression fracture is secondary to a fall, the patient’s balance systems also need to be addressed.

Selected References: Sinaki M, Itoi E, et al. Stronger back muscles reduce the incidence of vertebral fractures: a prospective 10 year follow-up of postmenopausal women. Bone. 2002:30:836-841.

Mathis JM, Eckel TS, et al. Percutaneous vertebroplasty: a therapeutic option for pain associated with vertebral compression fracture. J of Back and Musculoskeletal Rehabilitation. 1999:13:1117.

Harrington KD. Major neurological complications following percutaneous vertebroplasty with polymethylmethacrylate. J Bone Joint Surg. 2001:83-A:1070-1073.

Theodorou DJ, Theodorou SJ, et al. Percutaneous balloon kyphoplasty for the correction of spinal deformity in painful vertebral body compression fractures. Clinical Imaging. 2002:26:15.

Truumees E, Hilibrand A, et al. Percutaneous vertebral augmentation. Spine Journal.

2004:4:218-229.

Garfin SR, Reilley MA. Minimally invasive treatment of osteoporotic vertebral body compression fractures. Spine Journal. 2002:2:76-80.

Predey TA, Sewall LE, et al. Percutaneous vertebroplasty: new treatment for vertebral compression fractures. American Family Physician. 2002:66:611-616.

Dai L. Low lumbar spinal fractures: management options. Injury. 2002:33:579-582.

Crandall D, Slaughter D, et al. Acute versus chronic vertebral compression fractures treated with kyphoplasty: early results. Spine Journal. 2004:4:418-424.

Vaccaro AR, Kim DH, et al. Diagnosis and management of thoracolumbar spine fractures. J Bone Joint Surg. 2003:85-A:2455-2470.

Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs

Joe Godges DPT, MA, OCS

1

Pectus Excavatum Repair and Rehabilitation Surgical Indications and Considerations Anatomical Considerations: Pectus deformities refer to abnormal growth and alignment of the costal cartilages (ribs) and their attachment to the sternum.1 There are two primary deformities of which this Practice Guideline will focus on the more common of the two, the pectus excavatum.

1. Pectus excavatum (PE): an inward displacement of the cartilage causing a posterior (inward) deformity at the lower portion of the sternum, sometimes referred to as a "cavus" or "funnel" chest.

2. Pectus carinatum (PC): an outward displacement of the cartilage causing an anterior protrusion of the sternum, sometimes referred to as a "pigeon breast" deformity.

Pathogenesis: Pectus excavatum deformities can be congenital, acquired or both. PE occurs congenitally if the cartilage is overgrown, deformed or weak allowing the sternum to be pulled inward due to the negative pressure created during inhalation in the thorax.2-4 PE can also be acquired due to a dynamic muscle imbalance of the primary respiratory muscles: diaphragm, intercostals and abdominals. If the intercostal muscles are overpowered by the diaphragm, the sternum will be pulled inward resulting in a PE.5-7 This is a fairly common secondary development for infants and children with increased respiratory workloads secondary to pulmonary disorders and/or neuromuscular disorders.8, 9 Children with a genetic predisposition to PE who also have an imbalance in their primary respiratory muscles will see an exacerbation of their sternal deformity.

Epidemiology: Pectus deformities are the most common congenital chestwall deformities. The rate of occurrence varies among published reports from 1/300 live births to 1/1,000. 2, 10-13 PE is far more common than PC deformities. PE is generally reported as occurring in approximately 85% of the pectus deformities.2, 3. Pectus excavatum is more prevalent in males than females, with reports of incidences varying from 3 to10 times more often. 3, 14, 15 Diagnosis: The diagnosis of a PE is made visually by observing the shape of the anterior chestwall. Common tests to determine the extent of the PE limitation include physical, physiologic and psychological tests: 1. Physical limitations: a. Radiographs or CT of chest and spine on coronal and sagittal planes to determine PE severity and other possible musculoskeletal restrictions such as scoliosis and kyphosis 16 b. Haller Index rating of CT scan to rate the severity of the PE 16, 17

Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs

Joe Godges DPT, MA, OCS

2 2. Pulmonary limitations: a. Pulmonary Function Tests to determine the amount of lung restriction and lung growth retardation 14, 18 b. Exercise Stress Tests to determine the extent of exercise intolerance due to the compression of the lungs and heart 17 3. Cardiac limitations: a. ECG to determine any electric abnormalities 19, 20 b. Echocardiogram to determine the extent of the cardiac compression and to rule out other vessel abnormalities associated with connective tissue disorders that commonly present with PE 19, 20 4. Quality of Life limitations: a. Survey outcomes to determine the effect of the PE on the child's self image and willingness to participate in peer related activities 21, 22 Non-operative versus Operative Management: Typically, there are 2 options presented to the patient: have surgery or do nothing. The literature notes musculoskeletal problems frequently occur with or because of the PE, yet only 2 articles suggest physical therapy for the patients with PE and no article suggested PT as a regular screening test for PE. 23, 24 Currently, there is no literature to suggest that PE can be influenced by physical therapy, however I will share my nonsurgical experience with this population later in the guideline.

Surgical Procedure: Two different surgical procedures are commonly performed to reduce the PE deformity: the modified Ravitch 25or the Nuss procedure. 26 •

The modified Ravitch procedure is based on the technique described by Dr. Ravitch in 1949. It is also called the "Open Repair" technique and is championed by Dr. Eric Fonkalsrud at UCLA who has extensive experience performing this technique and reporting on outcomes for the past several decades. 2 The open repair surgically corrects and or resects the damaged cartilage (usually up to 4 rib cartilages). The sternum is then elevated to the proper position and a strut is inserted to maintain the alignment for around 6 months. The patient is hospitalized for 2- 5 days for the initial surgery. The strut removal is done as an outpatient. 2 The Ravitch procedure repairs only the damaged cartilage on the anterior chest wall. It does not affect the relationship of the entire rib with the thoracic spine.

•

The Nuss procedure was introduced by Dr. Donald Nuss at the Children's Hospital of the King's Daughters in Norfolk, VA in 1998. 26 His technique is also called "minimally invasive repair of pectus excavatum (MIRPE)". The Nuss procedure uses a Lorenz pectus bar, which is a thin long metal sheet that resembles the shape of old fashioned bicycle handle bars. The bar is inserted laterally through a small incision, fed under the anterior chest wall, and finishes on the opposite lateral wall. The bar is then "flipped" to mechanically reverse the PE deformity by lifting the anterior chestwall. The bar remains in place for 2 – 4 years to support normal growth of the ribs and cartilage around its support. 27 Although the Nuss procedure is less invasive from a surgical perspective, once the bar is flipped, the shape of the entire anterior chest wall and the relationship of the ribcage to the thoracic spine is changed. Because of this, more joints are affected and

Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs

Joe Godges DPT, MA, OCS

3 the patients generally report more pain than with the Ravitch procedure.

Both procedures have good outcomes, but each has its own followers. 13 Fonkalsrud reported the outcomes of the modified Ravitch and Nuss procedures that were performed at 2 large hospitals during 1996 – 2000 and is presented below. 28 Recent research shows that with continual modifications of both procedures improving the overall outcomes, decisions about which surgical technique to use should depend on the patient and the surgeon's particular situations. 28, 29

TABLE Patient Parameters Compared Parameter Number of patients Average age (yr) Mean pectus severity index Previous pectus repair Operating time (min) Blood loss (mL) Length of hospitalization (d) Epidural used Pneumothorax Transient pericarditis Intravenous analgesics (average d) Patients placed in ICU Bar displacement (flipped) Reoperations Rehospitalizations for pain Return to school/work (average d) Number sternal bars removed electively Bar removal operating time (average min) Time to bar removal (avg mo)

Nuss Repair 68 12 (5-19) 4.2 (3.2-9.5) 0 75 (45-130) 90 (10-120) 6.5 (5.8) 66 7 0 5 (3-7) 2 6 7 2 18 (14-26) 18 25 (17-40) 24 (23-26)

Modified Ravitch Repair 139 17.3 (3-53) 4.9 (3.1-9.8) 9 212 (110-260 90 (15-400) 2.9 (2-5) 0 3 3 1.7 (1-3) 0 0 0 0 12 (8-18) 107 19 (15-31) 6 (5.5-6.5)

NOTE: Values in parentheses are ranges.

The overall the morbidity and mortality rates related to either procedure are very low. 10, 30-36 Reported complications of both procedures include: • failure of the strut or bar to hold the corrected deformity • cardiac complications • pulmonary complications Pre-operative Rehabilitation: Generally, surgeons do not require any pre-operative preparation other than to complete medical tests. There is no report of pre-op physical therapy (PT) evaluations in any of the literature that I used for this assignment. I also directly contacted the offices of the 2 primary PE surgeons: Dr. Fonkalsrud and Dr. Nuss. Both program coordinators indicated that they do not use PT for regular pre-op or post-op screening or intervention. Tina Gustin, program coordinator at Dr. Nuss' office, indicated that the PTs are involved in general bed mobilization education following surgery. She stated that the patients are given a simple pre-op exercise form-sheet from the doctor and encouraged to "improve their posture and strengthen their back muscles" before and after surgery on their own. Gale Tiemann, Dr. Fonkalsrud's assistant, said they do not routinely use physical therapy.

Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs

Joe Godges DPT, MA, OCS

4 POSTOPERATIVE REHABILITATION Procedure 1: Nuss or minimally invasive repair of pectus excavatum (MIRPE): There were no detailed post-op protocols lists published in the articles or on the Nuss website, so Dr. Nuss' office was contacted directly for this information.

• • • • • •

Inpatient hospitalization is around 5 - 8 days. Patients are instructed to sleep supine, avoid "heavy lifting", and avoid twisting their spine. PT is utilized for general bed and ambulation mobilization. These limitations are in place for 4 weeks.

For the first 6 weeks, walking is the only allowed "exercise".

After 6 weeks, the patients can engage in swimming and other low risk activities that will not cause a sudden jerking motion of the chest or cause a blow to the chest or spine.

After 8 weeks, the patients can begin slowly begin a weight lifting program.

At 12 weeks, the patients can re-engage with all physical activities except those with a high risk for full body contact such as football, wrestling, contact martial arts, etc.

After 2-3 years when the chest bar is removed, the patient can re-engage in any sporting activity.

Goals: To maintain the position of the chest bar during the 2-3 year post-op period to allow the bones, joints and cartilage to reshape themselves along the improved chest alignment until the results are permanently maintained by the patient's own musculoskeletal system.

Interventions: PT is rarely utilized beyond initial inpatient mobilization period.

Procedure 2: Modified Ravitch or open repair technique: No published post-op protocols were available for the modified Ravitch either, so Dr. Fonkalsrud's office was contacted directly for this information.

• • •

Inpatient hospitalization is around 2 – 5 days. PT is utilized for general bed and ambulation mobilization.

For 3 – 4 months, the patients are instructed to avoid lifting over 10 pounds. They are also told to avoid lifting their arms above 90 degrees suddenly or to twist their bodies suddenly. No sports or no gym classes are allowed during this time After the strut bar is removed at 6 months, the patients can re-engage in full activities including contact sports.

Goals: Maintain the position of the chest bar during the 6-month post-op period until the cartilage and sternal junction is healed. Once it is healed, the results should be permanently maintained by the patient's own musculoskeletal system.

Intervention: PT is rarely utilized beyond initial inpatient mobilization period.

Procedure 3: Alternative Interventions to surgery: I work with a pediatric pulmonologist (Dr. Steen Boas) and a pediatric thoracic surgeon (Dr. Marleta Reynolds who uses a modified

Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs

Joe Godges DPT, MA, OCS

5 Ravitch procedure) as a team to evaluate the best intervention strategy for children with PE. The goal of the pre-op evaluation is: • • • •

to determine the physiologic restrictions (cardiac, pulmonary, connective tissue, etc.) if any, on the child as a result of the PE to assess the child's potential for physical rehabilitation as a means of reducing the PE and related postural abnormalities to determine the need for surgery to determine the best sequence of intervention strategies

PT Goals: Through the use of specific intervention strategies including those listed below, teach the patients how to use their own bodies to minimize the deformity and related physical and physiologic restrictions to the best of their own ability and to help determine whether surgery is necessary to attain a better result with all aspects considered.

• •

•

•

Musculoskeletal techniques to improve mobility of all affected joints, most commonly the chest, shoulders, spine, neck, and pelvis Neuromuscular re-education from a developmental perspective to teach these patients how to correct muscle imbalances that have been present their entire lives. In particular, retraining focuses on imbalance as they relate to breathing, postural control and trunk stabilization.

Cardiopulmonary interventions to teach more efficient breathing patterns and coordination with movement. Implement related pulmonary programs as necessary such as airway clearance (patients often have true pulmonary disorders such as asthma and broncho-pulmonary dysplasia).

Integumentary techniques to reorganize the underlying connective tissue structures that limit full erect posture and normal UE positioning.

Intervention: In our multidiscipline assessment, PT is regularly utilized to screen the patients for chest wall mobility, postural abnormalities, respiratory and trunk muscle imbalance, development delays of effective movement strategies, integumentary restrictions, swallowing/aspiration problems, etc. If a patient is deemed a PT candidate, surgery is put off for 6 – 12 months to see if physical rehabilitation can reduce the cosmetic and physiologic restrictions adequately enough to decide that surgery is no longer necessary. The outcomes of our team interventions are currently being collected and will hopefully be analyzed and published at a later date.

Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs

Joe Godges DPT, MA, OCS

6

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Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs

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Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs

Joe Godges DPT, MA, OCS