The Immediate Effects of Thoracic Spine and Rib Manipulation on Subjects with Primary Complaints of Shoulder Pain

Shoulder pain is a common orthopedic condition seen by physical therapists, with many potential contributing factors and proposed treatments. Although manual physical therapy interventions for the cervicothoracic spine and ribs have been investigated for this patient population, the specific effects of these treatments have not been reported. The purpose of this investigational study is to report the immediate effects of thoracic spine and rib manipulation in patients with primary complaints of shoulder pain. Using a test-retest design, 21 subjects with shoulder pain were treated during a single treatment session with high-velocity thrust manipulation to the thoracic spine or upper ribs. Post-treatment effects demonstrated a 51% (32mm) reduction in shoulder pain, a corresponding increase in shoulder range of motion (30°-38°), and a mean patient-perceived global rating of change of 4.2 (median 5). These immediate post-treatment results suggest that thoracic and rib manipulative therapy is associated with improved shoulder pain and motion in patients with shoulder pain, and further these interventions support the concept of a regional interdependence between the thoracic spine, upper ribs, and shoulder.KEYWORDS: Manipulation, Manual Therapy, Shoulder Pain, Thoracic SpineRegional interdependence, as described by Wainner and col-leagues^1,2, “refers to the concept that seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with, the patient''s primary complaint”. This model suggests that many musculoskeletal disorders may respond more favorably to a regional examination and treatment approach that, in addition to localized treatment, encourages physical therapists to examine and treat distant dysfunctions that may be influencing the patient''s symptoms. Although the specific mechanism (whether neurophysiologic, biomechanical, or other) has yet to be elucidated, several high-quality clinical trials have demonstrated the effective use of this regional examination and treatment approach in achieving positive functional outcomes for patients with a variety of musculoskeletal disorders^3–10.Three of these studies^3–5 have investigated the effects of including cervicothoracic spine and rib manual physical therapy into an overall treatment approach for patients with shoulder pain. Winters et al⁵ found that manipulative therapy applied throughout the shoulder girdle was more effective than physiotherapy in reducing the duration of shoulder pain in a subgroup of 58 patients whose shoulder pain was attributed to dysfunctions within the cervical spine, upper thoracic spine, or upper ribs. Bang and Deyle³ reported improved outcomes in strength, function, and pain when manual physical therapy techniques for the shoulder, cervical spine, and thoracic spine were added to an exercise program for patients with shoulder impingement syndrome. In a more recent clinical trial, Bergman et al⁴ assessed the added benefit of applying cervicothoracic and rib manipulations and mobilizations to a standardized treatment regimen of anti-inflammatory and analgesic medications, corticosteroid injections, and physical therapy (exercises, massage, and modalities) for patients with shoulder pain and dysfunction. The addition of manipulative therapy to this usual medical care resulted in significant improvements in short- and long-term recovery rates and symptom severity for these subjects.Although the overall treatment effect of manual physical therapy has been demonstrated in these studies, the relative contribution of specific manipulative techniques applied to the cervical spine, thoracic spine, and/or ribs towards the improvement in functional outcomes for patients with shoulder pain cannot be determined. The purpose of this preliminary study is to report the immediate effects of thoracic and rib manipulation on subjects with primary complaints of shoulder pain. Exploratory studies of this nature are needed to help define the potential interdependence between anatomic regions such as the thoracic spine, upper ribs, and shoulder.     

Regional interdependence and manual therapy directed at the thoracic spine

Abstract

Thoracic spine manipulation is commonly used by physical therapists for the management of patients with upper quarter pain syndromes. The theoretical construct for using thoracic manipulation for upper quarter conditions is a mainstay of a regional interdependence (RI) approach. The RI concept is likely much more complex and is perhaps driven by a neurophysiological response including those related to peripheral, spinal cord and supraspinal mechanisms. Recent evidence suggests that thoracic spine manipulation results in neurophysiological changes, which may lead to improved pain and outcomes in individuals with musculoskeletal disorders. The intent of this narrative review is to describe the research supporting the RI concept and its application to the treatment of individuals with neck and/or shoulder pain. Treatment utilizing both thrust and non-thrust thoracic manipulation has been shown to result in improvements in pain, range of motion and disability in patients with upper quarter conditions. Research has yet to determine optimal dosage, techniques or patient populations to which the RI approach should be applied; however, emerging evidence supporting a neurophysiological effect for thoracic spine manipulation may negate the need to fully answer this question. Certainly, there is a need for further research examining both the clinical efficacy and effectiveness of manual therapy interventions utilized in the RI model as well as the neurophysiological effects resulting from this intervention.     

Physical Therapy (92)

J eanine Yip Menck, Susan Mais Requejo, Kornelia Kulig: Thoracic spine dysfunction in upper extremity complex regional pain syndrome type 1. (University of Southern California, Los Angeles, CA) J Orthop Sports Phys Ther 2000;30:401–409. The objective of this case study was to demonstrate the importance of assessment and treatment of the thoracic spine in the management of a patient with signs and symptoms of upper extremity complex regional pain syndrome type I. The patient was a 38‐year‐old woman who suffered a traumatic injury to her left hand. Five months after the injury, she presented with severe pain, immobility of the left arm, and associated dystrophic changes. She was unable to work and needed help in some activities of daily living. The patient was treated for 3 months in 36 visits. Initial treatment consisted of cutaneous desensitization, edema management, and gentle therapeutic exercises. However, further examination indicated hypomobility and hypersensitivity of the upper thoracic spine. Joint manipulation of the T3 and T4 segments was implemented. The patient's status was monitored. Immediately after the vertebral manipulation, there was significant increase in the left hand's skin temperature and a decrease in hyperhydrosis as measured by palpation. Shoulder range of motion increased from 135º to 175° and the patient reported reduced pain. The decrease in the patient's dystrophic and allodynic symptoms permitted further progress in functional reeducation. The patient was discharged with full return to independence and initiation of a vocational training program. Conclude that the assessment and treatment of the thoracic spine should be considered in patients with upper extremity complex regional pain syndrome type I. Comment by Karen Crawford, RPT. This is a study demonstrating the importance of assessment of the thoracic spine to manage patients with signs and symptoms of upper extremity complex regional pain syndrome type I (CRPS‐I). The patient was a 38‐year‐old female with traumatic injury to the left hand. The purpose of this study is to determine the relation between distal symptoms of CRPS‐I and the thoracic spine and to describe the use of thoracic spine manipulation in the management of patients with CRPS‐I in the upper extremity. CRPS‐I in the upper extremity often exhibits postural deviations associated with protective positioning of the arm. It emanates as trunk motion during upper activities and may present with decreased thoracic intervertebral mobility. This study believes that the evaluation and treatment in areas proximal to a patient's symptoms in CRPS‐I may be necessary. Hypomobility secondary to abnormal posturing and anatomical proximity of the sympathetic ganglions to the thoracic spine may contribute to the link between upper quadrant CRPS‐I and thoracic joint dysfunction. In the study, a 38‐year‐old, left‐hand dominant, female who sustained trauma to her left wrist and hand while at work was seen in physical therapy for a total of 36 visits. Initial treatment consisted of desensitization, edema management, and general therapeutic exercises. Further examination indicated hypomobility and hypersensitivity of the upper thoracic spine. At that time, joint manipulation of T3 and T4 segments was implemented. The patient's status was monitored and range of motion, strength, temperature, and skin moisture were measured. The patient reported minimal changes in her status, and 1 month into treatments, she hit her left hand on a door and consequently discontinued therapy because of increased pain. Five months after the initial injury, patient was reevaluated. She then received physical therapy 3 times per week for 12 weeks and was discharged with significant improved functional status. At the initial examination, the diagnosis of CRPS‐I was based on the IASP Committee on Taxonomy. The initial treatment objective was pain management and edema control. The long‐term goal was return to a functional status. Initial treatment consisted of gentle active and passive wrist and finger range of motion and tubagrip for edema management. A home program desensitization was implemented. The patient's active participation in therapy was limited secondary to her willingness to move her left arm. Treatment 2 included evaluation and manipulation of the upper thoracic spine. Her clinician used her manipulating hand as a fulcrum by placing it under the supine patient at the level of thoracic joint dysfunction. A thrust was delivered through the patient's folded arms as she exhaled and there as an audible click. There was an immediate normalization of skin temperature, color, as well as significantly decreased allodynic response to light touch along the left arm and the left upper thoracic vertebral column. Segmental thoracic mobility was immediately improved and there was immediate increase in shoulder flexion after this treatment. This reduction of signs and symptoms of CRPS‐I made it possible to proceed with functional rehabilitation. Manipulation of the thoracic spine may have resulted in improvements in distal upper extremity pain, skin color, and temperature in a patient with CRPS‐I. One explanation is that disuse of the arm and abnormal posturing may contribute to thoracic hypomobility. The anatomic proximity of the sympathetic chain to the dysfunctional thoracic joints may predispose the ganglions to mechanical pressure. Therefore, it is concluded that the evaluation and treatment of areas proximal to the patient's symptoms are necessary. It is difficult to identify the mechanism responsible for changing distal symptoms after thoracic manipulation. The immediate increase in shoulder flexion after manipulation is likely due to mechanical change in the tissue. In conclusion, this study describes a link between the thoracic spine and distal symptoms in patients with CRPS‐I. Thoracic joint manipulation appeared to improve spinal mobility, and also appeared to relieve distal and autonomic symptoms. These improvements allowed for functional rehabilitation of the effected arm. Therefore, it is the opinion of the study that the mobility of the thoracic spine should be evaluated for patients with autonomic dysfunction diagnosed with CRPS‐I. The research also indicates a need for further research to define the relationship between neurogenic symptoms and musculoskeletal pathology.     

Use of thoracic spine manipulation in the treatment of adhesive capsulitis: a case report

Abstract

Adhesive capsulitis (AC) is a common and disabling shoulder condition seen in physical therapy, and there is no clear consensus as to the best treatment approach. Recently there has been emerging evidence that manual therapy directed at the thoracic spine may be beneficial for patients with shoulder pain; however, this has not been examined specifically in patients with AC. The purpose of this paper is to present the case of 59-year-old female referred to physical therapy with a diagnosis of AC. The patient presented with complaints of left shoulder pain and significant limitations in range of motion (ROM) and upper extremity function. The initial treatment included exercises and manual therapy directed at the glenohumeral and scapulothoracic joints, and after 10 visits only minimal progress had been made. Further examination revealed mobility and ROM deficits in the thoracic spine, and manual therapy directed at this region was incorporated into her treatment. After the first session of thoracic spine manual therapy (TSMT) a 25 degree improvement was noted in active shoulder flexion. After four total visits of TSMT substantial improvements in pain, ROM, and function were noted compared to those made during the first 10 visits. This case adds to the emerging evidence that manual therapy directed at the thoracic spine should be considered for patients with shoulder pain.     

Evidence for increased neuromuscular drive following spinal manipulation in individuals with subacromial pain syndrome

BackgroundThoracic spinal manipulation can improve pain and function in individuals with shoulder pain; however, the mechanisms underlying these benefits remain unclear. Here, we evaluated the effects of thoracic spinal manipulation on muscle activity, as alteration in muscle activity is a key impairment for those with shoulder pain. We also evaluated the relationship between changes in muscle activity and clinical outcomes, to characterize the meaningful context of a change in neuromuscular drive.MethodsParticipants with shoulder pain related to subacromial pain syndrome (n = 28) received thoracic manipulation of low amplitude high velocity thrusts to the lower, middle and upper thoracic spine. Electromyographic muscle activity (trapezius-upper, middle, lower; serratus anterior; deltoid; infraspinatus) and shoulder pain (11-point scale) was collected pre and post-manipulation during arm elevation, and normalized to a reference contraction. Clinical benefits were assessed using the Pennsylvania Shoulder Score (Penn) at baseline and 2–3 days post-intervention.FindingsA significant increase in muscle activity was observed during arm ascent (p = 0.002). Using backward stepwise regression analysis, a specific increase in the serratus anterior muscle activity during arm elevation explained improved Penn scores following post-manipulation (p < 0.05).InterpretationThoracic spinal manipulation immediately increases neuromuscular drive. In addition, increased serratus anterior muscle activity, a key muscle for scapular motion, is associated with short-term improvements in shoulder clinical outcomes.     

Knowledge-Based Practice

Abstract

Rib injuries are common in collegiate rowing. The purpose of this case report is to provide insight into examination, evaluation, and treatment of persistent costochondritis in an elite athlete as well as propose an explanation for chronic dysfunction. The case involved a 21 year old female collegiate rower with multiple episodes of costochondritis over a 1-year period of time. Symptoms were localized to the left third costosternal junction and bilaterally at the fourth costosternal junction with moderate swelling. Initial interventions were directed at the costosternal joint, but only mild, temporary relief of symptoms was attained. Reexamination findings included hypomobility of the upper thoracic spine, costovertebral joints, and lateral ribs. Interventions included postural exercises and manual therapies directed at the lateral and posterior rib structures to improve rib and thoracic spine mobility. Over a 3-week time period pain experienced throughout the day had subsided (visual analog scale – VAS 0/10). She was able to resume running and elliptical aerobic training with minimal discomfort (VAS 2/10) and began to reintegrate into collegiate rowing. Examination of the lateral ribs, cervical and thoracic spine should be part of the comprehensive evaluation of costochondritis. Addressing posterior hypomobility may have allowed for a more thorough recovery in this case study.     

Use of thoracic spine manipulation in the treatment of adhesive capsulitis: a case report

Adhesive capsulitis (AC) is a common and disabling shoulder condition seen in physical therapy, and there is no clear consensus as to the best treatment approach. Recently there has been emerging evidence that manual therapy directed at the thoracic spine may be beneficial for patients with shoulder pain; however, this has not been examined specifically in patients with AC. The purpose of this paper is to present the case of 59-year-old female referred to physical therapy with a diagnosis of AC. The patient presented with complaints of left shoulder pain and significant limitations in range of motion (ROM) and upper extremity function. The initial treatment included exercises and manual therapy directed at the glenohumeral and scapulothoracic joints, and after 10 visits only minimal progress had been made. Further examination revealed mobility and ROM deficits in the thoracic spine, and manual therapy directed at this region was incorporated into her treatment. After the first session of thoracic spine manual therapy (TSMT) a 25 degree improvement was noted in active shoulder flexion. After four total visits of TSMT substantial improvements in pain, ROM, and function were noted compared to those made during the first 10 visits. This case adds to the emerging evidence that manual therapy directed at the thoracic spine should be considered for patients with shoulder pain.     

Stabilizing effect of the rib cage on adjacent segment motion following thoracolumbar posterior fixation of the human thoracic cadaveric spine: A biomechanical study

BackgroundAlthough the rib cage provides substantial stability to the thoracic spine, few biomechanical studies have incorporated it into their testing model, and no studies have determined the influence of the rib cage on adjacent segment motion of long fusion constructs. The present biomechanical study aimed to determine the mechanical contribution of the intact rib cage during the testing of instrumented specimens.MethodsA cyclic loading (CL) protocol with instrumentation (T4–L2 pedicle screw-rod fixation) was conducted on five thoracic spines (C7–L2) with intact rib cages. Range of motion (±5 Nm pure moment) in flexion-extension, lateral bending, and axial rotation was captured for intact ribs, partial ribs, and no ribs conditions. Comparisons at the supra-adjacent (T2–T3), adjacent (T3–T4), first instrumented (T4–T5), and second instrumented (T5–T6) levels were made between conditions (P ≤ 0.05).FindingsA trend of increased motion at the adjacent level was seen for partial ribs and no ribs in all 3 bending modes. This trend was also observed at the supra-adjacent level for both conditions. No significant changes in motion compared to the intact ribs condition were seen at the first and second instrumented levels (P > 0.05).InterpretationThe segment adjacent to long fusion constructs, which may appear more grossly unstable when tested in the disarticulated spine, is reinforced by the rib cage. In order to avoid overestimating adjacent level motion, when testing the effectiveness of surgical techniques of the thoracic spine, inclusion of the rib cage may be warranted to better reflect clinical circumstances.     

Immediate effects of thoracic spine self-mobilization in patients with mechanical neck pain: A randomized controlled trial

ObjectivesTo investigate the immediate effects of thoracic spine self-mobilization in patients with mechanical neck pain.Study designRandomized, controlled trial.BackgroundThoracic spine self-mobilization is performed after thoracic spine thrust manipulation to augment and maintain its effects. To the best of our knowledge, no study has investigated the effects of thoracic spine self-mobilization alone in individuals with mechanical neck pain. The purpose of this randomized, controlled trial was to evaluate the immediate effects of thoracic spine self-mobilization alone without any other intervention on disability, pain, and cervical range of motion in patients with mechanical neck pain.MethodsFifty-two patients (39 females and 13 males) with mechanical neck pain were randomly allocated to either a thoracic spine self-mobilization group that was performing a thoracic spine active flexion and extension activity using two tennis balls fixed by athletic tape or a placebo thoracic spine self-mobilization group. Outcome measures were collected at pre-intervention and immediately after intervention, including the Neck Disability Index, visual analogue scale, and active cervical range of motion (ROM). The immediate effect of the intervention was analyzed using two-way repeated measures analysis of variance (ANOVA). If interactions were found, a simple main effect test was performed to compare the pre-post intra-group results.ResultsThe results of two-way repeated measures ANOVA indicated that the main effect of time was significant (p < 0.05) for all measurement outcomes. The main effect of group was not significant for all measurement outcomes (p > 0.05). The group × time interactions for cervical flexion active ROM (p = 0.005) and cervical extension active ROM (p = 0.036) were significant. The tests of simple main effect in cervical flexion active ROM (p < 0.0001) and cervical extension active ROM (p < 0.0001) showed a significant difference before and after intervention in the thoracic spine self-mobilization group.ConclusionPatients with mechanical neck pain who carried out thoracic spine self-mobilization showed increases in active cervical flexion and extension ROM.     

Immediate effects of thoracic manipulation in patients with neck pain: a randomized clinical trial

Mechanical neck pain is a common occurrence in the general population resulting in a considerable economic burden. Often physical therapists will incorporate manual therapies directed at the cervical spine including joint mobilization and manipulation into the management of patients with cervical pain. Although the effectiveness of mobilization and manipulation of the cervical spine has been well documented, the small inherent risks associated with these techniques has led clinicians to frequently utilize manipulation directed at the thoracic spine in this patient population. It is hypothesized that thoracic spine manipulation may elicit similar therapeutic benefits as cervical spine manipulation while minimizing the magnitude of risk associated with the cervical technique. The purpose of this randomized clinical trial was to investigate the immediate effects of thoracic spine manipulation on perceived pain levels in patients presenting with neck pain. The results suggest that thoracic spine manipulation results in immediate analgesic effects in patients with mechanical neck pain. Further studies are needed to determine the effects of thoracic spine manipulation in patients with neck pain on long-term outcomes including function and disability.     

Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions

In recent years, increased knowledge of the pathogenesis of upper quadrant pain syndromes has translated to better management strategies. Recent studies have demonstrated evidence of peripheral and central sensitization mechanisms in different local pain syndromes of the upper quadrant such as idiopathic neck pain, lateral epicondylalgia, whiplash-associated disorders, shoulder impingement, and carpal tunnel syndrome. Therefore, a treatment-based classification approach where subjects receive matched interventions has been developed and, it has been found that these patients experience better outcomes than those receiving non-matched interventions. There is evidence suggesting that the cervical and thoracic spine is involved in upper quadrant pain. Spinal manipulation has been found to be effective for patients with elbow pain, neck pain, or cervicobrachial pain. Additionally, it is known that spinal manipulative therapy exerts neurophysiological effects that can activate pain modulation mechanisms. This paper exposes some manual therapies for upper quadrant pain syndromes, based on a nociceptive pain rationale for modulating central nervous system including trigger point therapy, dry needling, mobilization or manipulation, and cognitive pain approaches.     

Differential diagnosis and treatment in a patient with posterior upper thoracic pain

BACKGROUND AND PURPOSE: Determining the source of a patient's pain in the upper thoracic region can be difficult. Costovertebral (CV) and costotransverse (CT) joint hypomobility and active trigger points (TrPs) are possible sources of upper thoracic pain. This case report describes the clinical decision-making process for a patient with posterior upper thoracic pain. CASE DESCRIPTION: The patient had a 4-month history of pain; limited cervical, trunk, and shoulder active range of motion; limited and painful mobility of the right CV/CT joints of ribs 3 through 6; and periscapular TrPs. Interventions included CV/CT joint mobilizations, TrP release, and flexibility and postural exercises. OUTCOMES: The patient reported intermittent mild discomfort after 7 physical therapy sessions. Examination findings were normal, and he was able to resume all preinjury activities. DISCUSSION: This case suggests that CV/CT mobilizations and active TrP release may have been beneficial in reducing pain and restoring function in this patient.     

Long Thoracic Neuropathy Resulting From First Rib Palpation

Abstract

Injury to the long thoracic nerve and subsequent scapular winging are serious conditions that create significant impairments. This case study describes an entrylevel physical therapy student who sustained a long thoracic neuropathy after another student palpated her first rib in a supervised lab that focused on palpation of the upper quarter. The student did not regain full active range of motion until more than four months after the injury, and one year later, she still reports mild, residual shoulder girdle weakness. The long thoracic nerveís unique position, tethered over the first rib, and its superficial location in the supraclavicular fossa make it susceptible to compression injury. Therefore, it is recommended that clinicians use extreme caution when palpating in the supraclavicular fossa. Preferably, clinicians should palpate the first rib along its posterior shaft or anteriorly on the costal cartilage of the first rib, avoiding the supraclavicular fossa all together.     

Biomechanical investigation of potential prophylactic scoliosis treatments following various sizes of chest wall resection

BackgroundA well-known problematic sequela of chest wall resections is development of scoliosis. Despite the seriousness and frequency of scoliosis following chest well resection, the etiology and biomechanical information needed to understand this progression aren't well-known.MethodsRange of motion of six specimen (C7–L2) was captured using a custom-built six degrees-of-freedom machine in each of three physiological rotation axes. Left posterior ribs were sequentially resected 7cm from the rib head, starting at the 5^th rib and continuing until the 10^th rib. Injured specimen were instrumented with unilateral anterior rod fixation and then with additional unilateral posterior fixation, each starting at T4 and then extended distally as ribs were resected. Relative motion between the constructs' proximal and distal ends was measured in all three axes for the intact, injured, unilateral anterior, and unilateral anterior with unilateral posterior constructs.FindingsRaw motion of the injured specimen increased in a stepwise manner as ribs were resected. Averaged across all injury sizes, the unilateral anterior construct significantly reduced motion by 47.0±13.4% in lateral bending (P=.001). The combined anterior-posterior construct significantly reduced motion by 57.6±15.9% in flexion/extension (P<.001), 70.3±12.2% in lateral bending (P<.001), and 51.1±14.5% in axial rotation (P<.001). Combined anterior-posterior fixation was significantly more stable than anterior-only fixation in flexion/extension (P=.002).InterpretationRegardless of injury size, posterior rib resection did not create significant immediate instability of the thoracic spine. Concurrent spinal stabilization was shown to maintain thoracic spine stability. Combined anterior-posterior fixation proved to be significantly more rigid than an anterior-only construct.     

Treatment of a female collegiate rower with costochondritis: a case report

Rib injuries are common in collegiate rowing. The purpose of this case report is to provide insight into examination, evaluation, and treatment of persistent costochondritis in an elite athlete as well as propose an explanation for chronic dysfunction. The case involved a 21 year old female collegiate rower with multiple episodes of costochondritis over a 1-year period of time. Symptoms were localized to the left third costosternal junction and bilaterally at the fourth costosternal junction with moderate swelling. Initial interventions were directed at the costosternal joint, but only mild, temporary relief of symptoms was attained. Reexamination findings included hypomobility of the upper thoracic spine, costovertebral joints, and lateral ribs. Interventions included postural exercises and manual therapies directed at the lateral and posterior rib structures to improve rib and thoracic spine mobility. Over a 3-week time period pain experienced throughout the day had subsided (visual analog scale – VAS 0/10). She was able to resume running and elliptical aerobic training with minimal discomfort (VAS 2/10) and began to reintegrate into collegiate rowing. Examination of the lateral ribs, cervical and thoracic spine should be part of the comprehensive evaluation of costochondritis. Addressing posterior hypomobility may have allowed for a more thorough recovery in this case study.     

The Immediate Effects of Upper Thoracic Translatoric Spinal Manipulation on Cervical Pain and Range of Motion: A Randomized Clinical Trial

This study examined the effect of translatoric spinal manipulation (TSM) on cervical pain and cervical active motion restriction when applied to upper thoracic (T1-T4) segments. Active cervical rotation range of motion was measured re- and post-intervention with a cervical inclinometer (CROM), and cervical pain status was monitored before and after manipulation with a Faces Pain Scale. Study participants included a sample of convenience that included 32 patients referred to physical therapy with complaints of pain in the mid-cervical region and restricted active cervical rotation. Twenty-two patients were randomly assigned to the experimental group and ten were assigned to the control group. Pre- and post-intervention cervical range of motion and pain scale measurements were taken by a physical therapist assistant who was blinded to group assignment. The experimental group received TSM to hypomobile upper thoracic segments. The control group received no intervention. Paired t-tests were used to analyze within-group changes in cervical rotation and pain, and a 2-way repeated-measure ANOVA was used to analyze between-group differences in cervical rotation and pain. Significance was accepted at p = 0.05. Significant changes that exceeded the MDC₉₅ were detected for cervical rotation both within group and between groups with the TSM group demonstrating increased mean (SD) in right rotation of 8.23° (7.41°) and left rotation of 7.09° (5.83°). Pain levels perceived during post-intervention cervical rotation showed significant improvement during right rotation for patients experiencing pain during bilateral rotation only (p=.05). This study supports the hypothesis that spinal manipulation applied to the upper thoracic spine (T1-T4 motion segments) significantly increases cervical rotation ROM and may reduce cervical pain at end range rotation for patients experiencing pain during bilateral cervical rotation.     

The Effects of Thoracic Manipulation Versus Mobilization for Chronic Neck Pain: a Randomized Controlled Trial Pilot Study

[Purpose] To investigate effects of thoracic manipulation versus mobilization on chronic neck pain. [Methods] Thirty-nine chronic neck pain subjects were randomly assigned to single level thoracic manipulation, single level thoracic mobilization, or a control group. The cervical range of motion (CROM) and pain ratings (using a visual analog scale: VAS) were measured before, immediately after and at a 24-hour follow-up. [Results] Thoracic manipulation significantly decreased VAS pain ratings and increased CROM in all directions in immediate and 24-hour follow-ups. The thoracic mobilization group significantly increased in CROM in most directions at immediate follow-up and right and left rotational directions at the 24-hour follow-up. Comparisons between groups revealed the CROM for the manipulation group to increase significantly more than for control subjects in most directions at immediate follow-up and flexion, left lateral flexion and left rotation at the 24-hour follow-up. The CROM for the thoracic mobilization group significantly increased in comparison to the control group in flexion at immediate follow-up and in flexion and left rotation at the 24-hour follow-up. [Conclusion] The study demonstrated reductions in VAS pain ratings and increases in CROM at immediate and 24-hour follow-ups from both single level thoracic spine manipulation and thoracic mobilization in chronic neck pain.Key words: Single level thoracic manipulation, Single level thoracic mobilization, Chronic neck pain     

Pseudotumor of the supraclavicular fossa

Minor musculoskeletal variants of the upper thoracic spine or of the ribs can cause effacement of the supraclavicular fossa, simulating a mass ("pseudotumor"). These variants may occur singly or in combination, and include unilateral prominence or asymmetry of the first rib, unilateral prominence or asymmetry of a cervical rib, and mild upper thoracic scoliosis causing prominence of the first rib on one side. The detection of variants by physical examination or more easily by review of the chest x-ray film may in selected instances obviate the need for costly diagnostic procedures and unnecessary biopsies. We call attention to this condition and describe our experience with four patients.     

Effect of sternoclavicular joint mobilization on pain and function in a patient with massive supraspinatus tear

Massive irreparable rotator cuff tears can be difficult to treat conservatively, especially when the patient has multiple comorbidities. Although there is evidence to support interventions aimed at the spine, there is paucity in the literature describing interventions to the sternoclavicular joint (SCJ) in individuals with rotator cuff pathology. A 57-year-old female with multiple comorbidities and a body mass index of 59 was referred to physical therapy with a 4-month history of right shoulder pain, significant functional limitations, and magnetic resonance imaging (MRI), demonstrating a full-thickness supraspinatus tear. She presented initially with active shoulder flexion range of motion (ROM) 0–80°, numeric pain rating scale (NPRS) 7/10, and QuickDASH 65.9%. After six physical therapy sessions, the patient had plateaued with improvements in pain and ROM. SCJ mobilizations at visit 7 immediately improved pain, active ROM, and subjective reports of function. The patient was discharged after 13 visits with increased active shoulder flexion ROM to 0–170°, NPRS 1/10, QuickDASH 31.8%, and Global Rating of Change (GROC) +5. This case highlights the successful conservative treatment of an individual with an irreparable rotator cuff tear and numerous comorbidities by using a multimodal approach including SCJ mobilizations.