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.