Thoracic clinical syndromes and treatment

Question 1

Describe the epidemiology of thoracic spine pain

Answer 1

-much less common than cervical spine and lumbar spine
-life time prevalence 13-17%

Question 2

what pain is thoracic pain also established with?

Answer 2

-neck pain
-elbow pain

Question 3

what are some possible physical causes for thoracic spine pain?

Answer 3

-trauma
-degeneration eg spondylosis, facet joint arthrosis
-inflammatory eg AS
-mechanical eg discogenic pain, postural thoracic pain
-syndromes eg thoracic outlet syndrome
-metabolic - osteoporosis

Question 4

what is scheuermann’s disease?

Answer 4

a growth disorder that affects the spine during adolescence causing vertebrae to become wedge shaped leading to increased spinal curvature
-more common in males
-juvenile !!
-more common in lower thoracic spine

Question 5

what is shingles and how is it relevant in the thoracic spine?

Answer 5

-virus affecting nerve roots- herpes zoster virus
-burning pain initially, then tingling or itching in a single area before rash developed, then sacs filled with fluid
-it can affect the thoracic region eg ribs or spine
-they need to be sent to GP for treatment
-over 60s in people who have had chicken pox, but can happen in younger people too

Question 6

what are common visceral regions that can refer pain to the thoracic region?

Answer 6

heart eg angina or MI - left shoulder, arm, jaw
pulmonary system/ lungs
oesophagus
stomach etc
liver - shoulders

Question 7

what is thoracic outlet syndrome?

Answer 7

a condition in which there is compression of the nerves, arteries, or veins in the superior thoracic aperture
-pain , p+n’s, weakness and discomfort in the upper limb which is aggravated by elevation of the arms or by exaggerated movements of the head and neck

Question 8

how can we establish if thoracic pain is visceral vs musculoskeletal?

Answer 8

-NB subjective - pain location, patterns, aggs vs eases etc
-MSK pain should be able to be reproduced.. things need to be ruled in and ruled out
-is it the neck tissue referring down to thoracic spine or is t from the thoracic spine?

Question 9

what are key things to include for subjective exam and thoracic spine pain?

Answer 9

-the impact of breathing on pain eg full deep breath, get them to try in front of you
-impact of cough on pain
-special questions: history of cancer eg breast, thyroid , unexplained weight loss, cord signs - p+n’s, numbness in legs,

Question 10

why is discogenic thoracic pain rare?

Answer 10

-small disc size
-protected by rib cage
-AP orientation of facet joints

Question 11

what are the most common areas for discogenic thoracic pain?

Answer 11

T11 and T12

Question 12

describe the clinical picture for discogenic thoracic pain

Answer 12

-severe pain, central, unilateral or band around chest
-pain on inspiration and cough (due to increase in pressure)
-central PA (>unilateral PA) provocative
-PPIVMs hypomobile and reactive
- thoracic discs could cause a radiculopathy but not common

Question 13

where could pain be referred with thoracic disc pain?

Answer 13

T9/T10 picture on right - pain goes into buttocks and inside leg

Question 14

how could we unravel multisite pain in the subjective exams?

Answer 14

-asking
-did one come on before the other
-can you get one without getting the other
-do they have the same aggs and eases

Question 15

what area of the thoracic spine has the highest incidence of intravertebral degeneration?

Answer 15

mid thoracic pain

Question 16

what is the most common hypomobility pattern in thoracic spine patients?

Answer 16

-hypolateral +/- rotation to painful side
-associated with either flex / extension restriction

Question 17

describe thoracolumbar junction syndrome

Answer 17

condition involving dysfunction at the T12/L1 level
-pain can rarely be felt in the TL junction due to it being a cutaneous nerve supply and more often referred to the iliac crest region / groin
-often in younger, more mobile person, particularly if hyperlordotic
-TL lateral flexion/rotation will provoke symptoms
-TL PAIVM examines and reproduces referred pain

Question 18

what are the 2 main types of thoracic outlet syndrome?

Answer 18

-vascular
-neurological

Question 19

describe some key points about TOS

Answer 19

-between 20-50 years
-females more common
-often related to repeated occupational stresses, poor posture, trauma eg clavicle fracture
-extra rib (1% population) but they are more likely to get TOS

Question 20

describe the clinical picture of TOS

Answer 20

-will depend on which structures are compressed - 90% neural, 10% vascular
-arm swelling
-hand or arm weakness
-feeling of tiredness in the arm aggravated by performing overhead work
-tingling or numbness, esp in the middle, ring and little finger
-radiating pain in the shoulder, arm or hand - commonly between 4th and 5th

Question 21

what are some special tests for thoracic outlet syndrome?

Answer 21

-Roos test - abd and ext rotn - 1-3 mins= P1 and p+n’s, can get
-Adsons test - deep breath and elevate chin and turn head x 30 second - not reliable
-costoclavicular compression - scapula retraction aabd depression while monitoring radial pulse - only pos if vascular compromise present

Question 22

are there any CPGs available for thoracic spine?

Answer 22

no

Question 23

describe thoracic postural pain

Answer 23

-primarily muscular paraspinal pain in younger patients due to tight or overactive muscles
-physical exam - muscle length tests, soft tissue palp, PPIVMS, PAIVMS

Question 24

even though there is no CPG’s for thoracic pain, what is recommended?

Answer 24

-multimodal program of care (ie manual therapy, soft tissue mobs, exercise, heat/ice, and advice)

Question 25

what are the mainlands thoracic algorithm for thoracic pain?

Answer 25

-these are for pain reduction! -start with central PA, then transverse for both unilateral and bilateral pain

Question 26

what manual therapy and exercise is recommended for hypomobility of the thoracic spine

Answer 26

manual therapy: it is recommended to treat as you find -so find the most restiicted/ provocative moments to restore exercise: mobilsiing: extension, flex and rotation + can also strengthen based on assessment eg core

Question 27

what is the upper cross syndrome

Answer 27

-weakness in deep neck flexors -tight pectorals -traps and levator scaps -weak rhomboids and elevator scap

Question 28

when muscle imbalance is present in thoracic spine, what is recommended for upper- mid and lower spine?

Answer 28

1. upper - mid - correct cross syndrome - ie strengthen your deep neck flexors, stretch lev scap and traps and pec 2. lower thoracic spine- patient may have excessive lordosis : consider lumbopelvic control - core strength,. TrA vs tight or overactive hip flexors

Question 29

are scapular exercises good for thoracic spine syndromes? what does poor scapular control lead to in the posture Ax? and what are examples of some scapular exercises?

Answer 29

- yes because the scapula plays a critical role in stabilising, supporting and moving the upper back and thoracic region -weak or poorly controlled scapular muscles ie serrates anterior, lower traps could lead to forward head posture, rounded shoulders, thoracic kyphosis example exercises? -serratus punches, scapular retraction etc

Question 30

how is thoracic outlet syndrome treated? conservative vs surgical

Answer 30

1. conservative - rest for aggs activities eg overhead and other repetitive activities + tape to correct position of scapula -posture correction -patient education - explain key principles of conservative management -muscle flexibility and control in neck and shoulder girdle scapular control 2. surgical -scalenectomy etc

Question 31

what are examples of some TOS exercises?

Answer 31

-pec stretch -scapular squeeze (squeeze shoulder blades together) -scalene stretch -arm slide on wall -thoracic extension in chair with hands behind head