Clinical Prediction Rule for Thoracic Manipulation for Neck Pain

1. 
   Symptoms less than 30 days
   
2. 
   No symptoms distal to shoulder
   
3. 
   Cervical extension does not aggravate
   
4. 
   FABQPA score less than 12
   
5. 
   Decreased upper thoracic kyphosis
   
6. 
   Cervical extension less than 30 degrees
   

Non-Neuromuscluloskeletal Causes of Thorax Pain

Cancer: Occurs in thoracic spine most often from lymphoma, breast, or lung cancer. Patients usually report symptoms of cancer and have neurological signs due to spinal cord compression. Patients with prostate and lung cancer usually present with back pain as initial complaint. Patients with breast, kidney, or colon cancer usually present with visceral symptoms as the initial complaint.

Cardiac Conditions: aortic aneurysm, angina or acute MI. These are usually accompanied by cardiac symptoms such as weak pulse, abnormal BP, unexplained perspiration, or a pulsating sensation in the abdomen.

Pulmonary Conditions: Symptoms should increase with coughing or deep breathing.

Renal Conditions: Pain is usually dull and constant with possible radiation to groin. For an acute infection the patient will experience chills, frequent urination, and blood in their urine. Percussion should be positive in the flank areas in patients with renal problems.

Gastrointestinal Conditions: severe esophagitis, peptic ulcer, and an acute gallbladder infection. Take a thorough history to identify GI conditions vs. musculoskeletal conditions.

Scapular Pain: Respiratory viral infection or pneumothorax cause scapular pain that is aggravated by respiratory movements

Pain due to: inflammation of ligaments/capsule, internal derangement, arthritis, muscle imbalance

Clicking

Loud click on opening is disc reduction

Smaller click on closing is disc dislocation

If disc fully anteriorly displaced no clicking will be present and the patient will have limited range of motion when opening their mouth. This is called a locked joint.

If disc is fully posteriorly displaced then it is an open lock. This occurs most frequently after a dental procedure

Local vs. Global Muscles

Local: A deep muscle that controls a single segment’s translation. Most likely to become inhibited or down regulated with pain.

Global: A muscle that produces movement. Most likely to become up regulated with pain.

Actions and Muscle Involvement

Elevation (closing): masseter, temporalis, medial pterygoid, superior fibers of lateral ptyergoid

Depression (opening): inferior fibers of lateral ptergoid, supra hyoids, infrahyoids, gravity

Protrusion: superficial masseter, medial pterygoid, lateral pterygoid

Retrusion: deep fibers of masseter, temporalis, suprahyoids

*medial pterygoids are the most common muscle to cause problems*

Normal Kinematics

Elevation (closing): teeth approximation

Depression (opening): maximum 40-50 mm or 4 finger widths, to be functional only need 35 mm or three finger widths

Posterior rotation of condyles during first half of the movement with anterior rotation occurring during the second half of the movment

Protrusion: 6-9 mm

Mandible and disc translate anterior and inferior

Retrusion: 3 mm

Lateral Deviation: ½ the opening range

Physical Therapy: mobilize restrictions, stabilize hypermobility, improve stabilizer muscle control through full range, educate about posture, empower the patient with self-management techniques, stretches, address pain control and daily activities

Rehabilitation After Cervical Spine Surgery

Imaging: Not necessary unless there is a neurological deficit. MRI used for soft tissue definition.

Surgical Indications: fractures from major trauma, fractures from minor trauma patients with osteopenia, progressive myelopathy (sensory disturbances in hand, intrinsic muscle wasting of hand, trouble walking, hyperreflexia), neoplasm

Posterior Approach: used for lateral herniation, allows patients to avoid fusions, more technically difficult surgery, more pain due to increased musculature

Anterior Approach: problems with swallowing and vocal changes

Cervical Radiculopathy

Description: nerve root impingement usually from disc herniation

MOI: forced hyperextension, rotation or both

Initial Treatment: non-operative, rest/NSAIDS/oral steroids, cervical traction

Surgical Indications: failed conservative management of at least 2-3 months, progression of neurological dysfunction (weakness), persistent numbness in dominant hand

Surgery: discectomy, possible fusion

Cervical Stenosis

Description: narrowing of spinal canal causing compression on spinal cord and nerve roots

MOI: congenital or acquired, acute trauma with fracture or herniation

Surgery: laminectomy

Cervical Myelopathy

Description: spinal cord compression causing upper/lower extremity weakness, bowel and bladder dysfunction, gait disturbance

Indication for Surgery: always, no indication for conservative care

Surgery: removal of vertebral body and disc and insertion of prosthesis, possible fusion

Rehabilitation Strategies

Acute Phase

General Rules: brace/collar for fusion patients (doctor will specify), no ROM, keep head of bed elevated (sleep in recliner), no lifting over 5-10 lbs

Physical Therapy: bed mobility, ambulation, stairs (may have trouble seeing with brace on the way down)

Outpatient

Physical Therapy: precision of movement including intrinsic muscles for fine control and making sure the extrinsic muscles do not become dominant, posture education, proper alignment of shoulder girdle

Rehabilitation After Lumbar Spine Surgery

Indications for Imaging: back pain in children less than 18 or adults older than 55 with severe pain, history of violent trauma, night pain, history of cancer, systemic steroids, drug abuse, HIV, marked morning stiffness, persistent severe restriction of motion, severe pain with motion, structural deformity, difficulty with urination, loss of bowel/bladder function, saddle anesthesia, motor weakness or gait disturbance, peripheral joint involvement

X-rays: used for young patients with spondylolisthesis and older patients with possible compression fractures

MRI: examining neural compression, can detect infections with gadolinium enhancements, problems with MRI include picking up pathologies that the patient is unaware of because they have no symptoms

Herniated Disc

Treatment from a Surgeon Perspective: most patients get better with time, epidural steroid injections, not likely to refer to PT and if do refer just want modalities

Indications for Surgery: positive straight leg raise, concordant imaging showing extruded disc herniations, cauda equine, severe motor deficit (MMT 1-2/5), no low back pain, few psychological stressors

Indications for Conservative Care: disc protrusions, annular disruption, mild to moderate weakness (MMT 3-4/5)

Surgery: discectomy/microdiscectomy

Research: no long term difference in outcomes between herniations treated with surgery vs. conservative care

Spinal Stenosis

Differential Diagnosis: rule out vascular claudication by treadmill test (spinal stenosis patients see less pain with uphill walking because they are in flexion)

Treatment from a Surgeon Perspective: pain meds, bracing, activity modifications, epidurals (especially good for elderly patients), laminectomy

Comorbidites: if a patient also has spondylolisthesis or significant scoliosis they will need a fusion

Spondylolisthesis

Causes: degenerative, congenital, post-surgical complication

Treatment from a Surgeon Perspective: bracing, pain meds, PT for grades I and II involving stabilization and core strengthening, epidurals, fusion and decompression

Lumbar Fusion Complications: decreased bone mineral density and increased segmental instability

Rehabilitation Strategies

General Precautions: log roll (patient should have hips at bend of bed), spinal orthotics, no hip flexion greater than 90 degrees, no twisting/bending/rotation, no forward bending/stooping, no lifting over 5-10 lbs, no sitting for longer than 30 minutes due to increased compression