Thoracic Spine Management. Jason Zafereo, PT, OCS, FAAOMPT

Transcription

1 Thoracic Spine Management Jason Zafereo, PT, OCS, FAAOMPT Clinical i l Orthopedic Rehabilitation ti Education

2 Objectives Describe the treatment interventions used for the management of pain from contractile and noncontractile tissue sources Describe the treatment interventions used for the management of stiffness from contractile and noncontractile sources Describe the treatment interventions used for the management of instability of non-contractile sources

3 PAIN-DOMINANT TREATMENT

4 Pain-Dominant Treatment Contractile Myofascial pain syndrome Treatment prescribed as for cervical spine, including progression Non-contractile T4 syndrome TOS Disc

5 T4 Management General guidelines TENS Tissue specific guidelines Graded mobilization T3-5 Graded d ROM Neural gliding Cervicothoracic spine, opposite spinal curve

6 T4 Management Contributing Impairments Environmental Ergonomics on sustained and end range slumped postures Mechanical Underlying rib dysfunction (1-3 ribs) into exhalation Mobilization of hypomobile spinal segments above/below level Stretching t of hypertonic muscles (Upper trap/levator/scalenes) Spinal/Scapular stabilization

7 Support for T4 Management Case study (28 year old female, 2 months onset tbue UE, neck, head and upper back pain) 6 visits over 3 weeks Heavy emphasis postural education T4 Graded PAs in flexion (position of provocation) Referral to Pilates class (did not attend) Outcome: Elimination of B UE, neck, and head pain by 4 th visit, st, lost osttoto long-term gte followup o Conroy and Schneiders, Manual Therapy, 2005

8 TOS Management General guidelines TENS Sinkus and Stragier 1994 Tissue specific guidelines Graded AROM Neural gliding Crosby and Wehbe, Hand Clinics, 2004

9 TOS Management Contributing Impairments Environmental Ergonomics on correction of depressed shoulders Cyriax release maneuver before bed, up to 30mins Gradual increase in sx before decrease Education on sleeping position Avoid overhead Physical Education on diaphragmatic breathing Hooper et al 2010

10 TOS Management Contributing Impairments Mechanical Mobilization of hypomobile first rib, ACJ, SCJ** Stretching of hypertonic scalene/pec minor Mobilization/stabilization of facilitated cervical segment t(c3/4) accounting for scalene hypertonicity Scapular stabilization* ation* Taping into upward* rotation *Watson et al 2010 **Hooper et al 2010

11 Support for TOS Management Interventions ROM: Shoulder rolls and seated upper cervical flexion Stretching: Levator, UT, SCM, scalenes, pec minor Strengthening: Serratus anterior Outcomes Satisfied with outcome 88.1% CRLF test negative and a normal range of cervical spine motion 81.5% Grip strength normal if reduced at admission 64.9% Tinel s sign normal if positive at admission i 58.5% 5% Lindgren, Arch Phys Med Rehabil, 1997

12 Disc Management Tissue specific guidelines Graded d Axial distraction ti Sizer et al 2001 Graded ROM (direc. pref.) Contributing impairments Environmental Ergonomics on sustained and end range postures Mechanical Mobilization of hypomobile segments above/below level Treatment of underlying instability spinal/scapular

13 Thoracic Traction Considerations T1-3 use cervical setup at 30deg T4-9 use cervical setup with bolster under thoracic spine T9-12 use lumbar setup with higher pelvic belt placement Grieve, Common Vertebral Joint Problems, 1988

14 STIFFNESS-DOMINANT TREATMENT

15 Classification Categories Treatment-based system (Olson 2009) Impairment-dominant i t treatmentt t Thoracic hypomobility Thoracic hypomobility with UE referred pain (T4 syndrome) Thoracic instability Thoracic hypomobility with neck pain Thoracic hypomobility with shoulder impairments Thoracic hypomobility with low back pain

16 Treatment Considerations Immediate focus for hypomobile structures in and around the area of undifferentiated t d pain Gradual inclusion for tissues transitioning from pain-dominant i state t Contractile myofascial pain syndrome Ischemic pressure and sustained end range stretching Non-contractile nerve and disc

17 Progression of Nerve Tissue TOS/T4 Progress neural glides to end range positions Simultaneous mobilization of mechanical interface sites First rib T4 in sympathetic slump position

18 Mobilization vs Manipulation Manipulation: Grade V technique According to (Shekelle 1994), best for: Entrapped synovial folds or plica Hypertonic muscle Articular adhesions Segmental displacement Technique may be accurately localized or globally applied (short vs long lever) Requires prepositioning at end range Applied one time (repeat once PRN if no cavitation) ti

19 Examples of Therapist-Administered Treatment PAs SP, TP CT, CC Inhalation/Exhalation CT, CV Rotation TPs Distraction ZJ

20 Examples of Patient-Administered Treatment Theracane/Tennis balls Soft tissue and joint mobilization upper thoracic spine and ribs Supine foam roller Extension T3 and below (flexion syndrome) Horizontal for targeted stretch, including ribs (rotation syndrome) Vertical for regional stretch Sidelying foam roller 3-10 rib mobilization

21 Support for Soft Tissue Treatment Population: 40 subjects with active trigger points Intervention: HEP consisting of theracane self mobilization and stretching versus neck ROM, 2x/d x 5days Outcomes: Significant decrease in pain (VAS) and pressure pain threshold in mobilization group Hanten et al, PT, 2000

22 Support for TSM for Thoracic Pain Population: 30 patients with mechanical thoracic spinal pain Intervention: US placebo versus spinal manipulation Outcomes: Short term improvements in pain reduction and lateral flexion ROM; no difference at one month Schiller, J Manip Phys Ther, 2001

23 PRIMARY INSTABILITY IMPAIRMENT

24 Treatment Considerations Immediate focus for joint instability with undifferentiated t d pain Terminal classification for all tissues transitioning i from pain-dominant i state t and hypomobility categories

25 Primary Treatment for Joint Instability Contributing Impairments Environmental Education on limiting end range positions, including rotation Mechanical Strengthening of Thoracic spine away from syndrome Stretching of CT and TL spine into syndrome Motor control of Thoracic spine into syndrome

26 Examples of Primary Treatment for Instability Independent activation/ Tonic hold Isometrics/isotonics of thoracic multifidus and scapular retractors t (flexion syndrome) Isometrics/Isotonics of RA/IO and serratus (extension syndrome)

27 Examples of Primary Treatment for Instability Integrated tonic hold Supine lying trunk flexion with cervical or lumbar emphasis (flexion syndrome) Prone lying trunk extension with cervical or lumbar emphasis (extension syndrome)

28 Examples of Primary Treatment for Instability Integrated tonic hold (rotation ti syndrome) Prone lying with scapular retraction/depression, neutral spine UE PRE Lee, Manual Therapy, 1996